Systems Innovation – disruption or adaptation

Demand/need is increasing. Austerity is taking its toll, adding to the pressure of the predicted impact of demographics and co-morbidities. GPs are stretched to the limit (one GP told me she had consulted to 80 people in one day). But this isn’t the case everywhere, some services are adapting.

We can wait for disruptive innovation from pharma or technology (be it online GP services, to no end of maps and apps to support dementia) to radically change behaviour, and there are champions of this approach who think it is the only game in town to really radically transform the NHS, who think we can’t wait for adaptive social change. I don’t agree, its not the only innovation that can generate significant shifts. There are examples (not many as yet, but they are running against the grain) of social innovation in primary care and communities that is stemming the flow from communities to A&E, and increasing reach without increasing costs. These result from a new relationship between public and third sectors and communities; and adaptation based on inquiry into better ways of working, using data.

Just to be clear as we see another drop in the % of DH funding going to primary care[1], there are two gatekeepers to NHS services – GPs and A&E. This has to be a significant focus of attention for any systems change efforts.

The biggest problem is that the NHS is playing catch-up and has needed for some time to focus on (alongside the disruptive innovations) a few key interventions that will change the way local health is organised and delivered. These are:

1. Data availability to support innovation (not for performance that’s different), and a culture of curiosity and peer review
2. Asset based community development and coproduction – de-professionalising neighbourliness, de-medicalising wellbeing.
3. Diversify the professional workforce based on need.
4. Learn from others – steal with pride.

Most social innovation is incremental requiring curiosity, inquiry, testing, adaptation and contextualisation. This means that social innovation will take time, and the clock is ticking. Starting can’t want any longer.

Its fascinating the amount of reports and evaluations into NHS social innovation that cites the same lessons over and over again, and which are repeatedly ignored, as the dominant hierarchical culture of public service, wedded too and shored up by the ‘steady as she goes’ approach, is challenged by the adaptive challenge of networked collaborations.

Here are two types of evidence – evidence-based stories of those local health systems that are making it work; and evidence from the evaluations of attempts to innovate at systems level.

Lets start with a story

Evidence: A Story of Reimagining General Practice

In our recent Health Systems Innovation Lab visit to Leeds, we visited Robin Lane Health and Wellbeing where a GP practice, catalysed by a partner hungry for a better way, has developed a model that:

1. Generated masses of community asset – with the partners investing in a Health and Wellbeing Centre, which as a charity runs over 67 new or extended health, social and voluntary service and volunteer run programmes, with 19 groups run by over 50 volunteer champions every week.
2. Recognised the need in care homes for one GP, and cut admissions dramatically with an 80% reduction in urgent care visits; 25% reduction in hospital admissions.
3. Understood that increasing access reduced demand, and opened its doors through both booked appointments and walk-in and has reduced overall appointment demand by 26.5% (before adjustment for 20% list size increase over the same time),
4. Reviewed their caseload and diversified their team accordingly, with an appointment model where professionals on duty review the patients needs (as identified by the patient when they check-in) and call off the next patient in the queue that they are competent to handle.

And in doing so has grown its list size from 8000, to 13332

This shows us what’s possible. It tells us that there are very few interventions required as described above, but they require a changed mindset to bring together citizens as equal partners, to professionally review of clinical and management practice based on data, and to test and adapt continually.

So what happens when health systems across primary and secondary care try to innovate? What happens at scale?

Evidence: A Review of Integrated Care

For years the NHS and Social Care system has been grappling with Integrated Care, and it remains an ambition for many health systems. Reviewing 5 evaluations of Integrated Care programmes revealed that it helps if:

• There is a history of collaboration – where the partnering organisations have been trying to work together for some time.
• Citizens are part of the diagnosis of the problems and determining the solutions from the start.
• There is dedicated time to learning together.
• The systems leaders don’t get distracted onto other projects or issues, but generate focus and attention and consistency for the duration.
• There is some start-up funding to generate head-space.

What consistently got in the way was:

• The difficult in data sharing.
• Lack of clear processes for decision making across the partners.
• Setting expectations too high, generating disappointment when these weren’t achieved.
• Lack of ownership across all partners and at all levels.
• The lack of experience in and attention to securing citizen partnerships.
• The vacancy of support from the centre to unblocking issues that cannot be resolved at systems level.

And what continues to be problematic is:

• The lack of ongoing evaluation to capture the impact over time (these innovations take 5 years).

Across them all it appeared that:

1. Evidence didn’t seem to count – it wasn’t part of the service development, and so there wasn’t a strong enough commitment to an evidence-based analysis of the real issues and the impact of any changes. It was unclear how the integration sites reviewed had learnt from others (including form the evaluations of other integration sites)
2. We are behind across the NHS on data – the availability and quality of data for innovation and improvement, and the shear ability to share data.
3. Citizen participation doesn’t just happen it needs planning and mindsets need addressing. We cant wait for professionals to decide if they can, or should involve citizens – its as basic condition.
4. Improvements are not likely to be found in the short term, it takes time.

At minimum the NHS needs to address:

1. The issues of data quality, analysis, accessibility and sharing across the system
2. The GP ‘business’ model – bringing improvement, coproduction and emergent change practices into the reshaping of primary, community, social and third sectors to a health and wellbeing service that complements and supports local community capacity
3. The role of specialist expertise in a ‘home-based’ model.
4. System-wide development of community assets
5. The ‘top’ in real service to the frontline

You can see more on our Lab visit to Leeds here

[1] that’s not so say actual money decreased its just GP spend grew 1.5 per cent – while overall spend grew by 3.4 per cent – HSJ 21st July

Doing Systems Leadership

“Leadership is becoming increasingly complex with a growing need to deal confidently with volatility, uncertainty, chaos and ambiguity” (Ghate et al 2013 p 4)

Understanding Systems Leadership

Systems leadership is fraught with the problems of multiple use. The term is frequently used to cover widely different and contradictory concepts (Ghate et at 2013), and different bodies of experience and knowledge have different perspectives on both the what and the how of systems change (Abercrombie et al 2015). Primarily the NHS means leaders of health and social care places when referring to systems leaders (in terms of position).

Systems are interconnected parts with a common purpose, or in Peter Senge’s (2001) words “A system is a perceived whole whose elements ‘hang together’ because they continually affect each other over time and operate towards a common purpose”. Systems have boundaries, usually geographical, and related to their core purpose. You can have a system that is intent on improving the lives of frail elderly in Ealing, and that comprises those elderly people, their carers, the third and public sectors looking after them (and all their parts), their neighbours….. Or a system can be a health and social care system charged with the health and wellbeing or a population. Or it can be a GP Federation, or a network – it depends on the system purpose.

These systems surface complex as well as complicated issues, which require peer based adaptive leadership, where leaders create the conditions in which those working in a system can make progress (Heifitz 1994). The capabilities of systems leaders in this context are summarised by Senge et al. (2015) as:

1. Ability to work at the level of and see the nature of the whole system
2. Ability to see issues through the eyes of diverse players in the system, which encourages openness in others
3. Listening in order to build trust and collaboration
4. Able to work with an emergent approach, freeing others to learn
5. Balances longer term value creation with short term reaction, co-creating the future with and through all the ‘parts’

“Systems Leadership describes the way people need to behave when they face large, complex and seemingly intractable problems; where they need to juggle multiple uncertainties; where no one person or organisation can find the solution on their own; where everyone is grappling with how to make resources meet growing demand; and where the way forward lies in involving as many people’s energies, ideas, talents and expertise as possible.” Leadership Centre (2015, p2)

System leaders have a critical role in clarifying purpose and providing clear expectation, enabling system players to make sense of the context in which they operate, leading decisions that are congruent with the purpose and values, questioning the underlying assumptions that govern the systems actions, sustaining processes that make the most of the system’s capacity to adapt, and bringing in diverse people and perspectives to find new possibilities for action (Malby and Fischer 2006)

However the NHS does have a tendency for the ‘old world’ to bite back, and to reframe language without reframing practice. As Ghate et al (2013) describes there is an innate attraction in the simplicity of a direct, linear and simple relationship between cause and affect for senior leaders.

Linear cause and effect models (the basis for most of our planning) assume that:

• The environment can be simplified enough to be modelled into a limited number of variables.
• The environment will stay constant such that the variables stay the same.
• The system will be predictable in how it reacts to these variables, no matter what the feedback loops are telling it, no matter what is going on internally.

(Faucheux and Makaridakis 1979)

This is the world of hierarchies that most leaders are comfortable with, and well versed in, but has little utility for most health and social care systems challenges – it is far from the norm (Abercrombie 2015).

Systems leadership requires leaders to let go of this desire to over simplify messy and complex issues and to work with the mess and emergence of non-deterministic change, and distance between cause and effect (Randle 2016). The NHS tends to revert to Systems Leadership as purely a peer based leadership effort over ‘simple’ or ‘complicated’ issues that require coordination; an essentially mechanistic, rather than adaptive approach to leadership (Malby and Fischer 2006).

Leading High Performing Health Systems

In a review of the literature of leadership of high-performing health systems and systemic improvement and innovation networks, Mervyn and Amoo (2014) found the that leadership of the collaborative was the most important variable in operating and sustaining the collaborative venture, and that key issues for systems leadership where the time needed for the participating organisations to learn and adapt to one another, the requirement for managers to relinquish aspects of their territory in service to a greater common purpose, the focus at an early stage in the collaboration on the plan for sustaining the capacities the collaboration creates, and enabling a professional culture of teamwork and working with the public as partners. These are the ‘conditions’ that foster successful systemic change.

Our Approach to Developing Systems Leadership

Our understanding and approach was first developed in the early 1990s at the Kings Fund Working Whole Systems programme, using complex adaptive systems theory (complexity science) as applied to social systems (Luhmann 1995). The most widely accepted and utilised texts in relation to this theory as applied to leaders cover the issues of ‘wicked problems’ (Grint 2010), Adaptive Leadership (Heifetz 1994), Public Value (Moore 1997), Emergence (Scharmer and Kaufer 2013). Using these theories alongside the proposition above in relation to the capabilities or system leaders, our focus is to generate an understanding, commitment and leadership practice in:

1. Generating value in systems – through clarity of purpose and congruent behaviours
2. Leading collectively as peers – and knowing the best mode of working for the range of systems leadership challenges through the spectrum of tame to wicked.
3. Securing the relational conditions of openness, embracing diversity, evidence-based decision-making, questioning underlying assumptions, learning and distributed leadership.
4. Developing adaptive capability through systemic feedback, sense-making and creating the system-wide conditions for emergence.

 

You can find out more about our Health Systems Innovation Lab here 

References

Rob Abercrombie, Ellen Harries and Rachel Wharton (2015) Systems Change. A guide to what it is and how to do it. NPC

Faucheux C & Makridakis S. (1979). Automation or Autonomy in Organizational Design. International Journal General Systems. Vol 5, pp. 213 – 220.

Ghate, D., Lewis, J. and Welbourn D .(2013). Systems Leadership: Exceptional leadership for exceptional times. Synthesis Paper. Virtual Staff College, Nottingham.

Grint K. (2010) Wicked problems and clumsy solutions : the role of leadership , pp 169-186 in Brookes, S. and Grint, K. (2010),  The new public leadership challenge, Palgrave Macmillan, Houndmills, Basingstoke

Heifetz, R. (1994) Leadership Without Easy Answers, Harvard University Press, Cambridge, Mass.

Leadership Centre (2015) The Revolution will be Improvised Part 11. Insights from places on transforming systems. A report by the Leadership Centre for the Systems Leadership Steering Group.

Knowles, M. (1984) Andragogy in action: Applying modern principles of adult learning (the Jossey-Bass higher education series). Jossey-Bass Inc.,U.S.

Luhmann, Niklas. (1995) Social Systems. Stanford University Press, Stanford.

Malby, B. and Fischer, M. (2006). Tools for change: An invitation to dance, Kingsham Press.

Mervyn K. and Amoo N. (2014). Brief Literature Review on Improvement at Systems Level. Leeds Institute for Quality Healthcare.

Moore, M. (1997) Creating public value: Strategic management in government. Harvard University Press.

Randle A. (2016). Systems Change in Public Services. A discussion paper. Collaborate.

Senge, P., Hamilton, H. and Kania, J. (2015). The Dawn of System Leadership , Stanford Social Innovation Review, Stanford University, Stanford.

Scharmer, O. and Kaufer, K. (2013). Leading from the Emerging Future: From ego-system to eco-system economies. Berrett-Koehler Publishers.