This is the final chapter of a series of three blogs that relate to the Next Generation NHS. They cover:
- Systems Change with Data
- Innovation is all around us
- Spread- what gets in the way and what works
The slides for the whole of this series are attached. Prof Malby Inaugural FIN
3. Spread- what gets in the way and what works
So far I have covered the importance of data now only to inform great decisions between clinicians and citizens, but also to get a real understanding of how your system works, and where you need to focus your effort. Data will move you from assumptions and prejudices about whats wrong, and what to do, to an evidence-based review, which has the impact of creating frustration with the status quo to the extent that it generated openness to change.
The second blog then looked at the innovations that are all around us and what it takes to generate an innovation culture. In this blog I’ll share my views about what gets inthe way of innovation and what needs to happen now.
What gets in the Way
1. The Old World Bites Back & Culture Eats Strategy for Breakfast
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. In fact systems identity means that of course every organisation seeks to preserve itself and any change is a change in identity which is hard won. Changing identity from organisation to system means leaders ceding power and doing the difficult stuff.
What makes the old world attractive? Well in the model of NHS we know its become normal to:
- Pretend the issue is simple and will respond ot performance management without any change in relationship
- Be heroic, to fix a problem without having to fix the underlying issues that caused the problem in the first place
- Be cterative at the top – taking all the space for imagination as if the tops job is to come up with the new ideas, rather than faclitating a system to find the best solution together.
- Avoid conflict and disagreement when we know diversity is where better solutions will be found
- Protect the identity we know – its out NHS as we know it
And anyway …its hard to imagine how to do it any other way
2. Over-reliance on performance management
In my blog on Professionalism v managerialism I proposed the problem of the NHS over relying on performance management as the dominant approach to change unlike high performing health systems where it takes up closer to 20% of resources and time, and where improvement and innovation methods are the focus of 80% of the organisations effort, data and attention.
3. Loss of Public Sector Values
The role of the public sector is in part of demonstrating/ safeguard and model the values we have as a society. Two values that I think have been undermines and critically eroded in recent years are those of:
- Caring for vulnerable people
I am told we have 300,000 nurses on the register not working. They aren’t working because the NHS doesn’t care for them, the work isn’t valued. In social care zero hours contracts for people caring for very vulnerable people with complex needs, where travel between visits isn’t paid for, demonstrate how caring doesn’t matter. If we don’t care for our carers, who do difficult work, and enable them to have a decent life where they can predict their monthly income, get mortgages and be responsible citizens, how can we expect them to respect and care for others?
A new Junior doctors contract that affects women unequally from men in the 20th century is shocking. When the review says that “Any adverse effect on women is a proportionate means of achieving a legitimate end.” we should be shocked. Until now, female doctors’ salaries have kept pace with men’s because small annual pay awards prevent part-time doctors, of whom the vast majority are women, earning less than their full-time colleagues over time.
The contract will adversely affect carers, women who take maternity leave. Increased rostering in the evening and weekends might offset this where women have childcare from family support/ informal care or it could do the opposite if relaying on formal childcare which will be more expensive in those times. Whilst there is an increase in basic pay there is now a new disparity in progression.
4. Confused Ideology
Policy is confused. The underlying relationships between the state and communities and individuals isn’t clear. At one point we are encouraging devolution and community power, and the next awash with centralist instructions. Citizens are coproducers with equal responsibilities as partners with professionals, and at another time they are consumers – making individualistic choices with no recourse to the collective or any personal responsibility. The ideology is confused which leads to confused policy and management of the NHS.
|Devolution and Localism||Centralisation|
These are just two examples but there are plenty more. Critically the underlying beliefs and ideology to policy is often hidden.
5. No shared process for systems change
I see leaders coming up with in their view great ways to change the system. its not always evidence based or learning from other places where there really has been progress. Primarily though leaders are not always clear about what sort of change process to use for different types of problems. Put simply there are three types of problems the NHS needs to work on:
Leaders need to be clear what to use when. At what point you need hierarchical performance management (tame/ linear) – calling people to account; when you need improvement (tame/complicated) when you need coproduced emergent systems change (complex)
Its no good trying the same thing over and over again and expecting different results (wrongly attributed to Einstein). I would also add the same people (usual suspects) the same results…. which takes me onto the final issue in terms of what gets in the way
6. Ignoring Emerging Leaders
There are two types of emerging leaders struggling to be heard, who have a critical connection to the future NHS:
- Young professionals – the Generation Y and Z
- Citizens – of all ages and types
These are the missing voices in many systems change efforts, and they re critical to a new NHS emerging from the one we know. I’m going to concentrate on young professionals, as there is quite a lot written about citizens voice and the value of partnering. We know we are leaving them out and where citizens are involved as partners better care emerges (see blog 2 in the series).
Jones et al (2005) in ‘Mind the Gap’ describe young professionals from Generation Y and Z like this:
- Generation Y (Millennial) 1980-1994 – I expect support to achieve – I am career motivated but not company loyal – I need a great sense of purpose and contribute to the greater good
- Generation Z (Digital Native) 1995-2010– I am self-directed- Don’t force fit me into a traditional work environment – Personal Freedom is non negotiable.
This younger generation relates differently and learns differently. I was talking to a consultant this morning who said that younger GPs run things by her by email, the older ones still send letters. This is the tip of the iceberg. The digital natives learn online as peers, they are networked and used to being in networked systems. Whilst the old world tries to shoehorn them into hierarchies through schooling, they break out of that mode all the time. These young professionals will see the world differently, will relates differently, will create differently and will just get on in a way we cant anticipate. Back to the junior doctors – keeping the young professionals at arms length from decision-making both creates unrest and frustration, but also stops us hearing the ideas, and working with the solutions the new NHS will need.
We have to have both young professionals and citizens of every generation both in strategy, and in coproducing solutions. They are critical to the emerging NHS.
What is known about innovation spread
This is adapted from The Innovation Unit
- Evidence isn’t enough
- Pilots don’t ‘roll out’
- Innovation is not then followed by spread
- It’s not the case that more innovations we have the more likely they will spread
- Citizens AND Professionals innovate & spread together
So that puts most of the NHS work in innovation into the ‘doomed to fail’ category. What i have found from exerpience, listening to innovators and from the literature is that:
- You need to be frustrated enough with the status quo
- You have to have the capacity to adapt – connections to others and ability to learn together
- You have to diversify who is involved – bring in emerging leaders
- You have to give up power at the top
Health Systems Innovation Lab: The Next Generation
here at London South Bank University we are setting up a Social Lab thaenables place-based innovation for better health, through:
- Data supported understanding of what’s really going on in this system
- Generating a possible picture of the Future with emerging leaders
- Catalysing the conditions that enable the system to change
- Connecting the system to relevant innovators locally, nationally and internationally
- Enabling translation of these innovations into practice locally
- Prototyping and adopting new to here solutions
The Next Generation NHS will have these features:
- Data at the core of decision-making and understanding, perturbing the system to change
- Change will happen through rapid prototyping and spread through networked connections
- Services will be delivered through networks and collaboratives
- There will be less reliance on institutions as the organising factor, logistics will take place there but identity and change will be at a collaborative level
- Citizens will be active partners and leaders
- Our young professionals will take an active role in leading the way if we step to one side and let them
Without data enabled review of what’s really going on, that sparks a frustration with the here and now and a passion for change, that leads to collective decisions between citizens, professionals and politicians – that is inclusive of diverse views and particularly of our young leaders; and a commitment to rigorous methods in experimentation of works – the NHS will not adapt. If we view this with fear the NHS will crumble, if we view this with courage the next generation NHS will emerge and it will be different from how any of us can predict. Muddling through is not an option.
Jones K, Warren A, Davies A. 2005. Mind the Gap. Exploring the needs of early career nurses and midwives in the workplace. NHS Health Education England, May.