I am examining several of the important changes in NHS and linked public services practice that we need to achieve in the next few years. For each I am demonstrating HOW six different methods of change will help to bring them about.
Today I want to talk about,
Thinking about spread from the start
I know there will be some reading this who simply see the idea of skill mix as employing people with a ‘lower level ‘of the same skill. This is not the case. All clinicians are highly skilled but as in all aspects of work, levels of expertise are rarely uniform.
But certainly everyone else has a lower set of clinical skills than clinicians. However, since much of the work that comes through the primary care door is not of a clinical nature, but involves cultural, social and economic issues, other people could have greater skills in those areas.
To take a real example from a location looking to employ health trainers.
One of the questions asked to assess competency was, “Have you frequently successfully persuaded people to do something that they initially didn’t want to do?”
Persuasion uses a set of skills that some people have developed much better than others. A successful coach of a primary school soccer team will know how to do this well. A volunteer in the Citizen’s Advice Bureau will know how to motivate families to take action on debt that they initially believed they could not.
Across our society there are hundreds of thousands of people who have important skills that can help members of the public maintain greater self-management of their health conditions (and I would suggest are better at persuading people to do something they don’t want to than many clinicians).
This is what we mean by skill mix in the NHS and social care.
Turning now to the HOW to bring about spread. The NHS is very bad at it.
I remember Ara Darzi telling me 20 years ago that the way in which innovation actually spreads around the NHS was an unusual loop. He worked at both Imperial College and the hospital. The example he gave me was of a good innovation which was developed at Imperial College, but which the innovators couldn’t get the NHS interested in spreading across the service. So, they took the idea to Germany where it was enthusiastically adopted in some regions. Over the years it spread to different countries – Australia, Canada, tthe USA. This took some time. Eventually after 15 years someone from an NHS hospital went to a conference in the US, came across this great idea and brought it back to the NHS. Here it was enthusiastically received and implemented. Ara worked out it that it took 15 years for the innovation to cross a street in West London from University to Hospital. But in the meantime it had circled the planet.
The NHS absolutely fizzes with new small innovations. In every part of the service people are looking at their work and thinking “I am sure we can do this better!” “Why don’t we try this?” Often this thought is dismissed by the person themselves but sometimes, it progresses.
Last December I published a Fabian pamphlet with Charlotte Augst about how parts of the NHS were empowering patients in their own health and health care. We highlighted half a dozen brave and thoughtful innovations. With a bit more research (and a much longer pamphlet) we could have found 60 similar groups of colleagues doing great things to improve involving patients in improving their health.
If we had a month to explore, we would find 600. Not ideas on paper but all actually operating in practice. And that is in just one area of practice. Across nearly every area of practice there are many hundreds of exciting innovations. New apps, new uses of technology for back-office functions; new ways of taking notes; new ways of nearly everything.
But very few of them spread.
Mistakenly innovators from other countries look jealously at the English NHS because they think that since it is a single national scheme it should be easy to spread innovation. All you would have to do is to find the person at, or near, the top of the organisation, and pitch it to them. Once persuaded, all they would have to do is tell everyone below them in the NHS that they had to implement it.
As we have seen previously the belief that someone near the top of the NHS can simply tell everyone what to do is just wrong. This doesn’t stop a lot of people believing it and acting on that assumption, but it really doesn’t work. Don’t have ‘telling people what to do’ as one of your spread mechanisms.
Create – at the very beginning – a workbook of lessons about ‘how’. Make sure nothing is missed or forgotten. Put in too much (you can remove it later), rather than not enough.
So DO think about spread from the very beginning.
In the current example of a new skill mix for clinical care, the clinicians that you persuade to adopt the initial innovation will be similar to those that, later on in the process, you want to adopt it. When you begin, you are mainly concerned with the WHAT of the innovation you are creating. However, you also need, at this very early stage, to recognise that you are doing the HOW as well. And these early lessons in the HOW are those you need to note for the ‘spread’ future workbook.
If you think about adoption from the start, you will recognise lessons from how you persuade those first few clinicians that you will use when you spread the innovation and persuade others.
In my first post in this series, I went though some of the conversations that you need to have to bring about change. These often include the genuine experience of loss that some clinicians will have when they are asked to change their practice.
One of the reasons for thinking about spread from the very beginning is that when you are talking to your first clinicians about change you will quickly learn which arguments work and which don’t. In those first few weeks there are hundreds of small pieces of learning that you will need to note down, there and then, to use when arguing for adoption. Which words worked, which failed completely.
As you develop a ‘how’, you will also develop a ‘who’. If this works there will be clinicians, managers, and scientists all of whom will become enthusiastic about ‘their’ change’. (It really doesn’t matter that it was yours – much better to make it theirs). And they will want to argue for it. Whilst you will have developed the how and the what of change in one location, you and the clinicians involved will all have friends and colleagues who might be interested in developing such changes elsewhere.
If, between you, you have five or six such groups of people who want to bring about this change, form a community of practice with them. Work closely with them to help them to bring about the change. Meet regularly – virtually or in person. Share the secrets of your workbook. Think in detail about the words you used to overcome the blockages in your original innovation and make sure your community of practice gets to hear them.
Start with the overarching public-facing narrative that I outlined last week.
Someone may come up with a better way of making this innovation happen. The community of practice will be creating the second edition of your workbook of how to bring about that change.
And, as we shall see later this week, in order to spread the innovation you are thinking about it will be vital to develop the financial flows that will incentivise it.