Professionalism v Managerialism – creating an innovation culture

 

More of the same won’t work

There is no doubt that across health and social care leaders know the system has to change. In most places and across the professional disciplines (clinical and managerial) there is agreement about what the future will look like (more coproduced care, resourceful communities, generalists better supported by specialists, care closer to home, integration, digital support for care and decision-making). As Nigel Edwards, at the Nuffield Institute for Health says, somewhere between what we know about the current and an agreed future there is a vacuum where ‘magic happens’.

Getting from here to there is not simple, and in frustration about the complexity of leading change the old world bites back – the NHS puts in structures, hierarchical governance and project management, the sorts of processes that work for ‘tame’ problems not for ‘wicked’ problems, for markets and hierarchies, not for collaboratives and innovation. Its clear that this is not working. The temptation is to just keep on trying do get innovation going, but I think we have to address some of the key underlying tensions and issues:

  1. The sense that ‘Innovation’ is soft and might not work and ‘Performance Management’ is proper management and will work.
  2. The demise of professional practice review.  Clinical leadership hasn’t as yet managed to secure clinically-facing data for improvement, innovation and clinical decision-making, or time to review practice as routine.
  3. The only way to collaborate is to cede individual (organisations) territory and individual (leaders) power.

The tensions between performance management and innovation

The literature from high-performing health systems tells us that the process of data generation and measurement, and associated knowledge generation is different for performance measurement than it is for innovation. High performing health systems invest in, and give significant attention to measurement for improvement and innovation.

 

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This widely cited model from Berwick et al (2003) demonstrated the difference between measurement for selection (in the diagram measurement for judgement and choice) – a top down, performance management approach; and measurement for Innovation and change – a bottom up, granular level improvement and professional review approach.

In the UK this dynamic becomes translated into a model of the management of risk with the tension being between safety / assurance and innovation, through a management lens. There is less discussion of the nature of professionalism in health and social care to achieve quality (and efficiency). In high performing health systems, professionals lead innovation. Improvement, scrutiny, review are all actions of professional practice, which secures improvement in quality.

A recent ipso Mori poll for the Future-Focused Finance Initiative, of finance and clinical staff in the UK, cited 24% of respondents were able to take time to reflect on how they were doing as a team. Recently Peter Lees (2016)[1] identified that in his view “Reluctance by doctors to engage in management and leadership at other than the clinical team level is prevalent”(p5). An example of a symptom of the balance of attention in the UK between the power of performance management for change versus the power of innovation and improvement for change is evident in the work of data analysts and scientists. In Intermountain healthcare, data underpins all clinically facing decisions as well as managerial decisions. Every clinical directorate team is supported by data scientists, providing granular data for clinical review and decision making. In the UK our data capacity is clearly focused on performance management data generated by analysts, not data to support great decisions between professionals and citizens supported by scientists.

Ceding power and territory

Health and social care struggles between the need for local solutions and locality based provision and delivering a national service. It is an age-old dilemma but in the context of innovation it comes into sharp relief. The devolution agenda hints at more localism and self-determination, but the structural and governance models emerging feel more like a centralist response. Devolution should mean thriving local economies with real citizen involvement (NEF 2016). In fact in high performing health systems – localism (local population based needs approaches) are at their heart from Nuka to Burtzoog to Jönköping.

A recent paper on integration (Hussein and Dornhost 2016)[2] for the Royal College of Physicians Future Hospital Programme explores the early work on population based integration bringing hospitals into the population model, requiring local collaborative networks, and the challenges for medicine. The Accountable Care Systems, Alliance Contracting, Sustainability and Transformation Plans, Vanguards Academic Health Science Networks and Collaboratives all emerging across the health and social care system, demonstrate a move to networked organisations and delivery models. This is a global trend with many organisations have both hierarchical working and agile network working (Shuman and Twombly 2009) [3] .Moreover interviews with CEOs in the UK (Leadership Indaba report) shows that there is a real struggle in one of the key factors required in leading networks, and critical from the evidence from high-performing health systems (Baker & Denis 2011[4]) –ceding territory and power. At the launch of the Collaboration Toolkit, the tension between finance being Finance Director’s responsibility and gift, rather than it being a collective Board responsibility was palpable, alongside concerns that innovation was ‘soft’ and performance management ‘trustworthy’.  Working out how hierarchical models of individual and organisational authority, can move to collective responsibility, and collaboration, is hard;  doing it in the context of a politically charged service and a range of ideologies about ‘localism’ is a challenge.

The cultural conditions for innovation

The context describe points to a number of cultural causalities that shape the innovation landscape:

  1. The reluctance to move from a performance management model of securing change to an innovation model
  2. The impact of policy, and the internal dynamics of the (clinical) professions in terms of the nature of professional leadership and practice in the UK
  3. The move to more agile networks as organising forms
  4. The need to cede power to secure population-based locally driven innovation.

[1] Lees P 2016. Clinical Leadership- are clinicians up for it. Clinical Medicine. Journal of the Royal College of Physicians. February 1, vol. 16 no. 1 5-6

[2] Hussein S, Dornhorst A (2016) Integrated care – taking specialist medical care beyond the hospital walls. A report to the Royal Collage of Physicians Future Hospital Programme. Royal College of Physicians, London, February

[3] Shuman J & Twombley J, 2009, “Collaborative Networks are the Organisation. An Innovation in Organization Design and Management.” CollaborativeBusiness (July): pp 2-24. Volume 8 in White Paper Series. Newton MA: The Rhythm of Business

[4] Baker GR, Denis JL. 2011 A Comparative Study of Three Transformative Healthcare Systems: Lessons for Canada. Canadian Health Services Research Foundation

 

 

The Old World Bites Back

New Leadership for Accountable Systems

It’s not that long until 2020 when we should have social and health care ‘all in’. The new system-wide models of commissioning, delivering and coproducing won’t be borne from project management, board room tables, and a day of workshoped future gazing.

Who needs to change?

A lot of effort is focused quite rightly on changing the frontline; the patients journey/ pathway. In my experience those folk are raring to go, they are suitably frustrated with the status quo, wanting to use their professional expertise, willing to learn, confused about the boundaries created in our health and social care system, and mystified about how to work in partnership with citizens. They want the system to work better, as both patients and professionals benefit. I was looking at the East London Foundation Trust and they have 150 QI projects running across the Trust or the wealth of emerging coproduction work such as PRESENT and Altogether Better

In terms of necessary conditions, we mostly have a hungry group of professionals, given the right attention, support, and data.

Creating the necessary conditions is the job of the systems leaders. There is intelligence on how Systems Leaders can enable innovation to emerge, this quote comes from the Leadership Indaba we ran at Leeds

“The intelligence is always in the system. People are out there with the answers. Our experience shows that once you bring a more diverse membership into the conversation, the solutions emerge that are a) owned by the system, and b) make the best of the assets in the system. This means CEOs move from an expert role into a ‘leader’ role, enabling intelligence to emerge and be acted on, rather than owning the intelligence themselves. It requires confidence in local ideas and humility.” Leadership indaba

What we know from the intelligence from high performing systems, and from our tacit knowledge of ‘what works’ is that what’s needed for fast change at scale is systems leaders who:

  • can really grasp what the future could look like,
  • are willing to give up territory and work hard at working together,
  • are prepared to do the work of generating a shared view not just of ‘what’ to change but ‘how’ to change it,
  • can stay focused, and
  • who are prepared to do the graft and sheer tedium of sorting out the systems issues that are their responsibility.

The challenge is that our systems leaders need to work hard on issues that have been around for years, and be creative in the areas where they have to cede power (to citizens or to partners). It’s not always an attractive proposition. It feels safer being the ‘lever puller’, the puppet master, the architect of change, but this is a both distraction and a waste of energy and resources. Talking with CEOs I found that whilst there is a real will to lead systems change, there is also concern about ‘the old world’ biting back – their experience borne from many years of talk of localism followed by the behaviour of centralism.

“We need a space where its OK to try some of this out. Its hard to be brave together in a system, we drift to what we know.” CEO

The old world biting back can be seen in the conflicts emerging from the Sustainability and Transformation Planning process, a process that requires collective leadership and community engagement, alongside clear national proprieties (46 deliverables), and coherence across integrated planning for finance, and workforce. The process requires a real bottom up locality to patch understanding, and a networked approach to leadership, change and governance. But the threat remains of top down intervention if it doesn’t all work out fat enough, and if the governance (and this looks like old style performance management practice) doesn’t look robust.

This challenge of balancing where you need performance management processes and where you need emergent innovation is the real job of systems leaders. Knowing this (together) and then creating (together) the appropriate conditions depending on the task is a sophisticated job.

All their instincts will be to hold onto hierarchical power in the face of this uncertainty, when the future calls for ceding of power to a new accountable care system. It’s a lot to negotiate.

Culture v Strategy

As we have often heard ‘Culture eats Strategy for Breakfast’ and it’s the culture of leadership that needs to change.

What process for what work?

I was talking to a GP recently who had been to yet another workshop trying yet another technique for working out how to work together. This is telling in terms of ‘system readiness’ i.e the organisational development capacity in the system. The trying out of innovative new workshop processes, without clear evidence that these work, is a stab in the dark – all be it well intentioned, with the unintended consequences of dissipating the hunger of frontline professionals for improvement and innovation. Systems leader need a really clear view about

  • How you form local self-determined teams
  • How you bring commissioning and provision together to design effective services and improve population health
  • What process of change works for what problems.

Innovation comes from frustration with the status quo, it then requires deep time understanding all the perspectives of players in the system, followed by coproduced ideas for change, and a commitment process where all players and partners really only commit to those solutions that they have the stomach and the energy for. Once commitment is clear, then the next stage is prototyping and learning fast. Its frenetic, and it feels out of control to the top as testing and adapting takes place with only minimal recourse to the ‘tops’ where permission is needed. At least the first phases of getting ready for change are well described in Theory U (Otto Sharmur)

Generating a consistent and coherent approach to change is key for systems leaders. Without it they run the risk of the peril of their anxiety at times of pressure leading to a tendency to revert to hierarchy. When uncertain the fear of not knowing what’s going on pulls system leaders into unwarranted control, and this in turn slows down the system’s ability to adapt. Another risk is that in the absence of clear models of change held by all, the latest ‘fad’ of OD gets a grip creating waves of ineffectual interventions. Asking frontline professionals to work hard on a real issue for citizens, but then pulling them out for multiple other ‘new’ ideas means no one is really focused on change, but are like hamsters in a wheel creating the sense of movement without going anywhere.

Beyond hierarchy

On the whole those who are over 40 (i.e. most of these system leaders) have earned their stripes in a hierarchical competitive system; this new world requires new skills and ways of learning. Bringing in the future leaders now would be a real help. The ‘usual suspects’ will be pulled back to doing what they know how to do, this new world of health and social care needs new models of leadership, with new energy and eyes. It is not going to be possible for current leaders to do all the new and manage the old – something has to give. If system leaders are struggling to even have the conversation about which of them is fit for purpose for this new world (who should lead the ACO), then the whole endeavour is lost.

In the world of the intent of the STP and what we know about emergent systems, Systems Leaders are less directors and more conductors, creating the conditions and direction of travel and then nurturing talent, and being steady about focus and effort. They are backed up by the performance system required for those issues that are amenable to linear management, and governed by a networked approach that bring diverse views into the process for accountability. More on this to follow in my next blog.

Mature leadership

There are some great lessons from high performing health systems that we repeatedly struggle to translate. Our system-leaders need a collective conversation about what it really takes to do this work; how to be mature leaders in collaboration. High performing health systems have a real understanding of their partners and employ mature processes to their collective decision-making, with a focus on feedback and review of their performance as leaders (Developing System Wide Shared Accountability, Becky Malby 2013)

“You have to move slowly to build relationships. It involves meetings with fewer items on the agenda, but it gets you further in the long-run. We often delude ourselves in the NHS, when we feel like we’re moving at a great pace, about what we’re actually achieving.” (Leadership Indaba)

They have to be sited on population health, data driven coproduced patient journeys, collective cost reduction, system accountability, and a real focus on the few issues they are committing to change.

Real Focus

The future means steadiness in priorities and radical prototyping of solutions. This isn’t always attractive to systems leaders, as the ‘fun’ part of creating new solutions rests in a collaboration with the frontline; rather than being the hero with ‘the answer’. It means bringing in diverse views that might challenge you, and it means letting go of the myth you are the expert. In fact the ‘top’ job is to be pretty invisible using your attention to create light around those who are doing amazing work – i.e. in system terms paying attention to what you want more of.

What we know from high performing health systems is that they are clear and rigorous about which health issues they are going to really work on together, and they pick only the number they can actually do, and then they ruthlessly focus on them. This is not a priority setting process done remotely by looking just at health need; it is a coproduced process of going beyond the ‘what’ to the ‘how’. It means using data to find what the real issues are (not the ones you think could be the problem), where there is the most gain to be made, where there are willing and able clinical people and citizens who want to make a change and then choosing a few to really go after together. Intermountain Healthcare started by choosing 6 per annum.

The system leaders job is to then make sure that all the other issues don’t get in the way of getting these few things really right, and using the lessons learnt and the difficulties they throw up to create the conditions to make it easier for all. That means systems leaders have to learn alongside the frontline, in relation to what they need to do to ‘unblock’ issues that are stuck. What does working on one area of care mean for

  • General practice as a whole?
  • How we commission?
  • How specialists and generalists work together?
  • Workforce planning?

How can systems leaders make it easier for professionals and citiziens together to generate better user journeys? Being in service to that question together will throw up real issues of power, data, partnership, effectiveness.

How to Lead in Accountable Systems

The Accountable care systems require clarity in:

  • What the focus is going to be –with commitment to solve the system-wide issues that get in the way of effective quality care.
  • Follow-through. As patient journeys come under review they throw up systemic issues, and they need tenacious attention to solve them. Leaders getting distracted by another new initiative, approach, scheme doesn’t help.
  • How accountability works – how is leadership exercised, how are disputes resolved. As the going gets tough leaders from the ‘parts’ the CCGs/providers will get fed up and go back to enjoying leading their part without worrying about the knock-on effects. How does the accountability get held at system-level so there is no going back?
  • Prototyping – how are new ideas challenged in terms of ensuring they deal with cause not symptom, and are evidence-based; and then what process supports prototyping so you can fail fast and learn? This is a new approach for the public sector – not one it has been comfortable with. Again it needs focus, attention and follow-through.
  • Expectation – reality checked real clarity from the leadership community on what is expected in terms of outcomes, behaviours; and modelled by the leadership community itself.

Evidence from high –performing health systems (from Denis et al and my own visits/learning), shows that in order to lead at systems level health and social care needs to:

  • Invest in data capacity so that all decisions are informed by data
  • Spend time with communities to coproduce the solutions
  • Connect provision to population health
  • Have a clear shared purpose and narrative
  • Distribute leadership so power is shared and decisions are taken at the point they are needed
  • Prototype new ideas, dropping the ones that don’t work and finessing the ones that can be successful, through rigorous testing and evaluation
  • Help patients and citizens be savvy about their own care, teaching them how to use their own data
  • Work on the collective leadership so any cracks between organisational partners are ironed out at the leadership level early

There are some real lessons for systems leaders if they are willing to see them. The easy job is to unleash the potential of citizens and front line staff. The difficult job is creating the conditions for that potential to generate real change and then keeping out the way. Bringing in new (younger) voices will help, alongside clarity of what change process works for what work.

Note: The Leadership Indaba was a peer learning group of experienced leaders, exploring systems change in the UK and South Africa.