Doing your local leadership differently

1. Doing your local leadership differently Steve Onyett Long Term Neurological Conditions 1st May 2009

2. “Leadership has been the neglected element of the reforms of recent years. That must now change.” “Darzi Review” final report (DH, 2008)

3. Putting People First • …stated that “national and local leadership is now essential if we are to achieve system-wide transformation” • and lists the first key element of a personalised adult social care system as: • “Local authority leadership accompanied by authentic partnership working with the local NHS, other statutory agencies, third [non-statutory] and private sector providers, users and carers and the wider local community to create a new, high quality care system which is fair, accessible and responsive to the individual needs of those who use services and their carers.

4. Thought for the day. Today Programme. Radio 4. 26th February 2009 • “Here is the gift of relationship. It lies at the very core of what it is to be human.” Rev David Wilkinson, principal of St John’s College, Durham

5. Start with what builds relationship for service users The artist is Mel Gittridge, and this image was exhibited as part of Expressions, a touring display of art by people who have experienced mental or emotional problems- this picture captures the idea of environments where people can take power, supported by other environments where people can take power.

6. Chris Ham on commissioning • Failed attempts at the purchaser-provider split suffered from “lack of time to develop skills, relationship and experience” • “too much attention appeared to have been paid to the legal form of contracts and not enough to the development of relationships between purchasers and providers (HSMC, 3).

7. Make time (somehow!) • “..recent research into the impact of Local Strategic Partnerships .. suggests the need for development time to explore the type of relationships that local agencies want to have and the organizational processes and structures that will be needed to deliver this. Making this time and space is crucial yet difficult, as the pressure to deliver better outcomes for service users can often seem in tension with the need to develop the capacity of the board and thus the partnership”. Glasby and Peck, 2006 p.16

9. Trust and social capital • “.. the greatest loss over the past 50 years may have been in squandered social capital. Social capital consists of those social networks of mutual trust and the associated norms of reciprocity that made the NHS “ours.” • The NHS is essentially a national partnership between the citizens and those who work in it. For all partnerships the defining element is mutual trust and generalised reciprocity—the willingness to contribute, confident that at time of need in the future there will be support in return”. Welsh, T. & Pringle, M. (2001).

10. Four underpinning principles in the new DH approach to change • CO-PRODUCTION • To engage people across “the system” to work together to make change happen • SUBSIDIARITY • Ensuring that decisions are made at the right level, and as close to the user as possible “Each tier of the system only does what it can only do”. • CLINICAL OWNERSHIP AND LEADERSHIP • Building on the Darzi concept of staff as “Practitioners, Partners and Leaders”. • SYSTEM ALIGMENT • Aligning different parts of the system towards the same goals as a way of achieving complex cultural change TAKEN TOGETHER THEIR WHOLE IS GREATER THAN THE SUM OF THEIR PARTS

11. CO-PRODUCTION- It is not just about delivering public services • “If co-production focuses exclusively on the types of labour needed to enable public systems to work better, it will tend to undervalue the significance of the effort invested in giving love and comfort, approval and disapproval, caring and mentoring – and equally the effort involved in civic engagement ranging from attending meetings to making phone calls to mobilising social protest”. • “Personalisation” needs to be rooted in mutual support and recognition that not everything can be bought • Should users use budgets to buy friendship? Edgar Cahn. Foreword. Co-Production. A manifesto for growing the core economy. NEF. 2

12. New Economics Foundation. Co-Production. A manifesto for growing the core economy.2008. 2

13. It is about “deepening and broadening” public service • “The point is not to consult more, or involve people more in decisions; it is to encourage them to use the human skills and experience they have to help deliver public or voluntary services” New Economics Foundation. Co-Production. A manifesto for growing the core economy.2008. 10-11

14. Co-production and working from strengths • “… people are defined entirely by their needs and so those needs become the only asset they have. No-one should be surprised when people then behave in ways that perpetuate such needs” (11). • “When ..assets are deliberately ignored or sidelined they atrophy”. (11) • “Co-production demands that public service staff shift from fixers who focus on problems to enablers who focus on abilities. … This role is not recognised or rewarded within the management structures that are currently in place”.(13)

15. “Front-line staff are essential to delivery and empowerment... • Their morale is as important as client morale. Yet in practice, the participation that they are asked to extend to clients is often not extended to them”. New Economics Foundation. Co-Production. A manifesto for growing the core economy.2008. 13

16. Trusting Relationships Conflicting Needs Shared Vision Pressures/Stress Shared Values Change/Uncertainty/Dishonesty Integrity UnclearCommunications Clear Communications Complex/Poor Data Reliable Information Lack of Time / Prior Experience Familiarity Distrusting Relationships Source: Richard Lauve, MD (VHA Inc.)

17. The energy of social movements • “Social movement thinking is about connecting with people’s core values and motivations and mobilising their own internal energies and drivers for change… • …[evidence from change management studies show] people change what they do less because they are given analysis that shifts their thinking than because they are shown a truth that influences their feelings • ..rather than a single individual, it is a network of leaders at multiple levels who guide and mobilise the successful movement” Helen Bevan of The NHS Institute

18. ‘Four Column Matrix’ Strategic Goals System Level Measures National Targets Projects Develop transformational goals that connect with the values that brought people into healthcare in the first place Develop system level measures that track progress against these goals Show how externally set targets sit within the context of the strategic goals to build ownership to delivery Align project level goals with the strategic goals of the system to create a sense of purpose and channel energy

19. Establish a system-level vision for improvement with ambition and commitment. • Leaders need to commit personally to the vision. This means taking a stand and framing the objectives as promises to users and the people that support them.

20. Aims framed as promises to users

21. System alignment • Allow yourselves with others to be moved by delivery stories • Give wide and shared exposure to the lived experience of service users • Envision the future together and ambitiously • Don’t be coy about the love you put into your work

23. Appreciative Inquiry Is about developing the competence to CHOOSE a way of thinking • “Appreciative Inquiry is the cooperative search for the best in people, their organizations, and the world around them.” • “It involves systematic discovery of what gives a system 'life' when it is most effective and capable in economic, ecological and human terms.” From “An opportunity to learn more about Appreciative Inquiry” Presentation by Anne Radford

24. Solution focus/appreciative inquiry- exploring what works so that we can do more of it We manifest what we focus on and “we grow toward what we persistently ask questions about” orWhat we talk about gets bigger!

25. It works to build the positive core of the organisations involved. • Organisations need a lot less fixing and a lot more affirmation. • Appreciation builds relationships, collective intelligence, and freedom to innovate From “An opportunity to learn more about Appreciative Inquiry” Presentation by Anne Radford

26. “The Power of Appreciation.. • ..rests with its self-reinforcing and self-generative capacity” Srivastva and Cooperrider, 1999 • This requires inclusion, safety in participation and good communication = • Effective teamworking and leadership • Teams are where this is modelled and enacted

27. The 2007 NHS National Staff Survey • 93% responded positively when asked: “Do you work in a team?” • However this shrunk to 42% when the survey explored whether the team in question fulfilled criteria for a well structured team • Findings consistent since 2003!

28. Real teams have.. • Clear and shared objectives • Members who have to work closely together to achieve the objectives of the team • This interdependency includes users and their supporters • Members who have different and clearly defined roles within the team • The minimum number of team members required to get the job done

29. Working well with living systems means working well with “complexity” • See for example – • Bob Hudson. (2006). Whole systems working- a Guide and Discussion paper. CSIP-ICN • Jake Chapman. (2004). Systems failure. Why governments must learn to think differently. London: Demos

30. Or just • “Recognising how the universe works and just getting on with it” • .. theory

31. Are your issues “wicked”? • Don’t be surprised of they are – the easy problems have been solved! • They involve many stakeholders with different values and priorities • “When confronting frustrating problems, an enterprise would do well to recognise that they may be wicked. Moving from denial to acceptance is important; otherwise companies will continue to use conventional processes and never effectively address their strategy issues” Camillus, J. C. 2008. Strategy as a wicked problem. Harvard Business Review

32. “Wicked problems” • Involve issues with roots that are complex and entangled. • Are difficult to get to grips with and change with every attempt to address them. • Have no precedent • So .. nothing to indicate the right answer Camillus, J. C. 2008. Strategy as a wicked problem. Harvard Business Review

33. Properties of “Wicked problems” • There is no definitive formulation • It is not obvious when you have reached a solution (no “stopping rule”) • There is no immediate and no ultimate test of a solution- the solutions have their own consequences • Every attempt at solution counts significantly Camillus, J. C. 2008. Strategy as a wicked problem. Harvard Business Review

34. Properties of “Wicked problems” • Each problem can be seen as a symptom of another problem • Discrepancies can be explained in numerous ways- because people have different definitions of the problem • You have no right to be wrong- there is too much at stake! • Solutions are not true or false but good or bad- it’s all down to judgement …there is only better Camillus, J. C. 2008. Strategy as a wicked problem. Harvard Business Review

35. So it’s a bit swampy! • “Swamps were generally seen as useless and even dangerous”. • “Swamps are characterised by rich biodiversity and specialized organisms.. • .. such as frogs”. • “…. swamp draining is nowadays seen as a destruction of a very valuable ecological habitat type” Wikipedia

36. Simple Complicated Complex Following a Recipe A Moon Rocket Raising a Child • Recipe is essential • Recipes are tested to assure replicability of later efforts • No particular expertise; knowing how to cook increases success • Recipes produce standard products • Certainty of same results every time • Formulae are critical and necessary • Sending one rocket increases assurance that next will be ok • High level of expertise in many specialized fields & coordination • Rockets similar in critical ways • High degree of certainty of outcome • Formulae have only a limited application • Raising one child gives no assurance of success with the next • Expertise can help but is not sufficient • Every child is unique • Uncertainty of outcome remains From - Plsek, P. “Complexity, culture and large systems change” presentation Source: Brenda Zimmerman, PhD

37. Questions? (after Chapman, 2004) • Are we spending too much time trying to apply complicated solutions to complex problems? • What approach would we adopt if we accepted that systems cannot be controlled nor their behaviour predicted? • What might we need to do differently?

38. The problem of Big Planning • “Long term planning and the rigid structures, precise task definitions and elaborate rules that often accompany it, may be positively dangerous, ‘fixing’ an organisation in pursuit of a particular vision when an uncertain world requires flexible responses”. Hudson, 2006 • May need “holding frameworks” for relevant subsystems to keep direction and coherence

39. Build collective understanding of what working in complex systems really means • Small changes can have big effects • ..and big changes very little effect • Emergence- the whole is greater than the sum of the parts • Tolerance of uncertainty and flexibility • Recognising the futility of control

40. The pointlessness of controlfrom Jenny Rogers “Influencing Skills” • You can’t force people to work effectively on something they disagree with. • Organisations are so complex and subject to so many diverse influences that it is pointless trying to control them. • Distance from most senior to most junior makes it unlikely that control can be exercised over that stretch • Much control is unnecessary -where there is openess and willingness to give feedback • Control reduces risk taking- a necessary precondition for the innovation on which organisations depend • It’s exhausting and your time can be better spent!

41. What implications of more ecological thinking? • Push and exhortation (nor even resources!) from leaders and policy makers can be counter-productive.

42. People’s ability to stay the same will always be greater than our ability to make them different

43. Working with your stakeholders- what is their • Readiness to change? • Confidence to change? • Judgement of the importance of change?

44. Respectfully consider these cells and provide information to inform

45. What are their natural attractors? • Patient/carer benefit • Feeling effective • Getting to know people better • Autonomy • Choice • Self image (e.g. as a scientist) • Reduced paperwork and boredom • Geewhizz gadgets • Feeling part of something important • Lifestyle enhancement • Good stories to tell • CV brownie points • Etc., etc., etc., etc.

46. What implications of more ecological thinking? • Change needs to happen bottom-up but the right conditions need to be created. • …like gardening, or throwing a party?

47. Working with complexity values • Allowing solutions to emerge by: • encouraging rich interaction, removing barriers and oppressive controls • giving space and time, • not overspecifying means

48. Working with complexity values • Valuing multiple perspectives • Using multiple approaches that make effective use of experience, experimentation, freedom to innovate and working at the edge of knowledge and experience.

49. Working with complexity as “surfing the edge of chaos”, Pascale, et al (2000) “.. In systems as in life, when threatened, [it] move towards the edge of chaos. At this edge experimentation and mutation occur from which creative solutions can emerge. When this occurs living systems self organise and new forms or patterns emerge. The challenge for leaders is to disturb or disrupt the movement at the edge to provoke the desired outcome” – sometimes referred to as “perturbing the edge”. McKimm et al, (2008) Panic Zone Discomfort Zone Comfort Zone

50. “..Success is the ability to go from one failure to another with no loss of enthusiasm”. Winston S Churchill