Leading large scale change for integrated care Dr Robert Varnam PhD MRCGP Head of general practice development, NHS England Clinical lead for CCG & primary care delivery, NHS Improving Quality GP, Robert Darbishire Practice, Manchester @robertvarnam [email protected]
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Leading large scale change for integrated care
Dr Robert Varnam PhD MRCGPHead of general practice development, NHS England
Clinical lead for CCG & primary care delivery, NHS Improving Quality
GP, Robert Darbishire Practice, Manchester
@robertvarnam
Leading large scale change for integrated care
The story so far Change in complexity Creating shared purpose Sequencing Top tips
Leading large scale change for integrated care
The story so far Change in complexity Creating shared purpose Sequencing Top tips
The story so far
Structure + process = outcome
Structures
Infrastructure
ProcessesBehaviours
The story so far
We have often focused on
structures & provider-led change
… and ended up with integration of providers
(more than care)
… made more improvements than transformations
... and found progress hard to sustain
… which was entirely predictable
So what are we dealing with?
Improvement or transformation?
Improvement Transformation
Doing thingsbetter /
differently
Doingbetter / different
things
What is ‘large scale’ change?
Depthof change vis-à-vis
current ways of thinking and doing; a.k.a
cognitive-behavioural or paradigm shift
Pervasivenessof change; does it affect whole or
only portionof the system?
Sizeof system experiencing change; e.g.
geography, numbers of people
Refs: Mohrman A. et. al. Large-Scale Organizational Change. Jossey-Bass, 1989 and Levy A. Second-order planned change: definitions and conceptualizations. Org. Dynamics. Summer 1986, 15:5-20
Large scale change usually fails
Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey of company executives
70%
25%5%
Leading large scale change for integrated care
The story so far Change in complexity Creating shared purpose Sequencing Top tips
Levers for change
What happens ...
Levers for change
What happens ...
Levers for change
What happens ...
Levers for change
What happens ...
Levers for change
What happens ...
Levers for change
Very few of our ‘wicked’ problems will be addressed by believing the health and care system is a machine.
Our experience shows that it behaves like a complex social organism.
It is time for a different paradigm of large scale change…
Complex Complicated
Chaotic Simple
Emergent practice Good practice
Best practiceNovel practiceSnowden D & Benford RD. The Cynefin Framework.
Cause & effect relationships exist, are obvious to most people &
predictable & repeatable. Can be known in advance.
Cause & effect relationships exist, but not obvious, so require
analysis/investigation +/- expert knowledge.
Cause & effect only obvious in hindsight, with unpredictable,
emergent outcomes.
No cause & effect relationships can be determined.
Probe. Sense. Respond. Sense. Analyse. Respond.
Sense. Categorise. Respond.Act. Sense. Respond.
Knowable
Known
Disorder
Several options
www.youtube.com/watch?v=ctMty7av0jc
Coordinated, behaviour – thousands of birds moving ‘as one’ – with no external controlHow? A small number of simple rules, internalised:• Separation: steer to avoid crowding local flockmates,• Alignment: steer towards the average heading of local flockmates, and• Cohesion: steer to move toward the average position of local flockmates .
Leading in complexity
A small number of simple rules
Acting within each unit
A few well-tested external influences & barriers
Leading large scale change for integrated care
The story so far Change in complexity Creating shared purpose Sequencing Top tips
A different paradigm
What’s the financial incentive?
Who is performance managing?
What’s the project plan?
“I have some KPIs
for your”
or
“I have a dream”
“You can’t impose anything on anyone and expect them
to be committed to it”Edgar Schein
Professor Emeritus, MIT Sloan School
Drivers of extrinsic motivation
regulation payment & incentive
systems performance
management measurement for
accountability
create focus & momentum for delivery
Intrinsic motivators connecting to
shared purpose engaging, mobilising and
calling to action motivational leadership
build energy and creativity
build energy and creativity
Internal motivators
connecting to shared purpose
engaging, mobilising and calling to action
motivational leadership
Drivers of extrinsicmotivation
System drivers & incentives
Performance management
Measurement for accountability
create & focus momentum for delivery
How do we create shared purpose?
Identify shared valuesCreate a safe space
Create a vision for the
future
Describe why the change is urgent now
Amended from work by Roffey Park
[Shared] purpose goes way deeper than vision and mission; it goes right into your gut
and taps some part of your primal self. I believe that if you can bring people with similar primal-purposes together and get them all marching in the same direction,
amazing things can be achieved.Seth Garguilo
Using shared purpose
The ‘why’ of your change
A gravitational force for drivers
The fuel that won’t run out
A uniting force for stakeholders
Leading large scale change for integrated care
The story so far Change in complexity Creating shared purpose Sequencing Top tips
Complex Complicated
Chaotic Simple
Emergent practice Good practice
Best practiceNovel practiceSnowden D & Benford RD. The Cynefin Framework.
Cause & effect relationships exist, are obvious to most people &
predictable & repeatable. Can be known in advance.
Cause & effect relationships exist, but not obvious, so require
analysis/investigation +/- expert knowledge.
Cause & effect only obvious in hindsight, with unpredictable,
emergent outcomes.
No cause & effect relationships can be determined.
Probe. Sense. Respond. Sense. Analyse. Respond.
Sense. Categorise. Respond.Act. Sense. Respond.
Disorder
Sequencing in large scale change
Identifying need for change
Framing/ reframing the issues
Engaging/ connecting
others
Making pragmatic change in multiple
processesAttracting
further interest
After some time
Settling inPossible outcomes1. sustainable norm 2. plateau3. run out of energy
Living with results and
consequences
Maybe later
Repeats many times in hard to predict ways
Time delay
Large Scale Change
The emergent process of mobilising a large collection of individuals, groups and organisations toward a vision of a fundamentally new future state, by means of:
• high-leverage key themes• a shift in power and a more distributed leadership• massive and active engagement of stakeholders• mutually reinforcing changes in multiple factors• a focus on changing patterns of behaviour, relationship &
power
Leading large scale change for integrated care
The story so far Change in complexity Creating shared purpose Sequencing Top tips
Conclusions from the evidence
Successful integration requires:• shared purpose & collaborative behaviours,
more than new structures• overcoming silos through communication
(leaders & staff talking, shared patient record, shared performance data)
• much can be done within existing regimes (eg tariff, Caldicott)
• no silver bullet
bit.ly/RzENMB
Conclusions from the evidence
“Leaders and managers tasked with applying integrated care ‘at scale and pace’ might … focus on driving forward the organisational solution or introduce various financial inducements in the hope this will be more effective [than starting with values-based shared purpose]. Such an approach would be a mistake…
A values-driven approach should be a pre-requisite to the successful adoption of integrated care.”Goodwin, Nick. “Taking Integrated Care Forward: The Need for Shared Values.” International Journal of Integrated Care 13, no. 2 (June 24, 2013).
Conclusions from the evidence
• Eventually, successful commissioners have to adopt different approaches:
• see the whole system, not just constituent services
• more relational, less transactional
• more clinically-led collaboration with providers, less finance-led negotiation
• more provider-led innovation & improvement
• less bound by annual & linear cycles, more flexible, long-term & iterative
bit.ly/13Otdyq
Top tips (NHS Academy for Large Scale Change)
1. Moving towards a new vision that is better and fundamentally different from the status quo
2. Identifying and communicating key themes that people can relate to and that will make a big difference
3. Multiples of things (‘lots of lots’)
4. Framing the issues in ways that engage and mobilise the imagination, energy and will of a large number of diverse stakeholders
5. Mutually reinforcing change across multiple processes/subsystems
Top tips (NHS Academy for Large Scale Change)
1. Continually refreshing the story and attracting new, active supporters
2. Emergent planning and design, based on monitoring progress and adapting as you go
3. Enabling many people to contribute to the leadership of change, beyond organisational boundaries
4. Transforming mindsets, leading to inherently sustainable change
5. Maintaining and refreshing the leaders’ energy over the long haul
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