Henry Kippin shares some lessons from Spain where health professionals embarked on some ‘dark work’ to create a better connected health system for local residents.
I spent some time in Madrid a few years back working with a group of clinicians, managers and technology experts to understand how they were getting better ‘connected health’ outcomes in parts of the city. Fascinating on many levels and, more importantly, I got to try on a Zinedine Zidane shirt at the Bernabeu Stadium while I was there.
The Spanish healthcare system works differently to ours, but the principle that sat behind the work these practitioners were doing was simple and universal: better insight and communication between different and diverse parts of the system will enable us to offer a more joined-up service to citizens.
Taking a pragmatic approach
The work I was doing was focused on technology, but even in this specialised field, the pragmatic approach was instructive. No fully interoperable system of data sharing and exchange? Well lets build one in small chunks, first understanding the tools and devices people currently use, and building bridges from this functionality outwards. As a result, practitioners and providers were sharing data and approaches through various means: from high quality coded patient data, through to basic sharing of PDF forms and scanned paper records.
The result of this was not a perfect or clean system delivered overnight, but the beginnings of a cultural shift. It gave people a shallow end to prove the concept and share early results. It avoided creating barriers that raised the costs of reform for clinicians and managers. And it worked with the things that people were already comfortable doing or sharing (the public, too) to build trust in a direction of travel, not a finished product. That direction of travel has led to some pretty impressive practice across the city region’s healthcare system.
The concept and the case study is rather well trodden territory to healthcare experts in the UK, but still not what you could call a standard practice in the aftermath of large-scale IT failures in the NHS. In Spain, too, regional variations in structure, culture and practice make it a mixed picture, as organisations like the Commonwealth Fund will attest. But as the NHS moves slowly but, probably, surely towards a more mixed and locally determined system – as shown by Greater Manchester, the vanguard pilots and the broad thrust of NHS England’s five year forward view – it struck me that we have something to learn from the way this group of people went about the business of pragmatically improving their offer to the public.
Fast forward a bit, and I am sitting on an Easyjet flight to Edinburgh (classy, I know) next to a couple whose son is playing with a Star Wars figure. Another simple and universal principle: Star Wars contains everything you need to know about reforming public services. Possibly. And to misquote that well-known advocate of collaborative models of healthcare delivery Darth Vader, we do need to harness the “power of the dark side” to build the readiness to work differently.
Doing the leg-work
The dark side is what links these two stories together. My Spanish colleagues talked about the “dark work” that went in to building their collaboration, a quote I have used many times since. They were pointing to the stuff that happens in the back room to build collateral and make it happen; to understand each others’ starting point; to unpick their own assumptions about how their services work; to unpick the system ‘blocks’; and to build enough trust to take a chance on changing a model without a proof of concept that would de-risk it in the traditional way.
This resonated with me. The ‘dark work’ is what makes sustainable collaboration possible. The Manchester model won’t work because a far-sighted group of civic leaders got together and cooked up a plan – it will work because different actors across the range of services to the public – from community groups to NHS providers to local government to the business community – feel a shared stake in a different way of working. This takes smart diagnosis, readiness and capability building, and a commitment to a different way of leading and bringing others alongside.
So what are the implications of all this for others looking to make a more collaborative set of health and human services to the public work? Here are three things to consider.
1. Don’t look for the perfect system – but do try to create the right conditions
The problem with systems thinking is that a great concept can, at worst, dehumanise what is a set of relationships and decisions between human beings that are … well … human. This is true of practitioners (clinicians and managers) as well as the public.
So the emphasis has to be on creating the right conditions for system collaboration to happen – with anchor agencies like local authorities, Clinical Commissioning Groups and NHS Trusts openly exploring how their own traditions and practices can undermine change, as well as, in the best cases, supporting it.
Collaborate is prototyping this through a collaborative system diagnostic tool in partnership with Coventry City Council and the Lankelly Chase Foundation. We are excited to see the results in Summer 2015.
2. Find the grain… work with it… then change it
Culture and practice cannot be changed overnight. Reform takes, as Julia Unwin argued in our Collaborative Citizen report in 2014, a different model of risk and trust, based on a proper dialogue between citizens and the business, government and social sectors.
Finding the ‘grain’ is the first step: that is, developing a picture of people and place outside of the public service lens. Behavioural economics, neuroscience, social network analysis and plain old social work techniques are crucial here.
But this must be accompanied by an approach – like that of the Spanish healthcare practitioners I mentioned before – that is prepared to work with the grain in order to eventually change it. Less ‘nudging’ today, and more learning and re-framing for tomorrow.
3. Unleash the power of the dark side…
Which is a dramatic way of saying “take collaboration seriously”. The corollary of disruptive innovation is the capability and readiness building that must be done in order to enable workforce change in a sustainable and meaningful way.
This ‘dark work’ doesn’t have to take years, but it does require some effort beyond convening a meeting of the key players. I don’t believe there is one single way to do this, but at Collaborate we think there are some core principles, including building a picture of the ‘collaborative ecosystem’, working with a range of stakeholders in an iterative and open dialogue, and creating the means to be ‘comfortable with uncomfortable’ in funding solutions for the public that will inevitably see organisational interests lose out.
If you ask Zinedine Zidane (or most other footballers, for that matter) what makes the game what it is, they will say the public – the fans who turn up every week and patronise the clubs that make it possible for players to realise their talent.
Ironically, it is this same public – citizens – that are often missing from conversations about collaboration in public services. These conversations quickly become deals between professionals without mechanisms to include service users, unusual suspects and the wider community – and this is a gap that health and social care reformers fully recognise they need to constantly address in Manchester and beyond. Collaborate is happy to support them in doing it.
This blog was written by Henry Kippin, Collaborate Executive Director, for the Public Service Transformation Network on 26 March 2015.
Click here to view the full blog on the Public Service Transformation Network website.
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