As the themes of the NHS Long Term Plan start to become reality through plans for legislation to support integration, is it just legislation that will make this happen? Is this more about large scale change management or is it cultural change, rather than the creation of new bodies and boards?
The direction has been clear for a long time- integrated care systems (ICS) are coming with joint working, sustainable use of resources, getting a focus on the system and not individual organisations. This is really a large-scale change programme, with changes in the way leaders and organisations work, at the heart of it. How could leaders’ approach this?
There are lots of change models, and resources available on implementing large scale change in the NHS. These highlight that this is an emergent process:
- mobilising a large collection of individuals, groups, and organisations
- towards a vision of a new future state
- where there will be a shift towards more distributed leadership, and power
- with active, comprehensive engagement of stakeholders
- with mutually reinforcing changes in multiple systems and processes.
With the NHS model for large scale change the need for a clear vision – better and different, making it meaningful for individuals and breaking the change down into smaller steps, best underpinned by improvement models, such as plan, do, study, act, Langley, G, Nolan K, Nolan T (1994).
However, to make real change stick, it needs aligning with culture, and it is worth considering “how things are done around here” and how to make the change sustainable. Without making the change stick the programme could be amongst the two thirds of change projects that fail. Most fail at the embedding or “re-freezing” stage with behaviours reverting to old behaviours after a short time, and usually after the change has been heralded a success. This is where leaders, of all organisations, involved in collaboration across the ICS, need to focus, and personally demonstrate the changes that will make an ICS really work, for the future. Getting the underpinning culture right to support, and embed, the changes is one of the most important roles for leaders.
Gerry Johnson and Kevan Scholes developed the Cultural Web in 1992, which allows an approach for looking at and changing culture.
The Cultural Web, Johnson, and Scholes 1992,
The Cultural Web identifies six interrelated elements that help make up the “paradigm”, the “how it is done around here”. Each of the six elements need to be considered to identify what isn’t working, needs to change and what can stay the same. For integration and collaboration to really make a difference and support the shift to successful ICS working what could be considered might be:
Stories – leaders talk about what they have seen as good, maybe, examples of how teams work together across organisational boundaries, with communities, making a difference and improving health and wellbeing for everyone in the community. Concrete examples of quick wins where the ICS is making a difference, and where behaviours support the system, not individual organisations.
Rituals and routines – how people should behave and what is valued. For example, leaders recognising staff for working across boundaries. Making it everyone’s business to enable patients and communities in improving their own health.
Symbols – the visual representation; focus on wellbeing, not illness, what can local networks achieve working with communities. Considering logos, pictures on documents, websites, and presentations to represent inclusive services, celebrating diversity, local communities, and wellness.
Organisational structure – this isn’t just the organisational chart but is also the unwritten lines of power and influence. Leaders need to make sure they have routes hear individual contributions, from across the system, including those communities more difficult to reach, getting the input of frontline experience.
Control systems – the way the system is controlled, including how financial allocations are made, how performance is monitored, and quality recognised. Make the most of flexibilities that may be available to develop non-bureaucratic ways to supporting change to happen, whether that is enabling people to work across boundaries or allocation of resources in a timely way.
Power structures – the pockets of real power, those who have the greatest influence on decisions, operations, and direction. Leaders need to connect these individuals well with front line staff, ensuring they are visible throughout the ICS and to the local community.
Leaders need to take this approach forward to make real and sustainable change to fulfil the triple aim of:
- Better health and wellbeing for everyone
- Better quality of health services for all
- Sustainable use of NHS resources
Working together across the system, or at place level within it.
PCC supports leaders, not just with the theory, but through pre-work to understand the issues the system is facing, the priorities for change, and then bringing leaders together to work on these issues. Our leadership programmes consider how best to approach change, how understanding yourself and others is crucial, the importance of emotional intelligence for leaders and how to use it; as well as the skills of influencing and genuinely working with patients and communities. Contact email@example.com to discuss how we can help you.