3. The Next Generation NHS

WhatweheardThis is the final chapter of a series of three blogs that relate to the Next Generation NHS. They cover:

  1. Systems Change with Data
  2. Innovation is all around us
  3. 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:

  • Equality
  • 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
Coproduction Consumerism

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:

problems

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:

  1. Young professionals – the Generation Y and Z
  2. 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.

Generating Spread

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.

2. The Next Generation NHS

next generation small

This is a series of three blogs that relate to the Next Generation NHS. They cover:

  1. Systems Change with Data
  2. Innovation is all around us
  3. Spread- what gets in the way and what works

The slides for the whole of this series are attached. Prof Malby Inaugural FIN

2. Innovation is All Around Us

Often, innovation is an improvement on an invention, not the invention itself. It’s adaptable, adjustable, and applicable to new challenges. The Rockefeller Foundation (Rodin 2013) (1)

“The Future is here its just not evenly distributed” (2)

There is Innovation all around us that answer many of the dilemmas of the future NHS. These are the challenges of innovation in any place:

  1. Knowing what’s really going on round here (in this place) – in order to be open to innovations that would work here (see my last blog)
  2. Finding others who have already found an innovation that works in the area you need
  3. Learning how they did it (not what they did) and being open to hearing what it took to do it
  4. Working out how to translate it back to your situation, place, teams

Lets look at some examples of these innovations. These are a small set that are relevant everywhere.

Intergenerational Learning Centre

Seattle

Firstly some simple innovations – that don’t challenge power bases or structures – they are complicated not complex to put into action. Here is an example from Seattle of an older people’s care home which also provides a nursery.

“Moment before the kids came in, sometimes the people seemed half alive, sometimes asleep. It was a depressing scene. As soon as the kids walked in for art or music or making sandwiches for the homeless, or whatever the project that day was, the residents came alive.” Evan Briggs, film maker

Bolton NHS FT

This example is of turnaround from an unexpected deficit of £14.4m (2012/13) to a surplus in 2015/16 alongside a positive staff survey and achieving quality markers.

In the first year of activity to secure a viable position Bolton NHS FT made £18.3m in income and cost improvements (6.4% of income), last year it was £21.2m (7.3%), and this year £15.3(5.3%)

They did this by:

 

The Principles

 

What it looks like in practice
Finance in service to patients

 

Entirely devolved budgets to directorates, with finance as a support function not a decision-making function. For example if Mark needs money for workforce development he has to negotiate it with the directorates.
Sort the basics Be clear on the policies and practices with good tracking of the known financial processes that ensure good financial management.
Teach the basics Ensure everyone has the skills needed (HFMA free online course for all budget holders)
(Near) Real time financial data

 

Working Day One reporting so directorates can make good decisions. It also brings a pace to the change work.
Clear expectations and accountability Directorates present their budgets signed off by their team with forecasts for each quarter, and receive clear feedback in terms of how that meets identified expectations from the Trust executive, and any requirements (escalation) for remedy.
Clinicians and Managers together Developing clinicians as budget holders with the skills for the job (HFMA training).
Know the business and be Consistent

·      Show what good looks like

·      How to do it

·      Hold to account rigorously

The executives buddy with wards. When one ward presented a fixed view about pressure sores, Simon and the Nurse Dir collaborated to help the ward see what was possible, and they are now proud of the lack of incidents.
Scrutinise your practice Getting in external auditors to review their budgets.

Rochdale Intermediate Care

In Rochedale they are making strides in keeping people at home so they don’t end up in care homes in the first place. The Intermediate care unit, community rehab unit and the urgent care community team (rapid response or crisis team) are led jointly on daily basis by GPs, lead nurses and overall support from the consultant clinical director. Prior to September last year the units were run by local authority and the urgent care team by Pennine care. They have generated 10-15% reduction in acute hospital admissions in the frail, and circa 20% reduction in nursing home placements. It seems by pro actively engaging they are seeing a spike in people staying at home.

Altogether Better

Now lets step into more relational and asset based innovation– moving beyond what a health & social care service can do. Altogether Better Practice Champions are in over 60 GP Practices, in 16 CCG areas, involving over 1000 citizens who gift their time as champions and have the ability to touch the lives of half a million people.

At Robin Lane Health And Wellbeing  Centre “We have increased our patient list by 4,500 people and seen no increase in demand for either primary of secondary care consultations because we do things differently” Mev Forbes, Managing Partner. It is an approach offering a new model of care for the NHS. The Centre has this approach

  • where we learn ways to work together with people, not do things to them or for them
  • where people in communities work alongside staff, becoming part of the Practice ‘family’ and unhelpful and outdated hierarchies break down
  • where there is a reduction in the pressures on staff in General Practice and staff morale improves
  • where patients get what they need and not only what professionals can offer

Action for Gipton Elderly

Some innovation is just in the realms of common sense. Karen Woloszczak who runs AGE has changed the way her small team works by moving from ‘doing’ to asset based community development asking:

  • What can citizens do for themselves?
  • What can citizens do with a little help?
  • What do citizens need done that they cant do?

She says they have trebled their work in a year but haven’t trebled the staff – providing small resources to help people get together e.g. for community TLC, or to take someone shopping. She says no one wants help forever or wants it needs assessed, and they don’t want a nosy neighbour, if they need help they want to buy it themselves. People want to be involved, Karen says this has lead to older people reading in schools, TV clubs, outings. Their ‘meetings’ are in the pub. In Karen’s view there is nothing worse than saying ‘you know what I’m really lonely’ and then qualifying for a befriender, because you’ve got no friends. “We don’t have befriending its patronising – we just help each other as a community” through community connectors not volunteers. “We have less staff but we do much more”. “You have to change your attitude – from provision and need, to generosity and sharing”

 

Coproducing Leeds

Coproducing Leeds

Here is an approach that really challenged the existing power of leaders and public servants and radically changed the way drug and alcohol service were commissioned in Leeds, generating a host of peer mentors and a collaboration across the City. Coproducing Leeds worked with 200 people (100+ service users/citizens, and 90+ service providers) for 1 day to understand the problems together, followed by groups going on learning journeys to discover the opportunities in how others were improving lives of people with drug and alcohol dependency, and then locality based commissioning events.

Buurtzorg

Here is an example of complex change – where leaders cede power and act in service to citizens and their frontline members, where care is personalised and where there is real professional accountability. Buurtzorg is the Netherlands fastest growing model of integrated care. It was developed against a backdrop of fragmentation, shortage of nurses, declining health, elderly multi-pathology, dementia, chronic disease. Buurtzorg’s answer to this problem was to set up place-based neighbourhood teams and to trust professionals providing them with data and a peer supervision/ learning network. The professional teams have delegated budgets for services and for their education. In 2011, Buurtzorg employed nearly 4,000 district nurses and nurse assistants across 380 teams. By 2013 this had risen to 6,500 nurses (an increase of 62.5 per cent) across 580 teams. Today, Buurtzorg’s workforce cares for over 70,000 patients and, according to Jos de Blok the MD, some 50 per cent of these have some form of dementia. The results have been a decrease in unplanned care; high pt satisfaction; 40% lower home care costs than other providers; 50% reduction in hours of care (move to self-care); overheads at 8%; lower staff sickness rate 3%; and a profit of 8%. They did it through learning networks; technology to support innovation and best practice; peer review; self-managed teams and minimising management.

BromleyBy Bow Centre

Now I’m stepping up to a new relationship between citizens and whole services, where services are ‘in service’ to wider community needs, where the whole person matters. For 30 years BBBC has worked as a Healthy Living Centre and GP practice with the community focusing ‘upstream’ to improve health, developing peoples skills, supporting social enterprises, helping people find jobs, enabling friendships and community.

“I urge you to take your colleagues down to the Bromley By Bow Centre and let them see what has emerged from nothing. Its one of the most impressive displays of social entrepreneurship anywhere in Europe” Lord Brian Mahwinney

Being ready for Innovation

So what happens? – there is all this good stuff but its not everywhere – why is that? Many teams and leaders visit innovators such as Bromley by Bow and Buurtzorg, but few translate it into their own workplace. In my last blog I argued that often teams/places/ systems just aren’t ready or don’t have a common shared understanding of the imperative for change or the areas that need change. But lets say these visitors have done that ground work – what is then needed to create a readiness to translate these new ideas into local practice?

I asked the live audience at this talk to think about the innovations above and decide which of the following had been the most instrumental in helping those innovations happen. This is what they thought:

Innovation happen

What we know in terms of generating a readiness to change and a culture of innovation is that innovating systems:

  • Get out more to discover (get information)
  • Know their own system (using data)
  • Are open to learn (relationships)
  • Work with the assets of their communities  and professionals– really engage (relationships)
  • Are not threatened by diversity but see it as strength (Identity)
  • Are adaptive and emergent

They also work through Hierarchies and Networks. Across all sectors organisations are having to move to a network way of organising – working along with partners and allies. This requires openness, learning, adaptability. The old world order of power at the top is receding.

Screen Shot 2016-05-01 at 16.32.15

Leading the Next Generation NHS

The next generation NHS needs 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
  • Find opportunities in opening up decision-making to diverse views
  • Can stay focused, and
  • Are prepared to do the graft and sheer tedium of sorting out the systems issues that are their responsibility.

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.”

Next Generation NHS needs leaders who can

  • Discover what others have done – look for evidence, go see what works elsewhere, seek inspiration
  • Be honest about what we (the system) has energy for and can commit to – what members are inspired to do together
  • Coproduce and prototype solutions, iterate or let go.
  • Test and Review

So far

In this blog I have covered:

  • The future is already here its just not evenly distributed – go find them and translate
  • You have to be frustrated about the status quo and passionate for change
  • You can only do it together moving from provision and need, to generosity and sharing
  • Change will come through Networks
  • Diversity is a condition of success
  • You need to test out and iterate solutions

(1) Rodin J. 2013. Innovation for the Next 100 Years. Stanford Social Innovation Review. 

(2) William Gibson 2003. The Economist, December 4.