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S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care
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S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care

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Health and Care Innovation Expo 2014, Pop-up University …

Health and Care Innovation Expo 2014, Pop-up University

S201 - Day 1 - 0930 - Developing large scale change strategies for integrated care

Dr Robert Varnam

#Expo14NHS

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  • 1. Leading large scale change for integrated care Dr Robert Varnam PhD MRCGP Head of general practice development, NHS England Clinical lead for CCG & primary care delivery, NHS Improving Quality GP, Robert Darbishire Practice, Manchester @robertvarnam robert.varnam@nhs.net
  • 2. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
  • 3. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
  • 4. The story so far
  • 5. Structure + process = outcome
  • 6. Structures Infrastructure ProcessesBehaviours
  • 7. The story so far We have often focused on structures & provider-led change … and ended up with integration of providers (more than care) … made more improvements than transformations ... and found progress hard to sustain … which was entirely predictable
  • 8. So what are we dealing with?
  • 9. Improvement or transformation? Improvement Transformation Doing things better / differently Doing better / different things
  • 10. What is ‘large scale’ change? Depth of change vis-à-vis current ways of thinking and doing; a.k.a cognitive-behavioural or paradigm shift Pervasiveness of change; does it affect whole or only portion of the system? Size of system experiencing change; e.g. geography, numbers of people Refs: Mohrman A. et. al. Large-Scale Organizational Change. Jossey-Bass, 1989 and Levy A. Second-order planned change: definitions and conceptualizations. Org. Dynamics. Summer 1986, 15:5-20
  • 11. Large scale change usually fails Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey of company executives 70% 25% 5%
  • 12. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
  • 13. Levers for change What happens ...
  • 14. Levers for change What happens ...
  • 15. Levers for change What happens ...
  • 16. Levers for change What happens ...
  • 17. Levers for change What happens ...
  • 18. Levers for change Very few of our ‘wicked’ problems will be addressed by believing the health and care system is a machine. Our experience shows that it behaves like a complex social organism. It is time for a different paradigm of large scale change…
  • 19. Complex Complicated Chaotic Simple Emergent practice Good practice Best practiceNovel practice Snowden D & Benford RD. The Cynefin Framework. Cause & effect relationships exist, are obvious to most people & predictable & repeatable. Can be known in advance. Cause & effect relationships exist, but not obvious, so require analysis/investigation +/- expert knowledge. Cause & effect only obvious in hindsight, with unpredictable, emergent outcomes. No cause & effect relationships can be determined. Probe. Sense. Respond. Sense. Analyse. Respond. Sense. Categorise. Respond.Act. Sense. Respond. Knowable Known Disorder Several options
  • 20. www.youtube.com/watch?v=ctMty7av0jc Coordinated, behaviour – thousands of birds moving ‘as one’ – with no external control How? A small number of simple rules, internalised: • Separation: steer to avoid crowding local flockmates, • Alignment: steer towards the average heading of local flockmates, and • Cohesion: steer to move toward the average position of local flockmates .
  • 21. Leading in complexity  A small number of simple rules  Acting within each unit  A few well-tested external influences & barriers
  • 22. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
  • 23. A different paradigm
  • 24. What’s the financial incentive? Who is performance managing? What’s the project plan?
  • 25. “I have some KPIs for your” or “I have a dream”
  • 26. “You can’t impose anything on anyone and expect them to be committed to it” Edgar Schein Professor Emeritus, MIT Sloan School
  • 27. Drivers of extrinsic motivation  regulation  payment & incentive systems  performance management  measurement for accountability create focus & momentum for delivery Intrinsic motivators  connecting to shared purpose  engaging, mobilising and calling to action  motivational leadership build energy and creativity
  • 28. build energy and creativity Internal motivators  connecting to  shared purpose  engaging, mobilising and calling to action  motivational leadership Drivers of extrinsic motivation  System drivers & incentives  Performance management  Measurement for accountability create & focus momentum for delivery
  • 29. How do we create shared purpose? Identify shared values Create a safe space Create a vision for the future Describe why the change is urgent now Amended from work by Roffey Park
  • 30. [Shared] purpose goes way deeper than vision and mission; it goes right into your gut and taps some part of your primal self. I believe that if you can bring people with similar primal-purposes together and get them all marching in the same direction, amazing things can be achieved. Seth Garguilo
  • 31. Using shared purpose The ‘why’ of your change A gravitational force for drivers The fuel that won’t run out A uniting force for stakeholders
  • 32. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
  • 33. Complex Complicated Chaotic Simple Emergent practice Good practice Best practiceNovel practice Snowden D & Benford RD. The Cynefin Framework. Cause & effect relationships exist, are obvious to most people & predictable & repeatable. Can be known in advance. Cause & effect relationships exist, but not obvious, so require analysis/investigation +/- expert knowledge. Cause & effect only obvious in hindsight, with unpredictable, emergent outcomes. No cause & effect relationships can be determined. Probe. Sense. Respond. Sense. Analyse. Respond. Sense. Categorise. Respond.Act. Sense. Respond. Disorder
  • 34. Sequencing in large scale change Identifying need for change Framing/ reframing the issues Engaging/ connecting others Making pragmatic change in multiple processes Attracting further interest After some time Settling in Possible outcomes 1. sustainable norm 2. plateau 3. run out of energy Living with results and consequences Maybe later Repeats many times in hard to predict ways Time delay
  • 35. Large Scale Change The emergent process of mobilising a large collection of individuals, groups and organisations toward a vision of a fundamentally new future state, by means of: • high-leverage key themes • a shift in power and a more distributed leadership • massive and active engagement of stakeholders • mutually reinforcing changes in multiple factors • a focus on changing patterns of behaviour, relationship & power
  • 36. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
  • 37. Conclusions from the evidence Successful integration requires: • shared purpose & collaborative behaviours, more than new structures • overcoming silos through communication (leaders & staff talking, shared patient record, shared performance data) • much can be done within existing regimes (eg tariff, Caldicott) • no silver bullet bit.ly/RzENMB
  • 38. Conclusions from the evidence “Leaders and managers tasked with applying integrated care ‘at scale and pace’ might … focus on driving forward the organisational solution or introduce various financial inducements in the hope this will be more effective [than starting with values-based shared purpose]. Such an approach would be a mistake… A values-driven approach should be a pre-requisite to the successful adoption of integrated care.” Goodwin, Nick. “Taking Integrated Care Forward: The Need for Shared Values.” International Journal of Integrated Care 13, no. 2 (June 24, 2013).
  • 39. Conclusions from the evidence • Eventually, successful commissioners have to adopt different approaches: • see the whole system, not just constituent services • more relational, less transactional • more clinically-led collaboration with providers, less finance-led negotiation • more provider-led innovation & improvement • less bound by annual & linear cycles, more flexible, long-term & iterative bit.ly/13Otdyq
  • 40. Top tips (NHS Academy for Large Scale Change) 1. Moving towards a new vision that is better and fundamentally different from the status quo 2. Identifying and communicating key themes that people can relate to and that will make a big difference 3. Multiples of things (‘lots of lots’) 4. Framing the issues in ways that engage and mobilise the imagination, energy and will of a large number of diverse stakeholders 5. Mutually reinforcing change across multiple processes/subsystems
  • 41. Top tips (NHS Academy for Large Scale Change) 1. Continually refreshing the story and attracting new, active supporters 2. Emergent planning and design, based on monitoring progress and adapting as you go 3. Enabling many people to contribute to the leadership of change, beyond organisational boundaries 4. Transforming mindsets, leading to inherently sustainable change 5. Maintaining and refreshing the leaders’ energy over the long haul
  • 42. bit.ly/1fBri9W bit.ly/1fUNUkl slidesha.re/1pSSbJh enquiries@nhsiq.nhs.net @robertvarnam

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