Delegate feedback included:
- “Diversity of speakers, pulls from personal experience and past mistakes.”
- “Wide range of speakers with very good reputations. Content important and relevant to my role. Up to date thinking, with an encouraging and energising tone.”
- “Good pointers for anyone leading change.”
We held the tenth in the series of Connect Health Change webinars “Service Redesign – a wicked problem? Learning from mistakes and activating the evidence for the right way to redesign services” on 17 March 2021.
System leaders and clinicians across the NHS are constantly dealing with the complexities of service redesign. This webinar aimed to provide practical solutions to the challenging issues of leading transformation during unprecedented times.
The webinar covered the importance of asking the right questions, with a focus on Darzi Fellowship and Versus Arthritis change programme techniques along with hearing about real life examples of redesign/transformation programmes – what went wrong, what went right and the importance of using a QI (quality improvement) approach.
Key learning points
- In any change or transformation, focus on two lenses – culture and infrastructure.
- Never stop communicating.
- The answers will always be found within the current team.
- Avoid silver bullets and sticking plasters.
- Never assume understanding, question everything.
- Start with the need, recognise interdependencies and redesign around that need.
Larry Koyama, Darzi Alumni, Versus Arthritis MSK Champion chaired the event, explaining:
I think the subject of service redesign is very topical at the moment and will be particularly relevant both in terms of covering some of the immediate challenges of Covid and also in terms of the proposed changes in the NHS white paper.
The webinar featured:
Rob Webster, CBE, Chief Executive, South West Yorkshire Partnership NHS Foundation Trust, and Chief Executive Lead for West Yorkshire and Harrogate Health and Care Partnership (WY&H HCP) (also known as an integrated care system), began by setting the scene. He said:
The Trust I work in operates in different settings, delivering community services, support for people with mental health illness, learning disability/autism and well-being support, as well as some specialised services, for example forensic outreach team.
WY&H HCP is a large, complex system covering thousands of public, voluntary and private sector organisations. Collectively we support 2.7million people, including 260,000 unpaid carers, and 23% (570,000) of the total WY&H population are children and young people. We are proud to be home to 20% of people from ethnic minority backgrounds and have a sense of pride in the richness, heritage and diversity of our communities. I mention that because it’s fundamental to some of the issues around service redesign and the way we work alongside communities and communicate across the area.
We’re a guest in people’s lives. We exist to improve outcomes for local people who face some of the most devastating health inequalities in the country. We need to manage unwarranted variations in care and to make sure that we use our resources wisely and in doing so; we can advocate for and improve the wider determinants of health, which have been further exacerbated by the pandemic.
In any transformation, there are two lenses to look through. The first is one of culture and the second is infrastructure. At both the Trust and WY&H HCP we encourage a culture of trust, where we share and adopt good practice. To that end we have striven to ensure three things: we are open, publish information constantly and meet in public; we engage and feed back to people on what they have told us; and finally we have members of the public on decision making bodies, as well as Healthwatch active at all levels. All leaders come together and in doing so it has enabled us to create meaningful provider collaboratives, such as the West Yorkshire Association of Acute Trusts, the Mental Health, Learning Disabilities and Autism Committee in Common, and our Joint Committee of Clinical Commissioning Groups. All have real power and authority for collective decision making. The crisis has strengthened relationships and trust. Without this solid foundation, our handling of the pandemic would have been much poorer.
Prof Becky Malby, Professor in Health Systems Innovation at London South Bank University (LSBU) went on to share her top tips from theory to practice. She explained:
We should think more proactively about mutual decisions made with patients as partners in communities. What’s interesting about this is, in the pandemic, we were able to do great things.
Let’s take an example of redesigning healthcare. Everybody wants A&E to be less busy and on the whole, people think it’s about rising demand, a lack of appointments in primary care and there’s no beds in the hospital. The solutions often reside at the top, saying there’s more people coming in, so we need to allow primary or community care to offer more appointments. But actually if you go and try and understand the problem, what we’re finding is that A&E breaches are not related to that, they’re actually related to increased complexity and more tests being done.
Primarily, care is organised around trauma, rather than complex needs and increased case management. There we need to take a very different approach to how we’re going to solve the problem. We start by looking at how we meet complex care needs and what we need to do at the front door and what we know is that for people with complex needs, you need your most experienced people at the front door. This is just an illustration about the need to really understand what’s happening because otherwise you put in solutions that don’t work and answer the wrong problem.
Carl Davies, Director of MSK, Berkshire West Integrated Care Partnership (ICP) described the application of complex systems theory to create meaningful and sustainable change.
I used to be a complex pain specialist physio and it struck me that a large percentage of the patients that presented were there because their complex needs hadn’t been met earlier in the system. 10 years ago I moved to very different roles in commissioning and operational management and noticed that people genuinely agreed on the need for change and they wanted to change, but were often disempowered.
So, I studied change theory and methodologies and leadership and one question always bothered me – “why, when there is a desire to change and all of this is known to be beneficial, do we still struggle to implement it”. It points towards deeper and more complex influences, which I’m currently studying as a PhD.
One of the things I’m looking at, is that the way we govern systems performance can often affect our ability to get the outcomes we want. Essentially too much control can inhibit our ability to create meaningful change and stifle innovate. That’s because people tend to direct their efforts away from doing what’s right for the long term, towards short-term quick fixes and sticking plaster solutions. These can appear logical and safe at the time, but actually create more problems as we move forward. Rather than tracking hundreds of KPIs, which are proxy measures for patient outcomes and experience – we should perhaps just get back to listening to patients.
The other thing to consider is complex systems are not designed – they emerge over time as a result of lots of small changes. This results in everybody and nobody being responsible for anything and can contribute to blame culture as those that want change become frustrated with those who appear to be preventing it. The reality is, we have all been part of the emergence of the system in its current state, therefore we are all responsible and need to all be accountable for helping shape the solutions – that need to be more complex and sophisticated that might first appear.
Mike Turner, Chief Operating Officer at Connect Health, talked about some of his takeaway lessons from redesign and change programmes over the years. He said “The first lesson is the need to get a balance between ambition and pragmatism or realism. When considering a change or transformation, we should start by thinking big, have a really clear vision and imagine the full potential of what we could achieve. What would it look like on its very best day if it was everything we wanted it to be? Don’t start off by being constrained by the likely obstacles and barriers. It’s easier to rein your ambition in later, rather than expand your vision.
The next one is not assuming the understanding of key stakeholders to the change. Try to understand their motivations and their needs. That could include patients in the context of healthcare change, as well as a wide variety of stakeholders. Finally, we need to manage expectations, be really transparent from the start and keep communicating throughout and keep testing that those expectations are understood.
The final remarks for each speaker covered this important question – “what is the one thing we need to focus on to make service redesign really work well?”
- Carl – recognise the complexity and make sure we understand the problems which are probably more difficult than when they first appear.
- Rob – when you’re sick of saying something, that’s when people have only just started to hear it. Never stop communicating!
- Becky – the answer is always in the team that you are currently working in. You can look at all the expertise in the world but let people bring forward all their skills, knowledge and expertise.
- Mike – assume we don’t understand the solutions and our stakeholders don’t understand what we’re trying to do and keep asking that question until completion.
See the accompanying Q&A summary for links to further reading.