Tuesday, December 6, 2011

The NHS – a social network?

I realise it’s unusual to get excited about an academic article in a somewhat obscure scientific journal, but a recent piece of research about the evolution of cooperative behaviour caught my eye and got me thinking. (Please stick with me here!)

‘Cooperative behaviour cascades in human social networks,’ written by Fowler and Christakis in the Proceedings of the National Academy of Science, describes a set of laboratory experiments testing how people cooperate and behave towards each other while playing a series of public goods games. In these games individuals were asked to make contributions to a group; some of the experiments also included punishments.

Rather than individuals seeking to maximise their own gains and self-interest, game participants were found to copy the cooperative behaviour of others, creating what the researchers call a ‘behavioural cascade’. The effect was observed even though group members’ relationships were temporary and anonymous.

The research left me wondering whether the success of the government’s NHS reforms might depend more on creating this sense of the ‘group’ – especially the willingness of people to cooperate – rather than promoting competition. This perspective chimes with my own observations and recent experiences helping clinical leaders translate the NHS reforms into reality.

Whether setting up new organisations, building local alliances, or creating constructive relationships in line with new accountabilities, these activities require a fair amount of cooperation, for example, between clinical commissioning group leaders and their constituent GPs, across the partners of a fledgling health and well-being board, or between healthcare providers, patients and the public.

The intrinsic motivation of the people I work with is to improve health and patient care, yet they are troubled. The forces of destruction and reconstruction brought about by the reforms seem to stray far from what got them into this business in the first place. By and large, they are more interested in integrating care systems and improving patient experiences, and not creating a healthcare marketplace. In a way, what we have today is a largely uncontrolled experiment – a very large public goods game structured on competition between the NHS’s different parts.

Fowler and Christakis’s research drew some interesting conclusions about the role of social networks in structuring human interactions. Perhaps we need to consider the NHS as a social network – focusing on the people in it (including patients) rather than its structural components. Or maybe the NHS is a conglomerate of social networks. Either way, re-imagining the NHS in this way opens up new possibilities for improving patient care.

We can now begin to think about how government policy might be used to strengthen social networks and reward cooperation. Shifting the emphasis of NHS policy towards cooperation and encouraging the formation of strong networks may in fact prove more beneficial in the long run – not just for the people who work in the health service, but especially for the patients who use it.

Tuesday, November 29, 2011

Challenges for clinical health leaders in changing times

As the NHS Alliance conference begins in Manchester, participants working in primary care and partner organisations will no doubt be keen to hear from leading practitioners, politicians and commentators. We can expect discussion to be wide-ranging, informative and occasionally impassioned as people debate the future health service and their roles within it.


There is obviously a substantial agenda – so many changes to implement and so little time to do it all – and many clinicians and managers are working with great professional commitment to ensure, as best they can, that new arrangements are put in place that will deliver against local and national challenges for health and social care.

But sitting within this demanding agenda are differing assumptions about the forms of leadership that will in practice bring about desirable and financially-necessary changes.

A new world of clinical commissioning

We meet many clinical leaders who are getting to grips with the new world of clinical commissioning and, in many cases, the substantial financial challenges that come with it. But in the context of these far–reaching, system-wide changes it is striking how many of the GP leaders we talk to first express concerns about maintaining and improving service quality, quickly followed by concerns about how they can best engage colleagues in other practices and encourage them to get involved in creating positive change. For these processes to work effectively they have to be done in ways that are broadly acceptable. The leadership development agenda may appear predictable, but clinicians tell us it presents them with challenges as well as opportunities.

Consider the fit between the need for complex problem solving, which undoubtedly describes the current situation, and appropriate leadership styles. GPs and other clinical leaders are generally used to working relationships characterised by collegiality, even when this includes a hierarchical dimension.

Equally they are used to drawing on evidence, making decisions on this basis, and assuming that most colleagues most of the time share their commitment to patients and quality service. These assumptions about the purposes of leadership create a web of connection, even at times when individuals may disagree on particular issues. Considering stakeholders’ goals through inclusive leadership is a characteristic of good practice, exemplified through the National Leadership Council’s clinical commissioning group (CCG) development framework.

In understanding and rhetoric at least it appears the need to move beyond old style ‘out-in-front, one-person-at-a-time’ leadership is fully endorsed. But the current need to ‘drive changes through’ at speed and with perhaps less than ideal levels of consultation threatens to reinforce a leadership style that some aspects of the reforms ostensibly set out to minimise.

The forthcoming debates in Manchester among the primary care community are an excellent opportunity to consider how high-quality and inclusive leadership can best be used to improve service quality and patient care as the reforms move forward.

Friday, November 18, 2011

From compliance to judgement: trusting more, controlling less

Local authorities – like many other public services – often struggle to move beyond the rhetoric when it comes to taking a common sense approach to managing risk. OPM’s recent work with the London Borough of Ealing provides an example of how turning the traditional ‘top down’ view of management upside down can help to identify practical steps to empower frontline staff.

Last week I was working with the Council’s Senior Leaders Forum – their top 80 or so managers – to think about the transition ‘From Compliance to Judgement’, or how a council like Ealing can shake off the sheer weight of bureaucracy and procedure that slows us down. The Munro Report has brought the issue back on the agenda – arguing that we have created compliance cultures that get in the way of good professional practice (Munro focused on children’s services, but the lessons hold across the piece). Ealing had a particularly good story to tell – about their ‘riot recovery’ work.


I read in The Times only this weekend that many small businesses across London are complaining about the red tape that is making a mockery of government promises to ‘repair the damage and get businesses up and running again’. This is emphatically not the case in Ealing, however. Executive Director of Environment Customer Services Keith Townsend and his team decided to cut the red tape – and after a very fast stock-take began to offer help within days. With a minimum of fuss and form-filling, businesses were given cheques to enable them to replace broken windows and get back to serving customers.

So the question we were asking ourselves is this: if we can do this in an emergency, what stops us doing it in everyday situations? Could we trust more, and control less?

In a second case example, we looked at radical approaches to working with families with complex needs, and the approach that Swindon is taking – not making judgements, but supporting each family in meeting their own aspirations for a better life. It requires a multi-professional team to work in flexible and creative ways, making their own judgements about the right intervention to help each family. (I blogged about Swindon’s amazing work a little while ago.)

If we applied this thinking more widely, and allowed professionals on the front line to exercise their own judgement, what would managers have to do to make that safe?

The answers we came up with were all about helping front line staff to understand the context, values, and goals, so that they can make their own trade-offs. The more staff understand about the competing needs of different service users, and the ways their decisions impact on others, the more sophisticated will be their judgements. Munro, in her report on safeguarding children, points to the evidence that staff treat service users they way they are treated. If we really want to empower service users, we have to empower staff. So the final question the senior leaders forum was asked was ‘if managers didn’t manage top down, but only offered the management that staff requested – what do we think staff would ask for?’.

This led to a fascinating discussion about coaching styles and supervision – using the example of junior doctors who watch and learn and practice steadily increasing the autonomy they exercise. We decided senior managers could help by showing the ‘working out’ of the decisions they make – helping staff to balance different interests and understand the nuances of policy.

This is work in progress, and we will be publishing a series of papers about the subject, but anyone interested in following the agenda could do worst than read Donald Schon’s famous 1983 book called The Reflective Practitioner. I’m interested in starting a debate about what the reflective practitioner of 2011 would need to know and do. If anyone’s interested in running a similar masterclass on the topic in their own organisation – do let me know. In the meantime I’d love to hear your own reflections in the comments box below, or by email: communications@www.opm.co.uk.

Wednesday, October 26, 2011

How collaboration can help address local delivery challenges

I recently had the pleasure to be involved in a two-day workshop hosted by the Institute for Government, part of a wider set of initiatives which make up ‘Transforming the Civil Service’ programme.  Although the event focused on Whitehall, the issues of running effective services (and other interventions) for the public good are as, if not more, relevant to local leaders.

The event looked at reducing re-offending, and local adaptation to climate change. From the insights generated on the two days it is possible to draw out a number of key lessons that can be applied locally in any process of reviewing and redesigning local services in a time of austerity.

Involving the people that ‘do’

The first, and perhaps most important, point to highlight is the importance of the knowledge and understanding of those who work at the front line. We explored this in 2002 in our report for the Cabinet Office: Involving the front line in policy making. Essentially those doing the work often have profound insights as to what works, and why – important perspectives to feed into any service redesign. We would also suggest that service users are a part of this front line and can have equally powerful insights.

Seeing the whole situation, anew

Making the most of these front line insights, and those of others, builds on three key ideas – the first is that all those participating in a situation will have views and experiences that should be valued and will help ensure a more complete picture of the situation.

Second, the idea of taking a ‘whole-system view’ of the situation – if we can step back, we will be able to see more of the wider connections in a situation, and the environmental context.

I have deliberately used the word situation, rather than problem – this relates to the third idea: we should enter a situation with as open a mind as possible in terms of what we think is going on (and what may or may not be the issue or solution).

When invited to advise on local service change we often find that the situation is more complex than first described, and that underlying cause and effect may mean the way forward lies in a different place to that first suggested. For example, the authority where an initial request to help embed local area agreements (LAAs) helped highlight how managing voids on estates could significantly reduce local street crime. Total Place and now Community Budgets are approaches that put some of these ideas into practice in real localities, holistically identifying better ways of addressing need and saving money at the same time.

All these ideas are drawn from the broad domain of systems practice – an approach that is holistic, recognises different perspectives are valuable, knows complexity can be seen in different ways, and that by taking a step back can we begin to explore and assess what is really going on, and thus what the best responses might be.

I look forward to seeing how the insights of collaborative working are used in the transformation of the Civil Service and in meeting the challenges faced by local authorities.

Friday, October 14, 2011

There’s more to commissioning than cost

Working with local authorities and others to help them improve their commissioning, I have encountered a lot of confusion about what specifications can and should contain.

In some places there is a view that lowest cost is the only thing that matters. But this can result in decisions that conflict with corporate vision and strategy and unintended consequences for communities, the environment and the economy.

Central government has just issued new statutory guidance about how social, economic and environmental value can be included in service, procurement and commissioning decisions. This guidance states that authorities should consider economic, environmental and social value when reviewing service provision.

Social value is defined as seeking to maximise the additional benefit that can be created by procuring or commissioning goods or services above and beyond the benefit of the goods or services themselves. This means that specifications and contracts (for all services including adult and children’s services) can include community benefit requirements.

Social value as standard

The new guidance is significant because it means that commissioners can specify environmental, social (including local governance and evidence of community involvement and leadership) and economic (jobs and apprenticeships for local people) as part of their general requirements. This can be done by some corporately agreed ‘must-do standards’ for all contracts (like a preamble in a building contract) and a clear commissioning policy.

We have been advocating this for a while through the Commissioning Support Programme (CSP) and more widely in our work with local government. It is also of great potential value to health and well-being boards where it helps public health people to link the environmental and exercise (bikes and walking) benefits with contracting for public services, including health services. It may also make it easier for local voluntary and community organisations to win work as long as they can demonstrate community benefit through community and service-user governance, reduced carbon footprint and local employment.

Wednesday, June 15, 2011

Isn’t it time for more self-managed learning?

Everywhere I hear the phrase ‘more for less’, a sign of growing pressure for significantly increased results from fewer resources, including ‘human resources’. If we accept that staff in cash-strapped public bodies need to take greater responsibility for their own learning, how can this be made to be a positive experience?

At first glance there might seem to be a natural case for organisations to invest in their people, particularly in learning and development. However, there is a big ‘but’: organisations that are under financial pressure often look to cut training and development budgets, perhaps because they are a soft target or that key decision-makers remain unconvinced about the correlation between expenditure on training and development and pay-off for organisations (and presumably for individuals). This may be because individuals learn but then don’t successfully transfer their learning into meeting organisational demands. It could also be simply that the learning feels ‘forced’ onto individuals who then go through the motions of learning rather than embracing it.

The Chartered Institute of Personnel and Development states that it is essential that individuals should be: ‘helped to take on greater responsibility for their own development and growth’. A laudable aim, but the question is: how?

Self-managed learning (SML) is about individuals managing their own learning. It includes people taking responsibility for decisions about the what/how/when/where and (fundamentally) why they learn. If individuals are supported in this process then a situation is created where learning is both owned by the individual and integrated with organisational needs. Personnel Today spells it out succinctly:

‘Many businesses set themselves up for immediate failure by spending more time thinking about the content of … learning programmes and not enough on supporting and nurturing the culture of the business and the individuals who are expected to complete it.’

Everyone manages their own learning to some extent but it’s evident from work done in this area over 20 or more years that just telling people to take charge of their learning can be very inefficient. Helping a person manage their own learning means a) that the learner may feel more passionate about the subject and the benefits that are likely to accrue personally and organizationally and, b) that the person can access a wide range of opportunities for learning, which may include:

Crucial success factors

So there are two crucial factors for successful self-managed learning. One is that individuals have the support to understand and to feel a personal sense of commitment to what is required by the organisation. The second is that individuals understand the parameters of self-managed learning, which means the extent to which there are any constraints on the what/how/when/where of their learning.

I’ve personally experienced the power of SML as a learner and as a facilitator of development. We need to move away from unstructured, unplanned learning that is very inefficient. Isn’t the time right for a less ‘sheep-dip’ way of learning to support organisational change?

Monday, December 6, 2010

Shared ownership in practice

There is a major drive at national and local levels to increase the use of cooperatives, mutuals and other models for employees, users and communities to take over ownership of public services. This has resulted in the Cabinet Office’s  ‘mutual pathfinders’, and plans for new ‘rights to provide’ to allow public sector employees to take over ownership of services. This report presents findings from in-depth case study research with public services that have already made the transition to employee and/or community ownership. These include employee-owned leisure services in Oldham, community-owned children’s services in Lambeth, and health care services in Hull.

Thursday, October 21, 2010

Striking the right balance between innovative and adaptive leadership

The current financial and political climate calls for genuine transformation, and for leaders who are able to encourage and harness different styles of thinking. Traditional salami-slicing of budgets cannot yield the required level of savings; radical thinking is required. But where does this leave managers and leaders who naturally adopt a more adaptive style? OPM’s Richard Field explores.

‘Innovative’ and ‘adaptive’ preferences

The work of Dr Michael Kirton suggests that individuals differ in their thinking, either tending towards adapting what already exists or innovating something different. Relatively adaptive leaders seek solutions to problems in tried and tested ways, generating ideas within the prevailing paradigm. Leaders who are, relatively speaking, on the ‘innovative’ end of the spectrum challenge assumptions and manipulate or reframe problems, generating a greater number and diversity of ideas.

This is a period of unprecedented change for public services, some of which is innovative, the rest a case of making adaptations on a grand scale. Views on what constitutes innovation vary; in my view an authority that switches from traditional bricks and mortar services to providing work and business opportunities for people recovering from strokes and brain injury is potentially innovative, at least for this authority. Choosing to sell off remaining homes for older people having sold one or two previously is large-scale adaption; it does not require a shift in thinking or involve anything new, simply a repetition and augmenting of previous actions.

For those leaders comfortable with uncertainty, complexity and paradox this is a time of unparalleled opportunity, a time for imagining, innovation and experimentation. For leaders who function best in conditions of certainty and stability this is a less comfortable time. Much of what has been developed over the last ten years is being reduced or dismantled. Established services, relationships and processes are transforming at a speed that allows little time for careful thought, planning or coordination.

Being naturally adaptive or innovative is neither a good or bad thing: particular contexts and circumstances call for relatively more adaptive or innovative responses. While individual leaders often face contexts that require a response that does not match their thinking style, management teams usually have a mix of styles and should be better equipped to lead in a diversity of situations. Successful responses to the current context will depend on the sense leaders make of their environment, their ability to correctly diagnose whether an innovative or adaptive response is required, thinking style diversity within the management team and the ability of those involved to harness diversity and adapt their behaviour.

Getting the mix right: ignore adaptive thinking at your peril

Both innovative and adaptive styles of thinking are valuable and management teams benefit from a mix, the balance of which will need to shift over time. While the current emphasis on thinking outside the paradigm makes innovation popular, ignoring adaptors is a mistake as they can make a significant contribution, particularly in shaping and implementing ideas. More important, however, is the contribution adaptive thinkers can make post-transformation in the quest for high performance, which at this point is more likely to be achieved via sustained continuous improvement.

As a user of adaptor innovator theory for many years I’ve found the following questions to be particularly helpful for senior public service leaders to ask top teams:

With the appropriate mix of innovators and adaptors an organisation should be equipped both to break out of the existing paradigm and make the new paradigm work. At present innovators are leading in many organisations and there is a need to ensure that those motivated to do things better rather than differently are engaged. Their time is coming, and soon.

Saturday, October 31, 2009

Leadership of place: light touch mapping

The Improvement and Development Agency for local government (IDeA), the Leadership Centre for Local Government, the NHS Institute for Innovation and Improvement, and the National Police Improvement Agency (NPIA) jointly commissioned OPM to conduct research into current activity around leadership of place.

The research used interviews and a review of documents to map current activity and identify options for possible future collaboration. Interviewees included key stakeholders across the four organisations, academics and other experts who have worked in this area, and the directors of a number of the regional improvement and efficiency partnerships.