New Models of Care – Key Ingredients of Success

An Interview with Dame Jackie Daniel, Chief Executive of University Hospitals of Morecambe Bay NHS Foundation Trust

 

The Darzi Fellows from Kent Surrey and Sussex (KSS) recently interviewed people who were leading Vanguards nationally and locally, and went to visit a site. As I was listening I was struck by how difficult it was for the NHS to see the key ingredients to these models, primarily because the success is framed by the current lens of the NHS (the dominance of hierarchy), and partly because they were busy ‘getting on’.

We worked with the KSS Darzi Fellows and together generated this list of key ingredients for any new model of care:

I then ran these past Jackie Daniel Chief Executive of University hospitals of Morecambe Bay NHS Foundation Trust, a Vanguard that in my view has managed to do the very difficult work of truly collaborating across a whole system for better services and health. This is what she said about what it takes to collaborate to develop new solutions to intractable problems in new models of care.

Commitment to Act Together

There is no short cut to spending time together and making decisions together. The early meetings didn’t have agendas, just conversations for quite a long time. Bay Together spent a day together every fortnight talking about nothing but system work in the same building. This meant doing the business together, having meetings with clinicians on the clinical agenda, working through the money, doing big and small meetings including board meetings.

When asking acute sector teams to spend time working on primary care pathways, which were a significant investment of time, they had to hold onto the need to develop the collaboration.

She said you have to be connected but not controlled. Bay Together have appointed multiple system GP leads – ICC leads, a GP Director of Primary Care Development and a Lead for Population Health (to try and knot the threads together so that the system including the other providers can make some sense of the complexity).

They have taken time to create coalitions and networks that are agile and nimble.

Devolve to Local Teams

Originally they had 2 Federations, then they found that that didn’t work out as it wasn’t local enough. The issue isn’t structure it’s the relationships you need to do the work, so now they have 12 ICC leads as GPs.

They recognised that you mustn’t drown these teams in project management, and that solution won’t do it, you need multiple solutions. She said that they needed to have teams in discovery mode, so they definitely didn’t need to be threatened with performance management approaches. In her view they had to make the most of the diversity they had in our teams to generate the solutions.

Devolve as much of the money as you can to integrated care teams in localities. Ask these teams what configuration of spend would work better.

Work with the Public

You have to talk to the general public, and it can’t be superficial. It’s got to matter. This helps partners understand that this is commitment to a multigenerational investment strategy (an investment in health of the place).

Governance

You need your NEDs fully engaged all the way through, as you have to have agreement across all the Boards. You have to agree one budget across all the partners. The leaders need to talk about all the cultural issues and hold each other to account across a diverse group.

Don’t have contracts being delivered by organisations outside your area; you need all your contracts back into local teams.

What Generates Progress

• Mindset – having sufficient trust to delegate decision-making, and to suspend belief on normal activity.
• General practice needs to feel they have influence.
• The solutions are found a many levels in terms of scale or focus (investment/ strategic priority shift/ technology). You need the right listening from top.
• There is a level of detail at the front where they understand the consequences, and get overwhelmed by detail. You need data to help translate top to bottom and visa versa.
• It needs real commitment to the meaning of the work.
• Bend the rules, do whatever we can to work differently
• Illuminate the ‘how too’.

I was struck by the relentless commitment to focus on the meaning of their endeavor, which in turn frames all their effort to work collaboratively in service to the local population. This persistent focus on purpose, on innovation locally, on relationships to enable collaboration, on data to know what’s working, on devolving decisions to where the work is done, on working with the local population as partners, on keeping the tops and frontline connected, and on holding off the temptation to project manage the life out of people are the key ingredients to success.

05/03/2018

Rules of thumb of ‘modernised’ public services – our current rules are failing us

February 2018

Guest Blog by Diane Plamping with commentary by Becky Malby

NHS Rules of Thumb

We wrote an article in 1998 in which we suggested that stability in complex systems emerges from the rules that guide behaviour of agents within the system (Plamping 1998). These ideas arose from our work discovering what shapes behaviour in a ’self organising’ systems which can help us understand why many structural changes do not generate the hoped for changes. We suggested the rules or guides that kept the NHS the same in spite of many structural reforms and numerous attempts to reform the NHS. To be instantly useable they have to be short and pithy so the rules of thumb in service provision we posited were:

1. Can do should do
2. Doing means treatment
3. Treatment means cure
4. I am responsible

This approach to understanding systems is akin to Gramsci’s concept of ‘common sense’ (2011) as in ‘that which is held in common and is an expression of hegemonic ideology’. This is not the same as the English language version, which implies ‘good’ sense. It can be understood as the means by which everyday patterns of behaviour are generated by individual social actors rather than imposed by hierarchical controls (although these exist too). In this way of thinking, ideology does not operate through the conscious application of theory or analysis but rather through a series of so-called ‘rules of thumb’. This is a phrase derived from tradesmen making judgments about length without recourse to using a ruler. The phrase suggests practice is shaped, not by direct reference to underlying design principles, but through rules that can be applied in the moment whenever a decision is required. Similar processes of translation from theory into practice are identified in many fields such as social psychology. In Eric Berne’s there is the concept of ‘scripts’ these are the ways deeply embedded assumptions ‘show up’ in behaviour. E.g. ‘hurry up’ is the behavioural prompt to a deeply held but unspoken injunction ‘ don’t think’. Both behaviour rules and underlying assumptions are probably left unspoken – ‘Going without saying because it comes without saying’ [after Gramsci]

Interest in rules that can shape autonomous agents’ behaviour arises from their capacity to shape the outcomes in complex social systems, where decision-making is held in myriad places and by multiple actors. They can be described as the dominant set of cultural rules. There is much interest in the idea of organisational ‘culture’ in change management and organisational development practice. However much of this interest is applied to identifying typologies of organisational culture. Whilst these may be accurate descriptions of what can be observed in a system, they may not be useful in generating change. An alternative approach might be to identify what guiding principles operate in the ‘sub-cultures’ that are always present and where appropriate find ways to for autonomous agents to amplify these and therefore generate new patterns of behaviour a the system. We called this Whole System Working.

The Current Rules of Thumb

In the decades since we posited the original rules they may have been evolving. Reference to ‘long term conditions’ appeared in policy formulations and ideas about ‘living with’ rather than ‘curing’ cancer are now current and there is a struggle between these and the other rules posited above. Despite our recognition of the ubiquitousness of health care practice within teams, we struggle to make find ways to operationalise ‘we are responsible’. So their original formulation may still be useful in generating conversations about service development.

If we were to apply this same way of thinking to current organisational development practice, I suggest we would produce a system which looks like our current public service management if the following rules of thumb were commonly in operation:

1. Private managers practices are more effective [than public service managers]
2. Outcomes can be measured easily
3. Human services are like manufacturing processes
4. Professionals are always resist change

I would of course reject these guiding principles but I am suggesting they are held commonly enough to shape our public service systems, and we could reflect on how and why previous rules were able to be supplanted. I am itching to offer justifications for why I think they are not fit for purpose but for now I offer these in the spirit of starting a conversation which we could use to generate the rules of thumb for a ‘Twenty First Century public services’.

Diane Plamping

Becky’s Response

Whilst Diane has set out the Rule of Thumb that guided service from the foundation of the NHS, through to the Rules of Thumb that seem to guide the NHS now. I’ve had a go at the Rules of Thumb that we should use for an NHS fit for the 21st Century and beyond. My proposition is that if we used these rules to design services, we would shape a very different NHS. This is my first draft:

1. Partnering with people as owners secures better health
2. We are responsible – partnership means everyone contributing [Not I am responsible]
3. Do what matters to people (health is contextual) and this will reduce demand
4. If we don’t know what’s going on now we can’t adapt.
5. Health is relational

My rationale is:

1. People are coproducers of their own health, and people as owners will contribute to wider service delivery, and help shape services that address their needs. Institutionalisation of health services has gone too far.
2. If we are responsible then we see health services as collaborative and take responsibility for our part in that. Abdicating responsibility to experts creates dependence and assumes passivity.
3. The multiple attenders come to GP surgeries and to A7E, they come because their complex health issues are intertwined with their social context. We cant divorce the two.
4. We need real time data to know what’s actually happening now and as we try out service changes, and new approaches to health.
5. We heal through relationships, and we generate new possibilities and take action together.

This is an amalgamation of observed rules of thumb in high performing health systems and those teams and systems who are innovating and making an impact in the NHS.

I’d love to know what ‘Rules of Thumb’ you think we need to guide our services.

References

Berne E (1975) A Layman’s Guide to Psychiatry and Psychoanalysis . Penguin Books Ltd, Harmondsworth, middlesex, England (1975)

Gramsci, Buttigieg, Joseph A, ed., (2011) Prison Notebooks (English critical ed.), Columbia University Press

Plamping D (1998) Change and Resistance to Change in the NHS BMJ 4^th July 1998 vol. 317 p 69-71