Social Movements and the Future of Healthcare


As the crisis in the Western World deepens, and the growing reality sets in that business as usual simply can no longer continue nor solve our problems, our systems must change the way they view, deal with and hold onto power. The NHS is no exception. If we want a health and social care system that is of the highest quality, safe, sustainable and economically viable for the future, we need to understand the power of social movements, both within our systems and through the wider society. This is something we are really committed to in Morecambe Bay and so it was with great delight that I listened to the excellent Helen Bevan, talk about just how vital social movements are for the NHS and healthcare, worldwide at the recent IHI conference in London, Quality 2017. This blog will be an amalgamation of what Helen shared and my own thoughts about our early experiences with social movements.

 

 

A social movement in health and social care involves us all learning to connect, collaborate, cooperate, cocreate and coproduce at a level we have never done so, until now. But our circumstances are forcing us to reconsider the ways in which we work. We need the creative substance that is within our teams to be heard and harnessed so that we cut our waste and work more effectively together. The issues we face, need facing by us all, together; not by some board in an isolated room, making decisions based on diktats from on high, on behalf of us all.  But even this will not be enough. Those of us stuck in the system have become too homogenized in our thinking for us to do this exclusively from within. We need our citizens to help us re-imagine what it means for us to be healthy and well. We must stop designing things for our communities or doing things to them, instead we must design and do things with them. We must analyse, create and enact together and to do this, we must learn to solve the issues of power.

 

Helen Bevan, with her background in social science, demonstrates the great debate about the interplay between our organisational structures (rules) and agency (freedom) when it comes to effecting change. Where does the “permission” come from to enact the change we need to see? Is it externally generated by those in positions of power, or is it internally generated by a personal motivation? Our experience in Carnforth and Morecambe in community conversations has been a bit of both. There are many people of incredible heart and goodness, waiting to do something new and good that will positively affect the health and wellbeing of society, but are perhaps waiting for that sense of community backing, support, encouragement or indeed permission. With a bit of coaching or spurring on, we have seen some amazing initiatives begin that are bringing transformational work into our area and causing us all think differently. We need both individual agency AND corporate agency. Helen describes individual agency as being when people get more power and control in their lives – we see this in patient activation, shared-decision making and self-care – a greater sense of autonomy and responsibility. Collective agency, on the other hand, is where we see people act together, united by a common cause, harnessing the power and influence of the group whilst building mutual trust.

 

 

We have seen this used powerfully, in just one example by our maternity liaison service committee, who together have challenged our system to think more carefully about how we communicate to women, especially at key or stressful moments of their obstetric care. These stories are now a compulsory part of training for all who work in our maternity service and have significantly improved both our skill mix and ability to provide excellent care.
What is absolutely vital to understand is that we do not become transformed alone. We are transformed when we are in relationship with others (Hahrie Han). The problem is that we don’t really encounter the “other” enough to be changed. However,  when we let go of the kind of power that is held by the few, pushes others down, uses command and control, that is closed and transactional, and instead embrace a power that is held by the many, shared, open and relational, then we can begin to see the change we need (Hirschman and Ganz).

David Holzmer says that we are witnessing the collapse of expertise and the rise of collaborative sense-making. I would suggest that this has been going on for some time, but our systems have been incredibly slow at catching onto the change around us.

 

Now, what is hugely encouraging is this: research by Kollectif shows that you only need 3% of people in an organisation/society to drive the conversations with 90% of other people. In other words, you don’t have to get everyone on board from the word go. You find your passionate people with a sense of agency, infect them with the virus and watch it spread. These people need to be a mixture of ‘lone wolves’, mobilisers and organisers. Lone wolves are people who have been trying to help change happen for a long time but can sometimes feel like an annoyance to the system, so they are given tokenistic positions, patted on the head and patronised into exhaustion. Mobilisers build power by calling large numbers of people to contribute, engage in change and take action. Organisers build power by growing leaders in a distributed network, building a community and protecting its strength. We need all of them, though mobilisers and organisers will be the most effective in creating agency and bringing about lasting change  (Hahrie Han).

Joe Simpson says that ” great social movements get their energy by growing a distributed leadership.” The cult of celebrity can be powerful, but is not effective. The beautiful thing about a social movement is that is depends not on money, materials and technology but on relationships, commitment and community, and as the movement grows, these resources increase, rather than diminish. The problem, as Don Berwick puts it, is that leaders in position of strategic influence, are simply not seeing the resources available to the biggest problems we are facing.

 

Jason Leitch and Derek Feeley have powerfully shown that performance management (keeping the power), based on targets, sanctions and inspections can only get us so far. Quality improvement (sharing the power) gets us a little further, but mobilising social action, or co-production (ceding power) has a far greater potential to bring lasting change and far better outcomes for all.

 

So, how do we catalyze a social movement and how would we know if the movement was being “successful”? Well, our experience in Morecambe Bay is that you start with the 3%. You start with those who are drawn to the conversation, who recognise the need for change and who want to be part of it. You start with transparency, with openness, honesty and vulnerability about the mess we find ourselves in and the truth that we no longer have what it takes to solve the problem. And you start with really good questions and then deeply listen to the conversation which is emerging so that we ourselves are changed and can therefore be part of the emergence of something new, which operates on an entirely different kind of power.

You might call this a re-humanisation of our systems based on love, trust and the hope of a positive peace for all. But this social movement is not aiming for some kind of hippy experience in which we are all sat round camp fires, singing kum-ba-yah! This social movement is looking to cause our communities to flourish with a sense of health and wellbeing, to have a health and social care movement that is safe, sustainable, socially just and truly excellent, serving the needs of the wider community to grow stronger with individuals learning, growing and developing in their capacity to live well. That is what we must measure!
And so we need disruptive co-creation, which breaks through the top-town/bottom-up approach and causes us to see and hear like we have never done before. It is hugely exciting and enables managers to stop feeling like they have to extract as much performance as possible from the system, flogging the workforce, blocking change and innovation and inadvertently driving down the quality of care in the process.

The invitation is instead to become part of the change that we all long for. If we’re going to have an NHS in the future, we have to give it back to the people and work with them. In order to do this, we have to deal with and change our relationship with the very notion of power – something I will turn my attention to on the next blog!

 

 

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Creating a Culture of Joy in the NHS

A Culture of Joy is the biggest determinant of safe and high quality healthcare! That is such a phenomenal statement that it is worth reading over and over again, making it into a poster, sticking it on your wall and meditating on it morning and night. It feels to be simultaneously absolutely true and somehow beyond belief. I’ve previously blogged here about the need for a culture of kindness in the NHS, and I hold to that – kindness certainly doesn’t exclude joy (!), but a Culture of Joy….. I don’t know, in a day in which 50% of our staff admit to feeling burnt out, can we honestly say we have developed this throughout our health system in the UK? So, what does it take to build this? How do we have a joyful workplace? If it is really the single largest factor affecting patient safety, which research from The Mayo Clinic, The IHI and The Quality Forum tell us it is, then we better sit up, pay attention and do something about it!

 

There are 3 key ingredients to creating a culture of Joy.  The first (and this is in no sense a hierarchical order!) is leadership, the second is how
teams actually function together and the third is personal responsibility. You will see the words incorporated from the ‘culture circle’ in bold!

 

Good Leadership: Here’s a fascinating fact, I learnt from Stephen Swensen, of The Mayo Clinic – The bigger the signature of a CEO, the worse the outcomes for patients, staff and the finances of the organisation!! CEOs are responsible for setting the structures in place that allow healthy cultures to develop. Leaders create a culture of joy by having humility and developing 5 key behaviours:

 

  1. Appreciation – good leaders build joy in their teams by saying ‘Thank You’ – it is one of the things the team at my surgery consistently tells us, as partners. Of course we are grateful, but we don’t say it enough. Every member of a team knowing that they have value is so vital. I remember, as a house officer on a medical ward watching a lady called Jean, cleaning the ward and saying hello to all the patients. I went up to her and said, “Jean, I just want to thank you for everything you do on this ward, every day. The way you keep this place clean helps fight off infections and keeps people well; and the smile and kindness you bring is really comforting to people who are scared or hurting.” To my great surprise, she burst out crying. I asked her what was wrong and she told me that she had worked on this ward for 25 years and no-one had ever said ‘Thank You’ to her. My favourite hashtag on twitter is trybeinggrateful – it costs so little.
  2. Transparency – good leaders communicate openly with their teams. They don’t do ‘special huddles’ in which they invite a few ‘high level’ people to know their secrets. No. They communicate with honesty and openness and this builds trust. And with trust they are able to negotiate difficult situations and requests of their teams, because there is a belief that everyone is in it together.
  3. Ideas – They look to their teams for ideas. One of the things I loved learning about recently is that the CEO of Toyota in Derby, deliberately does not park his car in the special ‘CEO parking space’ right next to the building. Instead, he parks it at the far end of the factory, so that the walk to his office takes him through every department, (a good 30 minutes of his time), so he he can say “hi” to his staff, connect with them and ensure that he is hearing about their ideas for innovation and improvement. Toyota takes 2.5 million suggestions from its staff every year. This simply doesn’t happen enough in the NHS, and I wonder how many CEOs take time at the start of the day, to walk the corridors, listen to patient stories, understand the pressures in the ED, hear the heartbeat of the wards and get a sense of the ideas brewing in some of the most compassionate, caring and intelligent staff of any organisation in the UK. If we are to transform the NHS into a system that is truly safe, sustainable and excellent, we must listen more to the ideas of our teams and in doing so, we will cut waste, undo the reems of red tape and instead find we are working far more effectively and efficiently. To embed this into the culture, there must be psychological safety – that means that no question is too stupid, no idea is too dumb and it is safe to bring to attention concerns a person may have, without a fear of retribution. One great question for leaders to ask is, “what are the pebbles in your shoes?’ – in other words, what matters to you? Or what are the barriers for you here? What’s getting in the way? Great CEOs do not have great answers, they are willing to work with complexity and have great questions!
  4. Career Mentorship – every person needs to be able to keep learning and develop in their role. We all need mentors or coaches at different stages in our careers, and ensuring these structures are in place to support staff as the complexity and pressure we deal with increase, is vital in building joy. People who are developing in their role are naturally safer in their role.
  5. Inclusiveness – To a good leader, it doesn’t matter who you are, what you look like, what you believe, what your sexual orientation or status might be. You need to know that you are welcome and you are loved just as you are. Inclusive teams that do not scapegoat, do not sideline and do not bully are joyful teams. Joyful teams celebrate difference and thrive off it.

 

Joyful Teams:  It’s really important to understand that joy does not mean false happiness. It does not mean that we walk around with fake smiles on our faces all the time and pretend that everything is ok. Joy is much deeper than that. We deal with very sad and difficult things in our workplaces every single day. We break bad news, we hold people as they take their final breaths, we watch people make terrible life choices, we see and carry the hurt of those who suffer loss and each of us has our own burdens we carry from the lives we live outside of work. Joyful teams do not pretend like that stuff isn’t happening every day – quite the opposite. Joyful teams develop three key qualities:

  1. Camaraderie. The high school musical song – ‘We’re all in this together’ is a great theme tune for NHS teams. People need to know that they belong, that they are loved and that people care about them. On good days, we celebrate together, on bad days, we pull together. Joyful teams develop encouragement, support and kindness in how they treat each other.
  2. Purpose. Joyful teams have a real sense of shared vision and purpose. They know what they are there to do and each person knows that they are valued in that team. The posh term for this is a sense of corporate agency. This is our job to do, we are responsible for what happens here and we want to do our work with excellence. 
  3. Trust. It is really important that individuals feel trusted to do their job without feeling like they are always being watched or criticised or that they have to give an account for every action. When people feel trusted, they actually work more effectively and produce better outcomes.

 

Personal Responsibility: in order to create a culture of joy, it is not just the responsibility of the CEO or team leader, nor the atmosphere created by the team as a whole – we each have a responsibility to steward and hold to this culture. And that means taking care of our own needs. We need to be active, eat well, take notice, be mindful, sleep well, forgive those who hurt us and have good friendships. Making sure that we ‘host ourselves’ well, ensures that we play our part in building the culture of joy that is so vital to the providing care that is of the highest quality and safety. There is a personal accountability to ourselves and to those we work with to ensure this is so. There is also personal agency that rises to the challenge that each one of us can set a new trend and make a significant difference to the culture in which we work.

 

In the midst of all we are currently facing in the NHS, for the sake of our patients and their families, it is vital that we build cultures of joy now and cultivate them for the future.

 

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