#Quality 2014 transformation in integration 2014.04.10

Transformation in Integration
Catherine Blackaby
NHS Improving Quality
@NHSIQ @CBlackaby #integrationpioneers

What do we mean by integration?

Surely it’s easy?
X Y
Just do it Efficient system
IHI and RC Lloyd & Associates 2008

X

The 14 Pioneers
ICSP Pioneer sites
Barnsley South Devon and Torbay
Cornwall Southend
Greenwich South Tyneside
Islington West Cheshire
Kent WELC London
North West London Worcester

The Pioneer Programme
• 14 areas across England
• Integrating…
– Acute and primary care
– Mental and physical health care
– Social care
– Housing
– Third sector
– All the care and support needs around the person

Source: The King’s Fund
http://www.kingsfund.org.uk/projects/health-and-health-care-london@NHSIQ @CBlackaby #integrationpioneers

?

In association with:
National partners

https://www.gov.uk/government/publications/integrated-care

Aspiration
The pioneer localities will act as “a
means of driving forward change at
scale and pace from which the rest of
the country can benefit”
(Collaboration partners)

Six conclusions from previous “pioneer type” programmes
in health and social care over the last decade
1. Promising pilot programmes are rarely replicated successfully
2. Issues of spread and scale are typically an afterthought
3. Change is highly context specific
4. People outside the pilot locality do not feel any ownership of, or
emotional connection with, the pilot project so change processes
have to be “pushed” onto other localities rather than pulled.
5. Pioneer sites have limited ‘bandwidth’ to coach others and
spread best practices
6. Very few evaluation studies look beyond the pioneers to issues of
scale and spread
Source: @HelenBevan@NHSIQ @CBlackaby #integrationpioneers

Emerging themes in large scale change
Foundation Emerging direction
Organisation Community
Power through hierarchy Power through connection
Mission and vision Shared purpose
Making sense through rational
argument
Making sense through
emotional connection
Leadership-driven (top down)
innovation
Viral (grass-roots driven)
creativity
Led by expert opinion Allow all talent
Engaged patients Passionate users
Clinical networks Mass communities
Tried and tested, based on
experience
Open innovation
Transactions Relationships
Source: @HelenBevan

Two kinds of system-level problems
A difficulty
• Broad agreement on
the nature of the
problem
• Some understanding of
what the solution might
look like
• Clarity about the time
and resources required
to solve the problem
A mess
• No clear agreement about
exactly what the problem is
• Ambiguity about how
improvements might be made
• Unbounded in terms of the in
terms of the time and
resources it could absorb, the
scope of enquiry needed to
understand or resolve it, and
the number of people that
may need to be involved
Source: System Failure - Why Governments must learn to think
differently, Jake Chapman, published by Demos

"The secret to getting ahead is getting started.
The secret of getting started is breaking your
complex, overwhelming tasks into small
manageable tasks, and then starting on the first
one.“
Mark Twain

Necessary behaviours for managing
wicked problems
• Establishing shared goals
• Build trust
• Exchange information & other resources
• Embrace emergence
• Explore new territory
• Create new knowledge
• Facilitate, enable & coach

Closed innovation Open innovation
As a “pioneer” test site , we want to be left
alone for a period of time so we can work it
out for ourselves
As a “pioneer” test site, we seek to continuously
get ideas and guidance from leading thinkers and
practitioners outside our local area; as a result we
sustain our energy for change and continue to
implement changes over a longer timeframe
We will test our new ways of working
internally “to destruction”. When we are
confident they will work, we will offer to
share our “best practice innovations” with
others
A wider group has contributed to the innovation
process, beyond our host organisation; this means
that when it comes to diffusing the learning from
pioneer sites, people from other localities already
feel that they own it. Spread is more likely to be
“done with” not “done to” and to be “pulled” not
“pushed”

The power of co-creation

How are we doing it?
1. Build the Integrated Care and Support Exchange (ICASE) as
a learning community with and around the pioneers
2. Create, capture and spread knowledge, skills and ideas
using open innovation and knowledge sharing principles
3. Put the pioneers at the centre of the learning community
but with an open innovation mindset
4. Build a compelling narrative that calls people to action and
that focuses as much on “big picture” aspirations for
change across the country as it does on the specific
localities

5. Plan for spread right from the start
6. Create a special status for localities that applied but didn’t
achieve pioneer status. Create opportunities for them to
progress more quickly and effectively than the pioneers.
7. Clearly define what being a pioneer; create a “compact”
(contract) that sets out the “give and get” as a condition
of being a pioneer e.g. participation in open innovation
processes .

Where have we got to?

How are we doing it?
1. Build the Integrated Care and Support Exchange (ICASE) as
a learning community with and around the pioneers
2. Create, capture and spread knowledge, skills and ideas
using open innovation and knowledge sharing principles
3. Put the pioneers at the centre of the learning community
but with an open innovation mindset
4. Build a compelling narrative that calls people to action and
that focuses as much on “big picture” aspirations for
change across the country as it does on the specific
localities
?

5. Plan for spread right from the start
6. Create a special status for localities that applied but didn’t
achieve pioneer status. Create opportunities for them to
progress more quickly and effectively than the pioneers.
7. Clearly define what being a pioneer; create a “compact”
(contract) that sets out the “give and get” as a condition
of being a pioneer e.g. participation in open innovation
processes .
X
X
?

“If you feel entirely comfortable, then you're not far
enough ahead to do any good. That warm sense of
everything going well is usually the body temperature
at the centre of the herd."
— John Masters

Support programme
• Support managers
• Experts for trouble shooting
• Leadership development
• Large scale change training
• Networks and events
• Communications
• Learning community development

ICASE
www.icase.org.uk
#integrationpioneers

A different approach
• Working with the Innovation Unit
– a not-for-profit social enterprise
– committed to using the power of innovation to solve social
challenges
– supporting leaders and organisations delivering public
services to see and do things differently to achieve
radically different solutions that offer better outcomes for
lower costs.
• www.innovationunit.org

A different approach
• Working with the Innovation Unit
• Being steered by sites’ preferences and comments
• Tailoring a programme of innovative support that can
be dynamic and co-produced with the sites
• Developing a taxonomy for this way of working,
where themes become key learning communities

CONVERSATION 1
Suzanne Devlin
‘This is the slide set that was shared at the Measurement and Evaluation Session at the first Pioneer
workshop on 11th December 2013 in London.’
Dec 12, 2013
Abraham George
‘Suzanne, thanks for this. I believe the work PH has done here in Kent using the Risk Stratification approach
to understand service utilisation and costs is a significant stepping stone towards developing whole systems
approach for monitoring and evaluating the Integration Pioneer programme. As mentioned in the presentation
I would like to explore further with the experts / organisations. How do I go about this?’
3 days ago
Jo Frazer
‘Hi Abraham, we can discuss on Monday as I'll be gathering comments on proposed measures and make sure
you're linked in to ongoing work on evaluation.’
3 days ago
Abraham George
‘Thanks Jo’

Sarah McBride
My ‘other’ vote is about large scale pooling
of budgets, including how to get the
governance right, and public, democratic
and clinical involvement. Thank you!
The voting so far (24 hours later) …

Next steps for the learning community
• Selected themes from our first poll: “Innovative
commissioning & contracting” and “Workforce
Development”
• Targeted support and face to face events
• Tweet chats – April
• Google hangouts – May
– Like a group webinar allowing you to chat face to face and
share documents and other materials

• Selected themes from our first poll: “Innovative
commissioning & contracting” and “Workforce
Development”
• Targeted support and face to face events
• Tweet chats – April
• Google hangouts - May
• Challenge prizes
• Network development
• Pioneer initiated tweetchats, events and meet ups

• The challenges of:
– Multiple national programmes
– Multiple forums for sharing
– Providing flexibility for different levels of
engagement
– Balancing the expert voice with the voice of those
on the frontline
• Commitment and energy of those involved

Our request to you
• Post on ICASE – join the conversation!
• Become part of the virtual user group
• Tweet using #integrationpioneers
• Take part in the horizon scanning and hangouts
• Look out for challenge prizes
• Tell us what else has worked for you
• What else should we be trying?

“We can't impose our will on a system. We can
listen to what the system tells us, and discover
how its properties and our values can work
together to bring forth something much better
than could ever be produced by our will alone.”
― Donella H. Meadows, Thinking in Systems: A
Primer

References
• Wicked problems and the role of leadership – INL
2009
• System Failure - Why Governments must learn to
think differently, Jake Chapman, published by Demos
• Integrated Care: Our Shared Commitment May 2013
https://www.gov.uk/government/publications/integrated-care
• Thinking in Systems: A Primer – Donella H Meadows
• @HelenBevan
• enquiries@icase.org.uk

#Quality 2014 transformation in integration 2014.04.10

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