Change in complex organisations – integrating support Networked Learning to enable SBC Inverness 6 th April 2009 Dr. Guro Huby School of Health in Social Science, University of Edinburgh Centre for Integrated Healthcare Research,

Overview of presentation Shifting the Balance of Care and High Impact Changes: ‘Whole System change’ Change in complex organisations: evidence, an evidence gap and a warning Headless Chickens, Total Gridlock or a modernised NHS? Organisations learning about themselves: The right people, In the right place and at the right time Asking the right questions Tight project planning based on constant evaluation Collecting and interpreting the right information Producing learning which is disseminated and used

S B C and H I Cs; The Challenge of Whole Systems Change 8 SBC improvement areas are all existing policy initiatives and provide and overall framework for change All 48 HI8 SBC improvement areas are all existing policy initiatives and provide and overall framework for change All 48 HICs can help SBC - but there are too many to be able to achieve change in all areas The shortlist of 20 / 48 has been assessed to have the highest impact Within the 19 HICs, CHPs and partners need to decide local community priorities and plans for change which will become part of LDPs, etc Change needs to be monitored locally to deliver HEAT and SOA. No additional targets and measures How ensure that changes work together for impact?

Change and innovation in Public services “[Innovation in service delivery and organisation can be defined as] …a novel set of behaviours, routines and ways of working, which are directed at improving health outcomes, administrative efficiency, cost- effectiveness or the user experience, and which are implemented by means of planned and co-ordinated action” (Greenhalgh et al, 2004).

Change and complexity Non-linear change: no progression through distinct and predictable phases Subject to a range of variables which interact to influence outcomes in often unpredictable ways. Local context and organisational culture impact on direction of change

But..attributes of success are linear Simplicity and clarity of goals and priorities Quality and coherence of policy Defined goals and milestones Rigorous evaluation Low complexity; Trialability Codifiability

Caught in the contradiction; a view from the middle manager position Fluid and shifting contexts – Constant organisational change – Change in strategic direction – Change in personnel Project goals and outcomes – Poorly defined – Shifting Time pressure – On top of the day job – Unrealistic time scales and expectations Information: – Too much but not enough Evaluation and learning – What is evaluated? – What is learned?

Directions of Change? No change The smoothly running modernised public service Headless Chickens: lack of governance Isolated changes, cancel each other out and work against each other Total Gridlock: too much governance Litigation, rules, risk management: nothing happens. Dunleavy and Hood 1994

‘Single loop’ and ‘double loop’ learning ‘Single loop’ learning: individuals change the way they work when something goes wrong – Change in part of a system – Isolated processes and tasks – Sustainability? ‘Double loop’ learning: the system changes the way it works when something goes wrong – Individuals strategies pull together – Change is sustainable (Argyris and Schon 1978)

Logics of complexity The change process is not random, It is shaped by an underlying organisational logic, This logic has to be understood in order to manage the process (Van de Van et al, 2008) How do organisations learn about themselves?

The learning organisation …organizations where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together. (Senge 1990)

Learning together: a way forward? The right people, in the right place and at the right time Asking the right questions: setting the right goals Collecting and interpreting the right information Tight project planning based on constant monitoring and evaluation Producing learning which is disseminated and used From Single to Double loop?