Working together more effectively in the NHS the challenges of implementing innovation to practice Professor Sue Dopso

1. Working together more effectively in the NHS the challenges of implementing innovation to practice Professor Sue Dopson

2. Approaches to Change 1. Establish sense of urgency 2. Form guiding coalition 3. Create a vision 4. Communicate Vision 5. Empower people to act on vision 6. Create ‘short-term’ wins 7. Consolidate improvements to produce further change 8. Institutionalise new approaches Unfreeze Movement Refreeze Lewin 1951; Kotter 1995 Prof Sue Dopson

3. Change as innovation • Relative advantage, the degree to which the innovation is perceived to be better than existing technology. • Compatibility, the perceived ‘fit’ of the innovation with existing structures, procedures and values. • Complexity, the degree of difficulty in learning about and implementing innovation. • Trialability, the extent to which an innovation can be tried by potential adopters without major investments of time or resources, and • Observability, the degree to which outcomes resulting from the adoption of innovation are visible. Rogers, 1983 Prof Sue Dopson

4. Focus of Studies: ROGERS, E. (1995) “Diffusion of Innovations” 4th ed. New York, Free Press. “we should increase our understanding of the motivations for adopting an innovation. Strangely, such ‘why’ questions about adopting an innovation have rarely been probed by diffusion researchers...” (p. 109) Prof Sue Dopson

5. The data base for reflection on EBM • Seven studies have been brought together, • These comprise 49 separate case studies. • In total, more than 1400 interviews with clinical professionals and managers in health care in the U.K. • Across the acute & primary care sectors Prof Sue Dopson

6. Findings on Evidence….. • No such thing as ‘the evidence’, but competing bodies of evidence • Credibility of evidence is based on source • Hierarchies of evidence exist • Different professional groups have different views on scientific evidence • Limited data to show inter-professional sharing of evidence Prof Sue Dopson

7. “I think that the problem with practice at my level is that it’s very individual. That is why I don't agree with evidence-based medicine; there isn’t any evidence to help you deal with a difficult patient and we get largely the difficult patients because the routine patients are dealt with by the general practitioners.” ENT Consultant Prof Sue Dopson

8. “We are just too busy to be able to stop on a ward round and discuss evidence-based medicine with every patient. It is inappropriate: nice in principle but difficult to do in practice.” (Registrar, ENT) “I don’t think GPs are the people to do EBM, GPs just simply don’t have the time, or in many cases the necessary statistical ability. By the time patients are ready for hospital, it is much easier to practice EBM on them because you’ve got a much more defined population. At a GP level you’ve got a hotch-potch of problems completely and they are nowhere as clear-cut as they are by the time the GP has sifted them out and sent them off to Hospital.” (General practitioner) Prof Sue Dopson

9. Prof Sue Dopson

10. Findings on Evidence…. Social & cognitive professional boundaries : • The source of differences between professional groups lies in education and socialisation into the profession; • Cognitive boundaries have rarely been recognised; • Many decisions about innovations and adoption are taken in uni-professional ‘communities of practice’ Prof Sue Dopson

11. The Influence of Context • History of prior relationships is critical • Diffusion is impeded when organizational structures are complex • Therefore • Only context sensitive diffusion processes will be effective; • Sound ideas always need customizing to local context; Prof Sue Dopson

12. The Complexity of Referrals Patterns inthe Case of a Child with Glue Ear Detection of glue ear Refer to or hold Refer or hold Parent/carer Community audiologists Hospital audiologists Health visitor School nurse GP ENT Prof Sue Dopson

13. The Influence of Context • Targets, both national & local can cause individuals to pay attention; • Individual actors will use & draw down evidence if it supports their values & objectives; • Individuals may choose to pay attention to less robust evidence over more robust evidence e.g if there is patient need locally Prof Sue Dopson

14. Roles of Actors and Interactions • Medical dominance maintained at local level • Where diffusion depends on heterogeneous groups; the quality of relationships between professions is crucial • Interdependence is both inter-professional and inter-organisational Prof Sue Dopson

15. Rolesof Actors and Interactions Opinion Leaders as Accelerators and Facilitators of Change • similar pattern across contexts • opinion leaders account for differential speed of adoption • opinion leaders perform a range of roles e.g. technical champion • opinion leaders play a key role in translation to local level Prof Sue Dopson

16. Roles of Actors and Interactions Networks: enrollers or controllers? • networks translate innovations to local level • networks can engage individuals in the diffusion process • or • halt the process by withdrawing support Prof Sue Dopson

17. Case Study: The Genetic Knowledge Path Idea • “[The idea for GKPs] appeared very late in the drafting of the NHS plan, virtually just a sentence, just a throw away sentence that took everyone by surprise & when [the then Health Secretary] was questioned what it was, he said, ‘You tell me.’ We then had to develop some themes.” • Funded GKPs as a “reaction to lobbying” • Unclear specification of what GKPs should do Prof Sue Dopson

18. Dept of Trade & Industry Dept of Health Health Secretary Science Medicine Social science Management / policy Senior civil servant Senior civil servant Civil servant Civil servant Other GKPs Old University Pathology Prof NHS Hospital Genetics Prof Medical Director Genetics Prof Genetics Prof Cardiology Prof Epidemiology Prof Social Science Institute Ethics Prof Genetics Prof NHS Science Labs Research Institute Lab Director Lab Director OGKP (Conception: 2001) Prof Sue Dopson

19. Community Affiliations Prof Sue Dopson

20. DTI DoH Commissioners (SHA) AGGR Civil Servant Primary Care Conflict Commissioner Misunder-standing Old University Network Director Other Labs Other GKPs Pathology Prof Genetics Prof Business School NHS Hospital Genetics Prof Medical Director Competitive pressure Genetics Prof (OGKP Chair) Consultant Geneticist Genetics Prof (PI WP2) Social Science Institute Prof Ethics Consultant Geneticist Cardiology Prof (PI WP1) Lawyer Economist Research Inst Scientist (New PI WP3) Scientist Sociologist Conflict NHS Science Labs Lab Director Lab Director Innovation Unit VCs GIG - Patients Genetics Prof (Old PI WP3) OtherUniversity Science Medicine Social science Management / policy Executive Committee in bold GKP Supervisory Board underlined OGKP (end 2007) Prof Sue Dopson

21. Epistemic clash between Dept of Health & University • Different epistemic understanding of genetics • As slow-moving ongoing science (University) • Funding a cool new innovation provides kudos (DoH) • Construction of GKPs • Ongoing academic genetics research (to produce publications & hence further funding cycle) • Or translation into NHS practice & networking – demonstrating money has been well spent (& enable further funding cycle) • Standardised quarterly reporting or tick box exercise without feedback? Prof Sue Dopson

22. Epistemic Clash Research vs. NHS Labs • “The way we work in the research lab is try & get everything as fast as possible because it’s a competitive world … [we] need … visible productivity… to scrape over the surface for the big prize…The clinical genetics lab is incredibly compulsive & obsessive… do everything in duplicate & never get that wrong. That’s very reassuring, but the problem is that if you are compulsive & obsessive, it just takes too long.” Medical Scientist • “They [NHS scientists] feel they are providing a service & being careful & we [research scientists] are feckless people who wander in at 11 o’clock & go home at three & look for glory.” Research Scientist • NHS Labs reluctant to share information due to concerns about competition with other Labs Prof Sue Dopson

23. Epistemic Clash Science vs. Social Science • Economist able to communicate with scientists (shared quantitative epistemology) & helped to prove SCD test as cost-effective (producing further funding) • Sociologist’s work weird & of no benefit • “Our world is very black & white so when a sociologist talks to me about barriers in networks it does not mean much to me.” Research Scientist • “These weird sort of sociology people… we were just providing material for them to write interesting papers.” NHS Scientist Prof Sue Dopson

24. Epistemic Clash Research vs. NHS Commissioning • “They hadn’t thought through the process to completion... we can’t just think about genetics in isolation… how does that fit in with the rest of the cardiac services? …think of the knock on effects, the unintended consequences… although its frustrating & you think, oh just give us the money & we can get on with it, you have to be more conscious of the bigger picture… The economic case for many service changes is fine, but the NHS works on a cash basis & unless it can get cash… [for] defibrillators … we can’t do it. Its not the cost of the test, it’s the cost to the NHS in the year of introduction.” Commissioner • “I think the main lesson is for us to tie up with the commissioning process, because it doesn’t matter how fancy your research is, if you are aiming to get it translated into practice, it has to be commissioned… it can’t just run on whim, you have to have the evidence behind it… in a timely matter & it has taken a lot of work to gather the information & make persuasive arguments… we have been lucky with our commissioner... he is on our side.” NHS Clinician Prof Sue Dopson

25. Why is knowledge ‘Sticky’ ?? • SPATIAL BOUNDARIES • ORGANIZATIONAL BOUNDARIES • INTER-ORGANIZATIONAL BOUNDARIES • PROFESSIONAL BOUNDARIES • BOUNDARIES BETWEEN ‘COMMUNITIES OF PRACTICE’ • MANAGEMENT KNOWLEDGE Prof Sue Dopson

26. Processes for sharing across boundaries • SHARING WILL NOT ‘JUST HAPPEN’ • ORGANIZATIONAL; INTER-ORGANIZATIONAL & PROFESSIONAL BOUNDARIES NEED PLANNED FACILITATION TO OVERCOME; • BRIDGING ROLES • RECOGNISE THE POWER DIFFERENCES Prof Sue Dopson

27. Solving what kind of problem? Prof Sue Dopson

28. Two Imperatives for Change 2 Eliminate obesity!! 20 years - Societal shift for national well-being Long-term purpose Shift in mindsets Many stakeholders, different solutions Innovation and boldness Local breakthroughs 1 Bird Flu hits the UK 3 months to immunise the whole population Short term pressure Major effort Known solution Predictable action Bias to command and rules What change approach do you adopt?? Prof Sue Dopson

29. The Challenge of Change • Do different kind of challenges require different kind of change? • Critical Challenges: Commander • Tame Challenges: Management • Wicked Challenges: Leadership Prof Sue Dopson

30. Critical Challenges: Commander Commander’s Role is to take the required decisive action – that is to: provide the answer to the challenge • Portrayed as self-evident crisis; often at tactical level • General uncertainty – though not ostensibly by commander who provides ‘answer’ • No time for discussion or dissent • Legitimizes coercion as necessary in the circumstances for public good • Associated with Command • Encouraged through reward Prof Sue Dopson

31. Tame Challenges: Management The challenge of heart surgery is a Tame challenge It’s complicated but there is a process for solving it & therefore it has a Managerial Solution/Answer Launching a(nother) new product is a tame challenge Relocating is a tame challenge Management’s role is to engage the appropriate process to solve the TAME challenge • Challenges as PUZZLES – there is a solution • Can be complicated but there is a unilinear solution to them – these are challenges that management can (& has previously) solved Prof Sue Dopson

32. Wicked challenges have no simple solutions because: Either novel or recalcitrant Complex rather than complicated (cannot be solved in isolation) Sit outside single hierarchy and across systems – ‘solution’ creates another challenge They often have no stopping rule – thus no definition of success May be intransigent challenges that we have to learn to live with Symptoms of deep divisions – contradictory certitudes Have no right or wrong solutions but better or worse developments Securing the ‘right’ answer is not as important as securing collective consent. Feasibility not optimality; coping rather than solving Uncertainty & Ambiguity inevitable – cannot be deleted through correct analysis – Keat’s “Negative Capability” Challenges for leadership not management; require political collaboration not scientific processes - role is to ask the appropriate question & to engage collaboration Prof Sue Dopson

33. Credibility & influence • ANALYSIS NEEDS TO INCLUDE STAKEHOLDER ANALYSIS • HARNASSING THE POSITIVE ROLES OF OPINION LEADERS • CRUCIAL IMPORTANCE OF INCLUDING ALL GROUPS/PROFESSIONS • USE THE DIFFERENT ROLES OPINION LEADERS CAN PLAY Prof Sue Dopson

34. Processes & skills required • CONSISTENCY & PERSISTENCE --too many priorities --time !!!!! • DEVELOPING FACILITATIVE SKILLS --planning meetings --developing and delivering a communication strategy • RECOGNISE THE IMPORTANCE OF POWER Prof Sue Dopson

35. Responses to Change: The Importance of Power Active Passive Opposition Support Prof Sue Dopson

36. The challenge of ‘engagement’ and the role of leadership ‘Technical Challenge’ Set goal and task Tell why Explain what and how Give instruction Motivate Measure and monitor • ‘Adaptive challenge’ • Set the context • ‘Get on the balcony’ • Describe a view of the future • ‘Give the work to the people’ • Manage conflict • Encourage, coach, challenge Prof Sue Dopson

37. Sir Geoffrey Vickers • Background • Victoria Cross, Classics at Oxford, City Solicitor, Director of Economic Intelligence, Board of National Coal Board (800,000 employees) • Para-academic, prolific writer, Visiting Professor at Lancaster University, aged 85 • Approach • ‘I have spent my life in practising the law and helping to administer public and private affairs; and I have thus had opportunity to observe and take part in the making of policy. The more I have seen of this, the more insistent has been the challenge to understand it both as a mental activity and as a social process, for it seems strange and dangerous that something so familiar and apparently important should remain so obscure. My enquiry into it has led me further than I expected. I have had to question sciences in which I am not professionally qualified and sometimes to supply my own answers, when theirs seems so ambiguous, inconsistent or absent. I present the result with humility but without apology. Even the dogs may eat of the crumbs which fall from the rich man’s table; and in these days, when the rich in knowledge eat such specialized food at such separate tables, only the dogs have a chance of a balanced diet’. Prof Sue Dopson