Lisa Sharples is a member of the OD Bootstrappers Action Research Group. In this blog, Lisa reflects on working across a complex system and her experiences of being a Bootstrapper.
The Leicester, Leicestershire and Rutland (LLR) STP is built on the foundations of an existing ‘Better Care Together’ programme. I joined the portfolio office team in April 2015, to lead on Organisational Development across the partnership of three local authorities, three clinical commissioning groups and three NHS trusts. The team were hosted by the system, but we were all new to LLR, and thus didn’t have any existing alliances to any one partner. This gave us an interesting perspective as somewhat detached and independent of the system, able to observe dynamics that perhaps others were unable to see.
I was attracted to the role because of the partnership/ cross organisational nature of it. I’d worked as a Head of OD in a large organisation before, and I wanted to challenge myself in an environment that I knew would likely be more political, and in which I’d have to trade heavily on my ability to build relationships and influence. I wanted to see what the difference was between working in a single organisation and working across a partnership where the organisational drivers, strategies and cultures would be different. How would that compare to working across departments in a single organisation? How would it change when the nature of the ‘problem’ (increasing demand and complexity of health and care needs, with little new resource ) was likely more complex, and when the diagnose-and-fix approach was struggling to impact?
One of the first things that struck me was that no one could explain quite what they wanted me to achieve. My remit was around ‘creating a system culture’ to enable transformation, but leaders were clear that whatever ‘system culture’ meant, it shouldn’t interfere with the culture of their own organisation. There was something there about identity – perhaps like identifying as European whilst having strong British values… identifying as part of the LLR health and care system whilst having a sense of identity at an organisation or team or professional level. In a lot of ways, this was similar to working with identity between departments or teams in an organisation – if there is a clear view of shared purpose and role, you’re on your way. The challenge in this case was in agreeing an articulation of shared purpose that took into account the language used in different settings – it was complicated, involved a lot of engagement, a lot of governance, and took longer than it would have in a single organisation, but wasn’t complex , and we got there in the end.
I was also struck by the level of connectedness (or not) of parts of the system. The chief executives met regularly and in some cases there were connections at Director level, but often there was no connection at all. Front line staff of all types told me that they’d lost connections that used to exist years ago in parts of the system that used to work more closely. Often some of our large scale engagement events and world café interventions would bring together people doing similar or connected roles who had never met. It was relatively straightforward to bring together cross system project teams to map existing services and think about system improvement. There were issues around accountability and risk to work through, and the ‘getting to know you’ and team development work to support. Sometimes simple and sometimes more complicated, but not often truly complex. I was able to bring the OD leads from each organisation together – we sought to understand our collective practices, to support cross-system engagement, and ultimately to create and deliver a System OD strategy and plan based on what workers in the system told us they’d need to support new models of care (systems leadership, purpose and story, space and time to think, cross boundary working methods and tools)
So not all ‘system level’ working is complex. In fact, a lot of it is straightforward and pulls on exactly the same skills and tools you might use in a large organisation. Yes, it often takes longer, and yes it can be more political, and involve misunderstandings around language, and the like. The saboteurs come from all angles with a whole range of agendas, but so do the innovators and the change agents.
For me, the complex bit came when the system simply didn’t have an answer managing the rising level of demand within it. Demand projections far outstripped the available financial resources using current models of care. Changing the model in one part of the system, might shift demand elsewhere, and often there were no existing ways to predict what the impact of making a change might be. There was a requirement to create a ‘Plan’ to both manage demand and return to financial balance and systems would be measured against that ‘plan’. The problems and challenges with this have been widely covered in literature by the likes of the Kings Fund, but for me in my system OD role, they could be summarised into the following:
- Each organisation was regulated and measured on its own performance. Moving demand and financial risk around the system meant that there were winners and losers at an organisational level. Ultimately the chief executives and chairs around the partnership table could lose their jobs if they didn’t act in the best interest of their organisation. Whist relationships and trust developed to a point where there was open conversation about this issue, the partnership struggled to resolve it at a system level and it was clear that national changes would be required to enable progress. My OD role here, although never explicit, was to enable these dynamics to be surfaced and spoken about safely and provide space for the partnership leaders to work and learn together, continuing to build and maintain trust, and to manage the levels of frustration and blame which could arise.
- Power and influence in the system would shift with the external political environment and with the relative resources of the organisations within the partnership. This for me was the truly ‘dynamic’ element of understanding the shifts and finding ways to work with them rather than against them. My OD practice here was very instinctive, often in 1-1 conversation and informal coaching. I had to regularly stop and ask myself ‘what am I observing about the dynamics of the system? What questions can I ask that will help others observe too?
- A new approach to care, focussing on prevention of ill health and on managing long term conditions in completely new ways for which there is no clear blueprint. Managing the transition to those new ways without losing the ability to manage demand during the transition. My OD role here, was to create interventions that enabled learning together – building the connections at all levels of the system (eg an intervention to bring together the GPs, district nurses, social care team and relevant specialist services in a locality to build connections and think of themselves as a test bed for experimental new approaches, looking for patterns in A&E admissions data as a result of their trials)
Working in this space meant a lot more ‘going with the flow’ and a lot less ‘building and implementing a plan’. There was a lot more ‘can you just come and be in the room while we talk about …’ and an expectation that I would help to make connections, join dots, ask challenging questions, make objective observations and help people step back and reflect.
Being part of the OD Bootstrappers work has helped me to reflect on my practice and my strengths. I think it’s natural when working across multiple organisations to assume everything is complex, and I’ve probably spent the majority of my time using my existing toolkit to apply simple principles at a ‘developing systems’ level. In the complex parts of my work, I’ve found myself drawing on ALL of my past experience, my tacit knowledge and my gut instincts to look for power and patterns and to build connections and enable learning. I dusted off my copy of the Fifth Discipline and reconnected with some learning organisation principles that I haven’t studied explicitly in years. I rediscovered the Cynefin framework, which for me has helped make sense of my OD role in different scales and spaces. I also enjoyed some of the Kings Fund work on system leadership which talks about working at different levels.
I’ve also made some truly wonderful connections to some fantastic OD practitioners who have challenged me throughout. They’ve provided inspiration in my darkest hours and illuminated new ways forward for my practice.
I’ve loved it
A new architecture of Organisational Development 