Why Conversations to Transform Health and Care?

I was Head of Applied Leadership at the NHS Leadership Academy for three years and was asked to sit on the ‘Building a Digital Ready Workforce’ National Steering Group.  This led to me thinking about what we needed to do to help the boards of NHS organisations in particular to lead the transformation of Health and Care Services making the most of ‘digital’ – whatever that meant.

After much thinking I started to believe that it didn’t really matter what we did to develop boards; workshops, bootcamps, maturity matrices or conferences about AI and genomics. Until we changed how they saw their world and tasted different ways in which they might be able to lead in it, they were unlikely to make substantial changes in their strategy.  They might drop a few tens of millions on a new patient record system – but would that really transform? Would that allow new patterns of power and relationship to emerge? Or would it just take some kinks out of the current system?

For me it felt like doing ‘the wrong thing better’.

But what was the right thing?  The thing that might ‘develop’ the system?

Conversations to Transform Health and Care

The thing that went against the habit of Board rooms, Board tables, agendas, PIDs, rag ratings and budgetary decisions?

Against hierarchical expressions of power delivered through plans and Gantt charts and (not so carefully) managed variances?

Well for those of us that have worked a lot in civic society, in community development, the place to look for some clues was clear.  Self organisation. Emergence. Transparency. Relationships, Inclusion, Diversity and Trust.

Work in the spirit of pioneers like Harrison Owen, Peter Vaill, John McKnight, Peter Block and others.  It was about leading with communities not over them or for them.

Connecting small groups of people with the passion, responsibility and power to make change happen locally and to invite the formal power structure to sit with them and listen. To be influenced and to influence. but mainly to encourage and support.  To ‘unleash’ the power of these small groups that care to do their work.

And so we started, with the support of James Freed and Maeve Black at Health Education England and Ian Macintyre from the NHS Leadership Academy, on our project to use Conversations to Transform Health and Care.  To see if ‘Leadership as Convening’  might help to really transform Health and Care.

Open Space Events were planned for York, Hull and Scarborough to see if we could find the people who might really have the passion and the responsibility to transform health and care and whether we could help them to find their power….

Just follow the links to see a short film about what we did in each location and to explore what the people that can wanted to talk about.

What is Open Space?


The future of a community…

What determines the future of a community?

Whether it becomes a place where most of its members live happy and fulfilled lives or ones that are full of misery and fear?

Does it depend on the decisions made by planners and politicians in national and local government? On what we might call ‘the planners paradigm’ where architects, planners, policy makers and property developers shape the places in which we live.

Or, does it depend on which entrepreneurs decide to operate in the community? On whether ‘Big Business’ comes to town or not?  On whether we can encourage enough of the creative class to join our community?  On what we might call ‘the entrepreneurial paradigm’ where the presence of many vibrant and creative entrepreneurs (that special breed) provide employment, products and services for those of us somehow less gifted?  Who create the wealth and taxes that provide the rest of us with our livelihoods and public services.

Or does it depend on the extent to which everyone is supported to recognise their passions and develop their capability to act in ways that make things better for themselves, their families, their community and the planet as a whole?  On the extent to which people are valued by others in the community and able to use the resources of knowledge and experience available to them to make progress?  What we might call ‘the capability paradigm’.

Of course all of these things have an impact.  If the planners provide poor infrastructure, or if big business hoovers up money from the community and filters it back to distant shareholders then it may be more difficult to develop a sustainable and vibrant community. But not impossible.

I believe that communities which learn how to respond to and support individuals and groups within their ranks who are seeking to make progress; who learn how to access, channel and develop capabilities and potentials will steadily become both more cohesive and harmonious.

I believe that ‘the capability paradigm’ holds the most effective key to building great communities.  Communities that embrace it, and learn to master it, will be reported by those living in them as good places to be.  They will start to become wealthier and healthier than their more fragmented, less connected counterparts.

But most importantly they will become more fulfilling places to live.

Paradigm Shifting and Thriving together

Paradigms are tricky things, sometimes almost invisible, certainly not often directly observable. But they are well worth thinking about, and learning to work with for those who want to try to improve things a bit.
If we can recognise our paradigm and change it a bit, then all sorts of new possibilities can emerge.
They are a bit like ‘the system’ that we live in. The system of widely accepted and normalised beliefs, methods, values, customs and practices that we usually just take for granted.
And just like fish don’t recognise that water exists, until that moment they are removed from it, most of us don’t recognise the paradigm that we live in. It is an almost invisible context or medium that we operate in.
Paradigms matter because they give us a context and ways of working, but they also bring with them limitations. They rule certain things out, or at least relegate them to the ‘unusual’.

The Horse Paradigm

For a long time the main paradigm that shaped transport policy, planning and practice was the paradigm of the horse. Horses were the most cost effective way of providing power to our transport systems. The paradigm was so powerful that at one time it was thought that the limits to growth of major cities was the capacity to remove horse shit, urine and carcasses from the streets. By the late 1800s most major cities were drowning in horse manure and urine. With more than 50 000 horses on London’s streets each producing 7-16kg of manure and a litre or more of urine it wasn’t just the smell and the mess that was the problem, but also the flies. But this is what ended the horse as the dominant paradigm. But it didn’t start that way. To begin with only the rich could afford to travel by horse. The rest of us had to walk. The horse was not the dominant paradigm to begin with. It was walking.

And this tells us something about paradigms that seems generalisable. They first appear in our world as a minority activity that gains in popularity before fading away. Sometimes this happens in the course of a few years and sometimes it take decades or even centuries.

Back to the horse paradigm.

Most of the experts of the late 1800s were seriously consumed by the challenges of the waste products of the horse paradigm and how to remove them from our cities – preferably without using more horses! Most were really not focussed on alternatives to the horse which all appeared outlandish, dangerous and rife with problems of their own. When the first steam engines were being turned into locomotives hardly anyone thought they were going to be the next big thing in transport. Canals were seen to be much more viable propositions than railways. When Henry Ford was messing about with the first motor car his customer research didn’t go well. People didn’t want his dirty, expensive, unreliable cars, they wanted ‘faster horses’.
And this tells us something else about paradigms that seems to be generalisable.

The clues to the paradigms of the future are to be found co-existing alongside the current dominant paradigm. Often ridiculed or feared, as the dominant paradigm outlives it usefulness or creates more problems than it solves, they gradually become more popular until perhaps they become the dominant paradigm.

And as one paradigm declines to be replaced by another there can be conflict. The dominant transport paradigm in most of our cities at the moment is of course the motor car, still largely petrol driven, already taking up too much space for our road system and still getting bigger, using a ton of metal and plastic to transport usually one <100kg passenger, killing and maiming people every day at a disconcerting rate and endangering our very existence through pollution and climate change while spending most of the time parked up consuming valuable land space.

Contenders for an emerging paradigm?

More but different cars, clean power systems, driverless cars and shared car fleets? Or public mass transit systems? Or bicycles, scooters and e-bikes? But we can be sure that the current dominant paradigm of the car won’t go without a fight. Often literally. And it will probably take a very long time to go completely. I mean we still love our horses.

Why does this stuff matter? Why should you think about it?

I suppose to some extent this depends on how you characterise the current dominant paradigm and whether you want to see it develop and grow, or whether you want to see it replaced by a new paradigm.
If you think that the current dominant paradigm is working well and has room to create more value then your focus should be on resourcing and supporting this work and perhaps ensuring that you don’t invest in emerging paradigms that might threaten this one. I mean if it ain’t broke, why fix it?
If on the other hand you think that current paradigm has become toxic, creating more problems than it solves then you might choose to invest your energy in supporting emerging paradigms and potentially undermining the dominant one, or at least trying to limit its growth.
Unless you think carefully about this stuff you may find that, while you would love to see a new and different paradigm emerge, you have been effectively captured by the current dominant paradigm and compelled to work in ways that support it, either directly, or by earning a living clearing up the mess that it makes. Our cities used to be full of people whose job it was to carry away the shit and the dead horses so that the dominant paradigm of the horse could continue unaffected. These days perhaps our cities are full of people clearing up the mess created by our own dominant paradigm; global warming, homelessness, mental health crises, plastics, crime…

Paradigm Shifting…

So can we shift a paradigm? Can we consciously act to accelerate the demise of one paradigm and the emergence of the next? Can we manage a transition from one paradigm to the next without a full blown crisis. And if a crisis does hit, is the new paradigm waiting in the wings, oven ready, to step up? Or do we have no alternative but to put the defibrillator on the old paradigm and spark it back into life? Like the banking crisis in 2008 for example.
Some people might focus their energy on bringing about the demise of the dominant paradigm while others fight to maintain and develop it. Some might focus on developing ideas and technologies that might lead to possible new paradigms while other innovate strictly within the dominant paradigm, reinforcing it further still. And often these players all co-exist side by side in the same place, at the same time. And learning how to work together to ensure that the dominant paradigm creates as much value as it can, while allowing new and perhaps better paradigms to emerge seems like a worthwhile leadership challenge. And at the heart of it is

  • paradigm awareness,
  • the effective management of power and resource imbalances and
  • the building of trusting relationships between those that could otherwise easily come in to conflict.

I work in a wide range of settings, from cultural education partnerships, local authorities, the NHS, the private and third sectors. In every setting I have found that an exploration of new and emerging paradigms and the implications this has for leadership, decision-making and partnership working has had profound and very practical implications. If you would like to explore whether some considerations of paradigm shifts might be helpful to you and your work please do get in touch.

Linking Up Services to Support People’s Needs








Linking Up Services to Support People’s Needs – a conversation proposed by Kath Dyer of St. Andrew’s Court (Exemplar)

This was to a large extent a discovery conversation – swapping notes on local food growing projects and networks, talking about Social Prescribing – for staff working for two new services. These were a residential home for people with complex needs and a multi-disciplinary outreach team for Modality, a company which has recently taken over the running of four GP Practices.

Kath described the facilities at St. Andrew’s Court and gave the example of an elderly man with dementia who was incontinent, needed 3 people to bathe him, was anxious and who had been sleeping in a chair rather than a bed for many months. He is now much less anxious, sleeps in his bed, and often needs fewer people to help bathe him. This level of care is expensive. The group discussed the fact that it is possible to have “all the bells and whistles” in terms of buildings and equipment, but doing activities and making sure that people are looked after and stimulated doesn’t always happen because of staff shortages and attitudes of staff. Members of the group involved in Social Prescribing talked about the practicalities of St. Andrew’s Court, for example transport, whether the home can take direct referrals or referrals through social services, how easy it has been to recruit staff.

The philosophy of the home was that workers were in the residents’ home, rather than residents being in the workers workplace. Activities, timetables and everything other than medication schedules are built around the residents. If they want a lie-in, they have one. Activities need to be useful, entertaining and meaningful, including baking, a sensory herb garden, plans for raised beds in the garden providing vegetables for meals, a probable cat, visits from dogs and a possible llama!

What do we do if the connectivity isn’t there?

What do we do if the connectivity isn’t there? How do we overcome?

This conversation was proposed by Kerry and soon took the form of an interactive art installation made up of knives, forks and soup bowls arranged on the floor – our Open Space event caters for all learning styles!

Some of what was discussed in this conversation was about infrastructure – rural areas have a lot less connectivity than urban – but some of it was about access, which inevitably includes issues such as GDPR and professional status/permissions.

There was also some conversation about how lots of things are linked, but there is always another nook and cranny to find out about, and that is why there is a role for a link person or Care Navigator. There was some frustration – “the system is shit” – but also the (age-old?) realisation – everything is really linked, we all really need each other, we just need better communication.

Kerry created a model in which everything was connected to everything else – so no vertical siloes, just data flowing everywhere in every direction, which she thought would be a good thing, and she asked “Am I being naive?” The answer from Adam Jennison, from Hull City Council’s Smarter Cities agenda, was “Yes”. Kerry was quite happy with this answer, and determined in future that she would direct her attention and energy to smaller number of data hubs, rather than shouting out to everybody! The next question for her was – so which hubs?

Social Prescribing

Social Prescribing (and how to meet people’s needs by connecting to community groups and activities) was a conversation proposed by Jade Whitelock and Joanna Smith of Modality.

Nobody turned up for the first part of this conversation, thus proving another of the laws of Open Space (whoever turns up is the right people!) so the proposer and notetaker had a chat about Social Prescribing in general, and then this conversation merged with another conversation, the one about what we do if Connectivity isn’t there.

Social Prescribing is a new approach for the GPs, which arose from ConnectWell commissioned by the CCG in partnership with Citizens Advice. It was designed to address social needs, loneliness, isolation, sometimes arising from medical needs, mental health needs, poverty. Activities such as gardening, going outdoors, crafts, and art therapy are known to support people’s overall health and wellbeing – what else is going on?

The conversation moved on to a little incident that had happened on Facebook the day before, where an elderly man had asked the group One Hull of a City what he could do to overcome his isolation and lonelinesss, on 2 or 3 days of the week. There were 67 replies, signposting him to Men in Sheds, All For One choir, arts and crafts and social activities all over the city. So what if there is already a fantastic network of social capital, social prescribing, working organically through social media? The man in question said it had been hard to reach out as he did, but he did it. What about those who don’t manage to do that, and what about those elderly people who do not want to learn how to use computers and smartphones, or learn how to use social media? For some, computers are causing isolation and loneliness, and there is a digital generation gap.

Shared Language (on all levels)

Shared Language (on all levels) was a conversation proposed by Louise. At first glance, it appeared that this conversation might be a familiar one, about specialist language and jargon and how it plays its part in multidisciplinary teams. It may even have started out that way.

What it turned out to be, or turned into, was a profound conversation about the necessity for the “team around the person” to be just as person-centred in relation to one another as they are (or aim to be) in relation to the patient. “Everyone’s humanity is part of the team, not just the professionals and their training”.

The conversation started by talking about domain-specific language and the challenges of moving a multi-disciplinary team “into GP-land”, whilst designing services to all be in one place, built around the person rather than sending people from pillar to post. The Protected Time for Learning that is a keystone of the Primary Care Network’s way of working was seen as precious and essential, especially to other disciplines that did not have that integral element of peer- learning, CPD and self-care embedded. Part of the Shared Language conversation became about “What brought you to the profession in the first place?”, the importance of one-to-ones with each patient, the need to take care of your own personal resources and vulnerabilities, and acknowledge this humanity, especially in the context of burnout in Health and Social Care.

“Thank you for seeing us as human beings not just healthcare professionals”.

This led to another strand in the conversation about changing culture, using a conversational model rather than solely a medical model, acknowledging the presence of hierarchy and jargon, and the kind of language expected in reports, but also the value of “gut feeling” and not just the DSM. The “signs of safety” model was seen as a positive, simple, conversational tool to identify what is working well, and what is not, whilst the words “parental capability” and “issues” got the thumbs down!

Technology, Productivity and Workforce in health and care

Technology Productivity Workforce in health and care was a conversation proposed by Dorothy Montgomerie who had a particular interest in how technology impacts the workforce in the context of an ageing population.

This conversation drew the largest number of attendees in the first instance and soon developed smaller eddies around the central emerging theme, which was about drug management, and the ways that people work with, and sometimes confound, the technology.

One of the attendees introduced the newest version of the Medi-Clear medication management system, which the manufacturers are aim to connect up to an app via an RFID tag, to make it part of the Internet of Things. The conversation went into some of the challenges – medication stashers, carers feeling like naggers, the push towards independent living, the way we can all become immune to alarms once we get used to them, and the gloriously detailed data from the Bar Code Medication Administration – which nobody then does anything with. It was acknowledged that sometimes, knowing that a seal has been broken and some medicine has been removed from the pack is not enough, you don’t know if has been taken or not, so there is always another step that has to be taken, by someone skilled and authorised to do so. But the first critical information piece of information – the seal has not been broken, so the medicine definitely hasn’t been taken – provides an alert.

This led to the issue of, for example, recalibrating Warfarin dosages, and ensuring that carers providing domiciliary care, often out in rural settings, were able not only to get the necessary information about dosage changes, but also the right sized doses themselves. It was suggested that Amazon (or another delivery service) could get these out to where they were needed more quickly and efficiently than carers (who have other things to do!). This would then raise the issue of who is responsible when something goes wrong, at what point someone senior signs it off, and who pays for it (and how).

There was a very strong sense in this conversation that there were easier, cheaper ways of doing this (managing care in people’s homes) that we could learn from private sector businesses, that this was the kind of thing that NHSX and NHSDigital should be doing – but that it would all fall down if we don’t have the internet connectivity.

Conversations to Transform Health and Care in Hull

Our third set of conversations to Transform Health and Care took place in Hull.  It was quite an emotional experience for me to go back to the Thornton Estate, home of the Goodwin Development Trust where I did quite a bit of work many years back!

People from a range of backgrounds, and from across the city, came together to take part in an ‘Open Space’ afternoon to explore how digital might be used to transform health and care.

We held a total of seven conversations over the afternoon.  These are listed below and each is accompanied by a short write up and some graphics too.  Just click the links on the ones that interest you.  And please do join the conversation by using the comments to add your experiences and insights or to ask questions.

It was such a pleasure to see people smiling, connecting with new people  and generally enjoying the work!   Hull has a population of about 285 000, so it is not a big city, and yet people working in the same field in the same town met each other for the first time.

Here are some notes from the conversations we held in Hull and some of the images that Tom drew to go with them…

    1. Who is Not in the Room? – a conversation about inclusion
    2. Shared Language – on all levels
    3. Technology, Productivity and Workforce
    4. Technology and Smart Cities
    5. Social Prescribing
    6. What do we do if the Connectivity isn’t There?
    7. Linking Up Services to Support People’s Needs

We’d love to know what you’ve learned, reflected on, what you feel you want to continue talking about. If you’d like to write a post for the blog, share your notes or help us connect with other people who might like to join the conversations please do let us know through the comments here…

Conversations to Transform Health and Care

To see what we talked about when we visited York… click here

For Scarborough…click here

Who is not in the room?

Who is not in the room?

This conversation emerged in part from the Smart Cities one, and the stream that was interested in the initial design of research being informed by local communities, as early as possible in the process.

This conversation ranged widely and made the point that if you want to reach the kind of people who don’t usually come to these kinds of things, then don’t put on another of These Kinds Of Things especially for them. Be creative. Piggyback onto something that is already happening, in places like East Park events like The Big Malarkey, or smaller free events near people’s homes. Bug people in queues. Be creative about how to reach people with mental health issues or mental disabilities. Decide who it is that you want to speak to and reach them through a gatekeeper. Recognise that there are other rings of people outside those know to your gatekeepers – social media can be away to get beyond the initial coterie.

The point was made that what designers of research programmes are looking for is a different perspective – not just a new or good idea from inside their own professional and lived experience – but information from outside that experience. So rather than asking why people are readmitted to hospital, what they might really need to be asking is “what happens when you get home?”. These shifts of emphasis can be crucial. What would you ask people in Bransholme in your shipping container, for example? Not big, open questions. Specific, something meaningful, for example, about the lived experience of a cancer diagnosis, such as how to you travel to and from your treatment, what is that like? If you have to attend an appointment Castle Hill, and it’s 2 buses, in winter, and the appointment is scheduled for 8 am…