This is a case study about change management work I did with the NHS to support integration of care services in Cambridgeshire.
I worked with an NHS-owned partnership called UnitingCare. It had won an £800m contract to provide the adults and older people's community services in the Cambridgeshire & Peterborough region. This included reorganising community care and improving the way health and care services in the region worked together. UnitingCare directors believed that traditional NHS ways of working could prevent the innovation and collaboration needed - and wanted to try doing things differently. My job was to help.
Here are three examples of what I did, one in each of my areas of specialism: facilitation, communication and change strategy...
Growing trust and collaboration
UnitingCare planned to manage change at local level through four Integrated Care Boards. These were designed as governance committees attended by reps from hospitals, GP surgeries, community services, mental health services, voluntary organisations, public health, local authorities and the Clinical Commissioning Group.
I worked with a UnitingCare director to set up one of these. We quickly decided that, to promote innovation and collaboration, the group would need to be much more than a committee; and that this wouldn’t be easy to do if the usual NHS group dynamics and meeting culture took hold.
I facilitated the group during the year. We did things differently. We held unstructured meetings and mingled with coffee; we invited anyone who wanted to come; we avoided big tables - and chairs in rows; we used a wiki and a messaging application instead of Word and email. We worked hard at developing personal relationships - making the group more interactional and less transactional.
Given the difficult circumstances of the NHS, there was frustration - but not with the group itself. People showed up; and began to bring others along. They saw value in it. There was honest conversation. We felt that an atmosphere was developing where change was possible. Things we didn't expect, began to happen: like a leader from the voluntary sector who stepped up to take responsibility to help solve a critical problem in discharging elderly patients from hospital; and a doctor who implemented his own wiki to improve collaboration with his colleagues.
Opinion: The big changes needed to improve care will not start from top-down commissioning of contracts and organisational redesign. They will come from adaptive change. Change seeded by bold people doing small things differently, experimenting with new ways of working and patiently building trust, conversation by conversation.
Making communication more effective
UnitingCare's challenge was significant and the situation complex. There were hundreds of managers, thousands of staff working in many diverse organisations who needed to be engaged. I was struck by the number of times senior managers cited poor communication as a significant barrier to progress. The local health and care system relied heavily on traditional mechanisms of communication - email, Word/pdf, newsletters, formal boards etc - there was little use of collaborative communications or social media tools.
To show how things could work differently, I introduced two collaborative software applications: a wiki and a chat messaging system - Confluence and Slack. Initially we used these in the Analytics Service (see below) and the benefits quickly became obvious. The wiki was initially used between UnitingCare and its customer - Cambridgeshire & Peterborough's Clinical Commissioning Group - to collaborate on a performance measurement system.
By taking opportunities to engage people in ones and twos - gradually developing understanding and commitment - I grew the membership to several hundred people. The tools, and the change to more open communication behaviours, became a talking point - drawing equal measures of cautiousness and vocal enthusiasm. Having seen the possibilities, some of those involved are planning further experiments.
Opinion: NHS has very little chance of bringing about the substantial changes it needs to without changing the way it communicates. Although collaborative tools can be tricky to implement, particularly in bureaucratic situations, they can bring massive benefits.
Using data to improve services
I helped set up UnitingCare’s Health Analytics Service. The service was to monitor elderly care services and provide data for improving them. I helped to work out a strategy for the service; to communicate how it would work; and to get it started.
The situation was complex. It became clear that success would depend on both getting access to data and developing a culture of data-driven improvement: both of these outside the direct authority of UnitingCare. Building technology was secondary. I helped get this understood and then establish an incremental, collaborative approach that would grow the right capability and the relationships the service would need. This avoided premature investment in costly technology that a standard analyse>design>build approach would have brought and provided a useful example of agile organisational change.
Opinion: There is rightly much discussion of the possibilities of (“big”) data but improvement will not come from the analysis of data alone. There has to be trust and collaboration across the care system - it’s vital that this leads the technology, not the other way around.
The value of my work
Caring for adults with long-term conditions is an increasingly significant challenge. Disparate and independently-delivered care services must work together more effectively. The situation is hugely complex: traditional, top-down, programmatic approaches to managing change are proving slow and ineffective; and are frustrating front line staff. My work is about enabling people involved in such situations to find better ways to change things.
In this work in Cambridgeshire, I helped a diverse group of people - including directors of UnitingCare, clinical staff and managers from across the health and care system - to understand more about what it takes to make change in complex situations and to learn how they personally might do things differently:
Unsticking seemingly stuck situations by focusing on doing small things differently: planting and nurturing seeds that develop quickly into new, enduring ways of doing things. Initiating change through fast, cheap experiments led by front line staff: avoiding the cost of requirements and planning work; and establishing enthusiastic support early on. Working openly and collaboratively in such a way that useful, authentic communication happens as a free by-product: reducing comms costs, building confidence and making things happen faster because people understand better what is going on. The NHS Leadership Academy expresses this kind of collaborative, boundary-crossing approach to change as "System Leadership"; a recent NHS report, on the future of its IT, talks about the critical need for "Adaptive Change" leadership skills. I can catalyse these new leadership behaviours, help re-train the muscle-memory of redundant ways of working and spark genuine organisational learning. Ultimately, I can help make lasting change happen quickly and cheaply.
As it happened, because of a lack of funding, UnitingCare was wound up prematurely at the end of 2015 - less than a year into its 5-year life. The experiments we started went with it but the learning from them is being applied now.
Here's what some of those involved said about my contribution...
Programme Director - Cambridge University Hospitals NHS Foundation Trust and former Commercial Director of UnitingCare
CFO of West Norfolk CCG and former CFO of UnitingCare
GP - Ely