Sideways Innovation

Robert Templeton of Well Street, Better Care and Health takes a sideways look at innovation

Innovation is a term widely used by government and industry, as well as in health and social care – and undoubtedly, in the run up to the General Election, all the political parties will be discussing innovative ideas and policies. Perhaps they’ll even use the reliable shorthand for the whole process, blue sky thinking, to identify the way they’ve come up with such ‘breakthroughs’.

Alas, in the real world, innovation is a lot more common that that metaphor implies. The problem; delivering its benefits is a lot more of an issue. It’s implementation of the good idea that’s the obstacle, not never having one.

But why is it so difficult to get innovative ideas to work in practice? There are perhaps three ways I’ve found to explain why ideas that look great on paper fail when implemented locally: Top down, Context and Suitability.


Top-Down Approaches 

One of the biggest roadblocks for innovation in health and social care is that the services such teams provide are for the most part funded at the national level. As a result, new ideas often first get traction centrally, which drags along an expectation that the front line will implement them. This creates a policy-to-practice gap, in which good ideas too often fall – largely because local health and social care organisations are unable to accommodate the change without significant risk.

Furthermore, without buy-in from frontline staff and service users, there is very often insufficient positive incentive to change. That’s a big reason why we see time and again new policy ideas are often short lived, too susceptible to changes in the political landscape. This ’top-down’ approach frequently leads to ‘badge engineering,’ in which services fundamentally remain the same – but are rebadged by latecomers to fit the latest policy Zeitgeist.

Is there a way out of this one? I think that taking a collaborative approach and expanding the number of people that contribute to innovation helps a lot. Innovation works best when everyone is involved with creating and implementing ideas that lead to success. A good example of this is the Think Local Act Personal (TLAP) initiative – a national partnership of more than 50 organisations committed to transforming health and care through personalisation and community-based support. The partnership spans central and local government, the NHS, the provider sector, people with care and support needs, carers and family members – and is a great case study of just what I am talking about, innovation that works.

Context 

To sell innovative ideas, it is vital to have examples of how they work in practice; for example, how a new way of working has positively changed someone’s life, or how this new approach saves money. There’s a problem, here, though; what works brilliantly in one context might not in another – and while case studies and examples definitely have a place, there is a risk in oversimplifying the narrative and ignoring the context in which the services are delivered. False impressions may get created.

This is a crushingly familiar snag with pilot schemes, which work in the context of the pilot area(s) but seem to fail when implemented nationally. Indeed, context is king when considering integration of health and social care services. As we all know, since the mid-1970s, greater health and social care integration has been the aspiration of successive UK governments. Despite this, progress has been glacial. Exceptions do exist (Torbay, North East Lincolnshire) and these examples get trotted out again and again as clear signposts to show how integration works. However, neither offer a ‘one size fits all solution’ to integration. Both areas are small and have a unique set of circumstances that led to the establishment of integrated services. This is well discussed in an evaluation of Torbay by the Kings Fund (2011), which makes the telling point that there is no ‘textbook’ to guide the process of health and social care integration because local context – especially the interplay of people, relationships and processes – are key variables.

Suitability 

Innovation often flourishes when money is available to groups of individuals who are organised and determined to make a difference. Short-term money for proof of concept is a good thing, but the obstacle here is deciding how such pioneering individuals and projects get supported and sustained in the long term.

An example of this is the independent social work practices for adults. In November 2010, the then-new Coalition Government announced £1m to pilot adult social work practice outside of local authorities. The outcome was six successful Social Work Practice pilots and ten Social Work Practice Pioneer Projects, all centred on people who use the services. Many involved in these projects took great personal risks by coming out of local authority employment to work for a social enterprise and there’s some real breakthrough here.

But it’s really only been in a very small scale. And the challenge for such social work practices is the same for all small innovative organisations… they may be able to prove concept – but are they sustainable in a competitive environment? Public sector procurement processes are often the stumbling block, of course. And although they can be circumvented for the purposes of a pilot, in the longer term procurement as it stands in the sector does still tend to favour larger organisations which can provide a variety of services, have economies of scale and business development functions, all of which easily outcompete smaller groups of dedicated individuals. Again a ‘one-size fits all’ approach to commissioning stifles innovation, forcing as it does an over-emphasis on winning new business above delivering great services.

Falling from a blue sky 

My point is that innovation rarely falls from a ‘blue sky.’ The best, most sustainable innovations, often come from the hearts and minds of those who work in or receive services. The trap in searching for the next centrally led ‘big innovation’ is that we miss good ideas already under our noses, I fear.

Is there an answer? Perhaps what is needed from any newly elected government is not new ideas but a strategy constructed in such a way as to foster and nurture grass roots innovation to flourish at the frontline?

That would be a Big Idea I’d vote for, don’t know about you.

I Want To Be A Systems Thinker… I Really Do!

Sue McGuire reviews Systems Learning, a free online http://www.systemslearning.org/systems-learning six video course that claims to be a ‘gentle, yet detailed’ introduction to making you be more effective. Does it work? 

I want to be a Systems Thinker, I really do. It’s the almost evangelical style of the Schumacher Institute’s tutorial package of six videos which makes me want this – and to share the love, too; less than halfway through, I find myself gripped by seemingly uncontrollable urges to stand up in unsuitable public spaces and announce to one and all how, ‘I’m saved’.

Joking aside, there is a definite ‘spiritual’ aspect to all this that can’t be denied; the main presenter/teacher on the course, Martin Sandbrook, even says (in video 4, fact-fans) that some of the objections to the philosophy he is espousing centre on how it can look how, ultimately, ‘You’re telling me I have to believe in God.’

There are many aspects of all this that I do find attractive. But the online approach to finding out about Systems Thinking sometimes doesn’t really help; the unbroken ‘talking head’ approach, spread out over these lengthy (18-19 minute) videos plus one long paper, consolidating a LOT of ideas, was not the least of the aspects I found challenging.

But it’s really not just the pedagogical style. Systems Thinking is a pretty revolutionary thing, asking us to rid ourselves of all thinking that owes its origins to Copernicus and Descartes – i.e., ‘mechanistic’ thinking… though every negative word the speaker can seemingly think of is here in this brief history of mechanistic thinking – I have so far counted reductionist, dualist, pervasive, controlled by experts, scientific, using the metaphors of machinery, material, and hard, judgemental stuff. And I’m not finished yet, remember!

You may not be too surprised to learn that by very sharp contrast, very positive terms abound when talking about Systems Thinking: democratic, holistic, respectful of nature, flexible, organic, open, interdependent, emergent, organic – using a lot of biological metaphors, e.g. fluid, descriptive, collaborative, reflective and so on.

I’m definitely going to want to be part of this. So why can I just not quite get there? I’ve been thinking about how to nail that down and I suppose it’s because I’m deeply sceptical about anything that has a slightly mystical sound to it. Which is what this video course has no shame at all in saying it’s proposing – promoting the approach as a ‘[new] way of seeing the world,’ ‘a better way of acting in the world’ and so forth.

Which is a shame, as underneath all this are some very simple and, I think convincing, useful ideas that don’t need all the baggage. Really, Systems Thinking is just a way of reminding us that self-awareness and awareness are just words for the filters we use daily to screen out the things not favourable to our world view and which we use to get in, for reinforcement, all those things which are.

There’s a quicker way to get there, I think, as watching the last one I finished, I was reminded of a story cult American writer David Foster Wallace told in his marvellous commencement speech at Kenyon College in 2005. Please read it if you never have…. As it might save you a couple of hours of trawling through at least a couple of these introductory talks: Two young fish are swimming along and they meet an older fish swimming the other way, who nods at them and says \”Morning, boys. How\’s the water?\” The two young fish swim on for a bit, then eventually one of them looks over at the other and goes \”What the hell is ‘water’?\” 

In other words, we all have different world views and we can gain a lot from trying to see how the other person is thinking. OK, that’s the basic overall idea, what else do you really need to know? The course suggests a number of techniques to develop your awareness, which I think can be perfectly well summed up by, asking more what other people think as a quick way to push your world view a little less. I did like the ‘Frame, Illustrate, Enquire’ technique expressed here, indeed have met a few people who could benefit from it, not excluding myself, incidentally, by any means.

I’m also convinced that we are too one dimensional in our current ways of analysing and trying to solve problems. Sandbrook tells us that in Systems Thinking you do not try to ‘solve’ a problem, but envisage a solution and work towards it. I see that as a useful perspective. In my and I am sure your experience, organisations are weighed down by problem solving and lose vision and motivation. We use rationalism as our only tool to the neglect of emotion and intuition. Vast amounts of creativity can get lost in a system of organisational development and improvement that only allows what is planned, what has a business case, fits with the programme and contributes to ‘step change’. I think Systems Thinking is as good a prompt as any to make us look at different ways of doing things.

Social Care 

Let’s apply all this to a real problem and see if it works. For as long as I’ve been working – certainly for as long as I’ve been aware of people having social care needs – the mantra of integrating the delivery of social care support with support for health care has been on the agenda. Yet still we hear stories of people routinely pushed around mutually exclusive systems, ignorant of each other’s policies and practices, working alongside but not with each other. A bit of Systems Thinking, one that puts the people and their needs at the heart of the solution could be great to anchor the attention of the deliverers of the service.

At the same time, paying attention to how systems interact instead of how they are structured internally, or even to how to push them together into a new structure, could also be a boon from this way of looking at the world. Why? Because systems interact through people. Give people objectives instead of targets and permissions, instead of rules and boundaries, will be automatically more flexible and optional.

What else did I like from my exposure to Systems Thinking? I did really like the understanding of organisations demonstrated in the course as complex responsive processes ‘mediated by conversation’, which I think are more free flowing and less rigidly bound concepts than we are used to imagining.

Why? Well, organisations typically describe themselves in terms of hierarchies and structures… but anyone working within them knows that they don’t truly function like that, but are instead actually a series of allegiances and alliances, constantly renegotiated, with people crossing their grade and task boundaries on a daily basis. Progression and change happening despite restructure and statements of corporate values, not because of them. For instance, I will never forget working in an organisation where the cleaning staff, who were in fact critical to its overall effective functioning, thought that the ‘boss’ was the Premises Manager. They had never even heard the name of the Chief Executive and that person was in of no interest to them …..whatsoever. 

Another nice find from my bit of extra-curricular learning was the claim that long-term planning is largely a waste of time. Well, yes. I have always been sceptical about project planning approaches. Systems Thinking says a better way is to talk more about looking to the next base; it wants to build into organisations ways of dealing with things that crop up, rather than ways to explain and excuse them as though they are signs of failure, as they were not in the plan. How often have we been in that place, guys – where some good thing seems to have been delivered in the end in spite of the costly and interminable project machinery, rather than because of it?

So how to sum up? Like I said, I want to be a systems thinker…I really do. In fact, I think I am. I’m just not sure what I can do with it yet – except see the limitations of mechanistic thinking. So I am in a sort of half-way house.

Which is all well and good, but this course tells me I have to be saved from myself. I can’t just be a mechanistic thinker who tries to use some of the systems thinking tools from time to time – that’s the primrose path to Hell, it warns, you can’t sit on the fence here and try and do both styles of thinking, you have to commit to one thing or another.

Well, that’s a bit off-putting for me, though of course that kind of strict either-or stance might be a style that appeals to others. But what I can say is that this short look into Systems Thinking has definitely left me wanting to find out more.