Service Redesign – a wicked problem?
Webinar Blog and Q&A summary, 17 Mar 12:30-13:45
Connect Health “Change” brings you the tenth in a series of webinars to make and embed transformation in healthcare. Aimed at system leaders and clinicians across the NHS, the webinars provide practical solutions to the challenging issues we are all grappling with.
Our webinar involving change experts, system leaders, commissioners and academics debated what are the essential elements to service redesign.
The webinar covered:
- The importance of asking the right questions – consider what you need to do to make it work and the context in which you’re doing it
- Focus on Darzi Fellowship and Versus Arthritis change programme techniques
- Real life examples of redesign/transformation programmes – what went wrong, what went right
- Using a QI (quality improvement) approach
- Diversity of speakers and pull from personal experience and from past mistakes.
- Wide range of speakers with very good reputations. Content important and relevant to my role. Up to date thinking. Encouraging and energising tone.
- Good pointers for anyone leading change.
- Inspirational speakers
Watch the Webinar in Full
Larry Koyama, Darzi Alumni, Versus Arthritis MSK Champion – introduction from the Chair
Rob Webster, Chief Executive, South West Yorkshire Partnership NHS Foundation Trust, and West Yorkshire and Harrogate Integrated Care System
Question 1: What has frustrated you the most in redesigning services and in particular, bringing the community with you. How did you go about resolving some of those challenges?
Answer: Frustration is a function of expectation and what I’ve learned over time is, if you want change that’s embedded, it’s worth taking a bit more time to get it right. The thing I’ve come to realise is I don’t have all the answers, in fact I might not even understand the issues. Becky, who’s on next, taught me a while ago that you should look at the issues not just what the answer is because you might actually be focusing on the wrong thing. They should be starting with ‘what is it that we need to fix from a service user perspective, from a staff perspective, from a citizen perspective’. You overcome that by getting the right people in the room from the beginning and really listening, then working together on a solution.
The other thing that really frustrates me is when people’s assets are wasted. We call someone a patient and then waste all of our assets because we’ve labelled them, put them in a box and then said ‘we’re here to treat them’… What we should be doing is recognising you have somebody who lives with an issue, is probably pretty well informed, has a view, lots of experience and can then move on with you. I have some frustrations… but I think there’s always solutions.
Question 2: How do you achieve moving away from competition in practice when organisations are potentially fighting for recognition and even survival?
Answer: The narrative is important. Someone described to me that ‘we should stop organising services around our own egos and start focusing on the people that we’re here to support’. That requires a certain style of leadership and takes time and effort but once you sit down and talk to people you realise everyone’s got the same fears and dreams. I do think there are also some practical things you can do and so you can take away the financial threat. We moved to aligned incentive contracts.
We’ve got a mental health alliance and all the money is given to the providers collectively to deliver the outcomes that are required for people with mental health issues in Wakefield and my trust hosts it.
We then talked to one of our partners in an independent sector organisation who was doing poorly on recovery for IAPT and we’re collaborating on ideas, we’re partners, and working on what’s the best way to deliver for people’. I think some of those practical things, about taking the fear away of competition, taking the financial incentives away around competition, will help drive a different conversation that can go even faster and better where you’ve got good relationships around shared purpose.
Question 3: When we talk about change its often top-down, obviously in the work that you’ve done that’s not the case… Are there any thoughts and ideas about how to bring staff along and making sure that cultural piece is embedded because often that is a key predictor of success?
Answer: You’re not starting with a ‘greenfield site’, you’re in an organisation with a culture and you’ve got to understand the culture, and people’s experiences first-hand and talk to them face to face. Somebody said once; ‘leadership’s a combat sport’. It’s a direct contact sport isn’t it? You need to talk to people, see where they are, see what it’s like for them. At the root of this, what you’re asking people to do is take responsibility for doing the job and improving the job rather than being passive recipients of being told what to do from the top. Firstly, you have to recognise that is quite a scary place for some people. You’re expecting me to take responsibility for changing things, that means I might get the blame… so the kind of tone that you set is important.
The simple thing I always say is that; “I’m very happy to remain accountable but I’m giving you authority to act”. That permission is more powerful than I imagined in my career
We train 250 people a year in accredited change programmes, we help and support them, we stop doing things that don’t work and we celebrate success. When it happens, over time you recruit people who want to be in that kind of organisation. Those features of giving people authority and retaining accountability yourself giving them the tools to do the job and celebrating success, are all important features.
Question 4: Can you give one key point of something that we need to focus on to make service redesign work well going forward?
Answer: When you’re sick of saying something, that’s when people have only just started to hear it! My thing is communication never stop communicating.
Question 5: In terms of ICS’s going forward, as we move from PBR to blended/block contracts, how will that change provider behaviour? Will perverse incentives creep back in?
Answer: We have had aligned incentive contracts across acutes for 3 years. It’s all been very positive as it gets away from the accounting and into the action required to deal with issues faced by people
Prof Becky Malby, Professor in Health Systems Innovation at London South Bank University (LSBU)
Question 1: How do we move away from the competitive stuff which often undermines relationships?
Answer: It’s a false narrative, I mean competition is dead, no health system in the world is using it anymore, it doesn’t work. We are interdependent, there is more demand than there is money. The only way we survive is recognising our interdependences and working out how we collectively meet needs. Our job here, is not to protect institutions our job is to meet people’s health needs.
Question 2: How do we improve culture?
Answer: There are some things you can do that are very simple because people are quite worried that ‘we’ve got to be at the top to do this’
The very first place you can start is with ‘how are you?’ and then, at the end of the meeting ask ‘how did we do?’ ‘did we do the work we thought we should have done?’ ‘have we done as well as we could have done?’ ‘what would make it better?’.
This is a short time at the end of any session, but it really helps develop the culture, just with the people you know, it’s very simple but it does make a little bit of difference. It changes the nature of how we relate, which is that we care about each other and we want to do better.
Question 3: The delivery system around PPE in the early days was seen as a complete disaster whereas the system focused on vaccination a great success. Any views on how these approaches differed and what can we learn from this in terms of service redesign for the future?
Answer: This is a very unpopular response, a heroic NHS delivered both of those things – being heroes means that some people turned up to work to save lives, putting themselves at risk despite the fact that across the world people are saying don’t do that, don’t put yourselves at that level of risk. That has caused real distress, now we know that there are all sorts of reasons for that, however, with aerosol generated COVID some people have had very difficult personal experiences, as a result of being heroic in those conditions, because they felt like they had no other choice.
We’ve got quite a complicated relationship with the public as NHS organisations and staff. We have to move into the space where those looking after people with learning disabilities, with mental health needs, people wiping bottoms, helping people eat, helping people who are suffering and holding people’s hands as they die… that they, are as valued as the ‘heroic saving lives version of the NHS’.
Question 4: Can you give one key point of something that we need to focus on to make service design redesign work well going forward?
Answer: The answer is always in the team that you’re currently working in. You can look at all the expertise in the world but actually you’ve got it there and so you let people bring forward all the knowledge, skills and expertise that they have.
Carl Davies, Director of MSK, Berkshire West Integrated Care Partnership (ICP)
Question 1: What would you say has been the most important thing for leading change in the current NHS, which is obviously going through lots and lots of changes at the moment?
Answer: It’s probably two-fold. First, I’d say letting go of the ego is really important. Often ideas get dominated by one particular interest group and that distorts the balance, if we’re going to work in the best interests of the patient, then we probably need just to let go of that. Also, to just be open and honest about not understanding the problem. We collectively have different pieces of the puzzle, so we’ve got to work together. Also, remembering why we’re doing it… if it’s about patients, it shouldn’t matter that it’s your job to do something specifically and change might adversely affect what you perceive to be your role.
I often go into most jobs focused on management or transformation knowing that if I do my job well, I’ll make myself redundant. Hopefully, we go in there and empower people, then we actually improve the system. It means that we need less people and less resource, but we deliver better outcomes and that really should for me be at the heart of everything that we do.
Question 2: Carl, you mentioned moving away from competition but how do you achieve that in practice when organisations are potentially fighting for recognition and even survival?
Answer: First, you have to remember why competition was created. It was created because we thought it would give us the best outcomes. Over time, we’ve learned that perhaps it doesn’t. There are some trade-offs that you have to have so it’s a call to people with control and influence over how they govern across the system.
If you’re stuck in a system that has already got a very competitive environment, that’s a really difficult challenge. If you haven’t got the climate, the infrastructure and the culture, which enables joint working and partnership to work, it becomes really difficult to get sustainable change.
There’s an argument to say, people want the same outcomes and the same things – we all want better services for patients.
Question 3: There’s lots of issues around cultural change in NHS, particularly around staff expectations. How do we move forward with making sure we’re able to deliver change that meets staff experience and needs?
Answer: Making sure that they’re engaged in that process and it’s not done to you. There’s two parts to culture, there is the overarching framework and the infrastructure that we create and making sure that people have safe spaces to air their concerns and share their stories. Then, there’s also the part which they play a role in helping shape those solutions. It’s those two things, there’s only so much you can do, the system will move as fast as it will allow itself to be shifted and certain key leadership positions might be able to influence that, but just starting to chip away and create those spaces becomes extremely important.
Question 4: Can you give one key point of something that we need to focus on to make service design redesign work well going forward?
Answer: I think it just comes back to what the key thing has been around recognising the complexity and making sure we understand that the problems are probably more difficult than how they first appear, therefore, working in partnership to understand that and to deliver those solutions.
Mike Turner, Chief Operating Officer, Connect Health
Question 1: How has Connect Health embraced change? What systems or things have you had in place to achieve that change across the organisation?
Answer: Just be open to that reality and keep talking about it. keep going back to that point of who your key stakeholders are and those people who are experiencing or benefiting from the change. Constantly check in with that experience. and the understanding people have.. Then, don’t be a slave to the methodology or approach. The solution that you thought you were starting with – just be really opened to flexing that as you go along and accepting that from the word go. It’s almost part of the scope of a project, it’s not going to be what we thought it was.
To the second part of your question. The stakeholder piece is one of the things we’ve focused hard on. I wouldn’t sit here and suggest we always get that right but trying to be really clear (and this might be internally within our organisation or external stakeholders), who are the key stakeholders to the change? What’s their perspective?
The risk I’ve experienced over the years, is you put a lot of time in at the start really understanding your stakeholders and their perspectives, then kind of assume that’s put in the box ‘we’ll carry on doing what we’re doing’ and then at the end of the change almost go back and say so is it what you thought?
The other really practical one, is all of this takes time and effort of your resource to manage a change, to engage with your stakeholders, to keep an eye on your risks – whatever it might be. Just be realistic. Try and create that headroom for change.
Question 2: Can you give one key point of something that we need to focus on to make service design redesign work well going forward?
Answer: Assume that we do not understand the answers, or the solutions and our stakeholders do not understand what we’re trying to do and keep asking that question until it’s all over and being done.
Watch the webinar again, which includes further insight from the speakers including a full Q&A session, and read more about the speakers here:
Read more about transformation at Connect Health: