NHS partnership working and improvement; we've been here before

A number of large scale programmes are running in the NHS in England where communities are getting together to improve health and social care services. The projects have a wide membership from mostly statutory public sector organisations but also some in the voluntary sector. As some of the strategies sounded familiar I checked the Department of Health website.

I was involved in partnership working in the NHS in the mid and late 1990's. At that time in England there were also Healthy Action Zones which seem very similar to many of the programs underway at present. It seems to topic is coming round again but with a new language and consequently a delay in making changes. There are many papers and documents available form around 2002 - 2004 which have self-assessments, methods, best practice examples, case studies and similar. I find it so disappointing that those who are responsible for the spread of good practice and large scale change feel the need to continue to reinvent wheels - thus not practising what they preach.

If you are interesting in learning what has gone on before and in adopting and adapting existing ideas for large scale change then try out these papers from the Department of Health:

Working in Partnership; developing a whole systems approach (notable because it covers productivity - and this was 2002...)

Governance in partnership checklist of good practice

If you only want what is new then try
Working with Stakeholders which is 2010

Spread or Adoption? Which terminology works best for you?

Do you talk about spreading good practice or helping other to adopt good practice?

The difference is one between push and pull. Spread implies a push out, top down and hierarchical approach and adoption suggests we are unable to do the change and that the best we can do is help someone else to do it.

It sounds subtle but the difference is significant. Enabling the pull is difficult to do using a top down approach in the organisation. Yes, it is not only possible but downright useful for the organisational leaders to create a context and structural environment that enables professionals to be aware of and be able to implement existing good ideas. However, the application, the changes, are made by those who are affected by them, not the leaders.

It sounds to me that in the last year or so healthcare around the world has started to use the phrase large scale change to take the place of spread and adoption. I wonder whether this is due to the difficulty of the original two words?

The quickest way to spread scale up change

The most common question I am asked is whether there is a quick way to spread desired change across groups.

My Nobel Prize entry for answering this question is as follows:

"Yes and No"

The fact you are asking the question means you are in a type of powerful relationship over those with whom you want to interact and change. Namely you want them to do something different/ly and you want them to do it quickly.

The "Yes" answer is dependent on the carrot and stick approach. Pay a twelve year old to clean his bedroom and if the reward is big enough, the bedroom will be cleaned. Pay doctors a reward for meeting a quality target and they will achieve it (evidence the NHS and GPs). The stick approach is less effective but still works. It is no longer common to see anyone on their mobile phone while driving in the England. The stick of a fine and points on your license has worked, combined with appeals to common sense.

The "No" answer comes from asking questions like those listed below. If I get more than two or three "No's" in response then I suggest to the person asking that they have probably answered their own question.
- are you making the change yourself?
- can you describe to me the three main reasons why the person you want to change thinks this will be a good idea?
- do you apply the methods you are proposing in your own work and/or personal life?
- is your reason for this work more than doing a good research project you can publish later
- will the person/group you want to change see the change as coming from somewhere other than yourself?
- do your plans involve more than a communication exercise?
and so on

Spending Challenge - HM Government using crowdsourcing

The UK government is using a simple online webpage to gather ideas on how to save money. It is called the Spending Challenge. You can input your idea, some words about how it can be implemented, add a tag or two and then post it. You can read through others' ideas, add tags and ratings. The system allows you to search by tag, new ideas, most commented or highest rated.

This is crowdsourcing at its most pragmatic. I doubt they spent more than £1000 setting up the system. The addition of a rating system gives it power and meaning. Especially as anyone can rate any idea - not just those in power.

In the same month this is launched I've worked with a variety of public sector teams who range from denying the existence of technology, denying they have permission to use anything remotely interfacing the public (or their staff) unless there are controls, or want to create their own thing. Probably worse, some are still working at the level of theory and concept for social movements, mobilisation and networking, running workshops and developing programmes to spread the word of change. By the time they've spent a fortune on their programme, a huge part of the UK population will have been mobilised using simple techniques such as this Spending Challenge one.

I feel that so often we get lost in the theory and concepts, and the need to develop eloquent (and controllable) solutions, that we overlook the most simple mechanisms, complemented with speed and pragmatism.

Well done HM Treasury for getting the Spending Challenge social movement underway.

Crowdsourcing shifts us from what to how

"to improve" is a verb. A verb is a "doing word". Improvement is action. Collecting and storing examples of good practice is a displacement for action. Huge knowledge banks where the thing of the 1980's (yes, thirty years ago) and by the late 1990's were largely discredited as a mechanism for helping spread good practice. The few organisations that did manage to leverage the codified knowledge, did so because they institutionalised through clever IT systems, the search and sharing of knowledge. Note, this sharing was linked to the individuals with the ideas and not odd pieces of extracted information. The personal relationship mattered.

What does the modern day action to improve look like when we are aiming to avoid the reinvention of wheels?

a) We crowdsource. We call on the community for their ideas. However, asking for and then collating ideas is not crowd sourcing - it is a cheap way to create an ineffective database. Crowdsourcing works when participants rate ideas, decide which is best. Many organisational leaders fear crowdsourcing because the answers may not be what they want.

b) We get more active in presenting the problems and then asking people to provide answers - as an open call. The joy in this approach is it is not limiting the solution to the thinking and mindsets of employees. This has been around for at least a decade and the are many websites and systems to help make this happen. Some organisations even provide all their data so others, not part of the organisation, can use it to help solve the problem. The first step to making this happen s to give up control and to ask for help.

In the UK we are experiencing the crowdsourcing as the Government has set up systems to ask for ideas on solving problems. I like the way they are asking the citizens on ideas and not restricting it to Government employees only.

Crowdsourcing gives the vote to the hungry consumers and nto to the turkeys.

Some Crowdsourcing links and resources


1. Wikipedia: for starters

2. IdeaScale is where you can set up your own Q&A and ranking community for innovations. There are hundreds of existing web applications for crowdsourcing so if you are spending money creating your own then let's hope there is am excellent reason for doing so.

3. Fevote - place to make suggestions and get votes on them (great for research and tests of change)

4. Kluster: - stunning group decision-making tool

5. Good blog post on crowd sourcing resources

4 kinds of relationships

So much of spreading good, known and evidenced practice is based on social connections and relationships. John Maxwell has four ways in which relationships can be categorised.

1. Some people add things to life (we enjoy them) +
2. Some people subtract something from life (we tolerate them) -
3. Some people multiply something in life (we value them) *
4. Some people divide something in life (we avoid them) /

If a key role of the person who group is trying to influence others to change their behaviour then it might be useful to reflect on the relationship between the "spreader/pusher" and the "adopter/puller".

There are some people I avoid (4) and I am unlikely to even receive the messages they are pushing out, let alone act on them. In a similar vein, those I tolerate (2) I will probably put them low on my priority list and will be fairly sceptical about what they put out. Whether I adopt anything they are pushing will be a matter of personal judgement.

On the other hand, those whose company I enjoy (1) I will probably get to hear a lot about what they are saying, thinking about and pushing in my direction. I will take their information in quite quickly, though may still toss the ideas about before making any changes to my behaviour.

Those I value I will probably not wait for them to send me information. I will be finding ways to connect, listen out carefully and will most likely shift my behaviour quite quickly when they send out behaviour related messages.

So which types of relationships are you creating and endorsing?