By domcushnan On

In Journal

“From an early age, we are taught to break apart problems, to fragment the world. This apparently makes complex tasks and subjects more manageable, but we pay a hidden, enormous price. We can no longer see the consequences of our actions: we lose our intrinsic sense of connection to a larger whole.”
— Peter Senge, 1990

A network of people.

Making change within healthcare is not about organisation or hierarchy or structure. It’s about a network of individuals in different places, at different levels, creating a shared endeavour.

This is crucial.

Shared endeavour is when you stand collectively all wanting to achieve something, having an understanding of what you all mean and have a shared understanding of what that is. Creating an earnest and conscientious activity intended to do, or accomplish something.

Everywhere where systems leadership works well, people have trodden slowly, thinking through the process before acting. They’ve taken the time to work through what they understand to be the particular issue, planning how to take things forward to achieve the goal. Where projects have failed, those part of the project have dived in believing they know what is meant by integration or fragility or whatever it is. This has led to the project stalling, hitting insurmountable problems and often being abandoned.

More is needed for systems leadership to achieve change there has to be collaborative leadership, of a network, based on a shared endeavour.

Some may be anxious about change and show resistance to it. This is to keep the status quo. There can be many reasons for this, but to tackle it and move minds and hearts we need to frame it differently. Estine said ‘if you want a different result you have to try different approaches’. Often when we want to make changes we start by asking, ‘do we have the time to do this, how much money is this going to cost or how will we make staff change their way of working, but we could approach it a different way. We could ask, “what do we want services to be like for the people we care for?” You could also ask, “is this suitable for the local area/population or who else needs to be in the room to make this happen? It can be maternity services, cancer services or services for people with diabetes, this does matter, but that we use networks of people to achieve the endeavour.

For example looking at the Greater Manchester Devolution: Memorandum of Understanding it says very clearly, “There will be a principle that all decisions about Greater Manchester will be taken with the people of Greater Manchester,” So when we start to think in this way, we will seek to use the networks we have around us to make changes. Don’t start with structures or organisations or governments. But do start with relationships and influence and trust.

Systems move at the speed of trust.

When talking about systems we need to understand the importance of relationships in changing the culture. If we have good relationships, we can weather the most fierce of storms. If our relationships lack depth and trust, we can have all the charts and all the data, but this will not achieve real change.

Also we don’t have to do everything all at once. We can take the scenic route. It is much better to take a couple of steps, see where you are, and then decide what your next step should be, rather than rushing in pursuit of a strategy that you found has changed before you were halfway there.

Change is about collaborative leadership, it’s about networks, it’s about relationships, and it’s about where you are trying to change.

There are about four things, I believe, that help when you’re leading systems. First, know what you’re dealing with and how a system might work to support it. Remember that a system is not the same as an organisation. If you ask people to describe their organisation or their organisational chart, it’s likely to be quite linear and quite boxy. You will have your name and your job title. A system is seemingly much more chaotic and kinetic.

A good example of this is the internet. The early internet was quite simple and structured.

Can you imagine how much more complex it is now?  There will be about 75 billion devices that will be connected by 2020. We don’t need to panic, feel daunted or worry about this. We don’t need to be able to read the whole system, and anybody who tells you they can is lying. We only need to know the part of the system that we use.

The same with systems for change. The only part of the system we need to know is the part that we want to work on based on our shared endeavour. Systems are good because they are very, flexible, it gives us room to manoeuvre. We can ask, “Who might give me insight? Who can share some of the heavy workloads with me? What are the other connections I can make?” This can allow us a real set of freedoms, rather than us feeling change is daunting and overwhelming.

When thinking about a system some have the view it as benign, something unhelpful or at least neutral. Why? Because not all systems are nice. Some of them are ‘out to get you’ metaphorically. Possibly not dangerous literally, but certainly metaphorically. There are a couple of evolutionary biologists who have likened a system to an organism. Something like an amoeba. It might not have much of a brain, but it can feed, it can reproduce, it can get about, and it is absolutely adapted to its environment. It can take over and even destroy other things in its path.

So, we come along with an idea. We want to make some changes for really good reasons. Better patient care, better outcomes, lower costs. The response of the system is not to say, “That’s a fantastic idea. I would love to adapt to that.” No. The response of the system may be to see it is a threat and therefore try to stop it, to kill it. We may hear responses instead these like, “That’s really interesting, I’d love to discuss that with you, I’d love to meet up. But then what happens? How about never? Is never good for you?” sadly the idea never gets listened to and we can feel low and deflated.

My lightblub moment when attempting any change in healthcare came when listening to Debbie Sorkin.

Sorkin says: “People don’t necessarily fear change, but they do fear loss.”

Loss of status, loss of connection, loss of control, loss of job, loss of something. Loss can be terrifying. To support this is we need to be aware of what we are dealing with and think about how we might want to preempt some of this loss happening.

If an organism is given sufficient time, it adapts to the new condition. So too with time, we can all adapt to change.

If we come along with a new idea and we tell someone, they are unsupportive, do not lose hope. The thing to do is to keep going. It may take longer and it may take more out of us than we first thought. Also we cant do this on our own.  We need a coalition, our network. Have a group of people around us that support and encourage, that help us believe that it is possible to make a change.

So, first, know your system.

Second, actually practice good systems leadership. We don’t need to be the charismatic leader speaking from the stage. When talking about systems leadership, many people think that leadership isn’t for introverts. But we can practise systems leadership as a thoughtful and calm personality, who supports and enables other people. It is not about saying, “Taa-Daa. Here we are.” It is about having people that follow you because they believe in your shared endeavour.

There are about six key dimensions in systems leadership that we know from the research works.

    1. Ways of feeling – about strong personal values
    2. Ways of perceiving – about listening observing and understanding
    3. Ways of thinking – about intellectual rigour in analysis and synthesis
    4. Ways of relating – the conditions that enable and support others
    5. Ways of doing – behaving in ways that lead to change
    6. Ways of being – personal qualities that support distributed leadership


First of all, it’s okay to live in our values. We are not doing this because we have a particular role or because we have letters after our name. We are doing this because we think it’s the right thing to do for those who we care for. We can step back and ask how do I feel about what I am trying to achieve. Does it fit in with my personal values?

Most of all, think about telling emotionally resonant stories. It’s about what this means for patients and service users based on evidence, based on data. It sounds woolly. It is not. Stories are some of the most influential tools in our armoury to assist change. We need to know our story, it’s worth practising sharing it to let our narrative be heard and getting people in your teams to do the same. When we are trying to move people from other sectors or from political environments to change what they do, don’t underestimate stories and the way we frame things can move people to action.

The third thing is to learn from what other people have achieved and failed at. Often when change is successful, relationships are the core. By which incidentally I don’t mean super friendly relationships, perhaps if we viscerally hate each other it may be more challenging, but we certainly don’t need to be best of friends. All we need is enough respect that we can keep talking when to push us forward get stuff done or to keep us on track when we disagree. Perfectly fine to start small as well. Start anywhere. Follow it everywhere. Keep going even if it takes longer than you think.

While management support can be helpful, don’t leave it just at the senior level. Change is something that has to percolate all the way through. It is about working with the willing. It is about hearing all voices, all ideas. It is also about using prototypes and keeping on tweaking until we get improvements. Also, we can seed leadership, rather than just trade it. Sometimes it’s better for a CCG or a trust or a local authority to lead, and can move change on.  Don’t be scared to seed leadership, instead nurture it and watch it grow.

This is not to say that it works every time. Sometimes stuff just gets in the way. It may be the history or culture. If you’ve got a history of toxic relationships, it’s going to be difficult. So too an ingrained culture can be hard to break. Sometimes geography gets in the way. Better to start it in a small geographic area than a larger one. If you’ve got political imperatives, sometimes it’s just the wrong time and the wrong place and the wrong people. The key thing is to hold fast in that shared endeavour and to keep going and think about what the scenic route might be. There are lots and lots of examples around in the country where we have done things differently, from better dementia services, better mental health services. Where referrals that used to take a week, now take a day. It’s interesting how this is starting to be used to join up the workforce and around data sharing as well.

The other thing we can do is just learn by doing. This is not something you read about. This only makes sense by actual practical application. Do something that’s real. Which means incidentally being real about performance as well and who’s accountable for performance. This isn’t about just saying, “I sent you an email,” this is not the same as actually sorting an issue together. It is about creating just enough clarity, for now, to get going. Don’t worry if we can’t see every little step of the way, start, use our narratives and frames to change perspectives. It is also about taking things down to the front line and getting people to try new things and giving them permission to do so, so they don’t feel scared to fail. There is a saying that we shouldn’t be afraid to fail we should be a not to try.

So be brave and try something different because the process we use to get to the future determines the future we get. If we keep doing things in the same old way, we shall miss the prize because we will only achieve the same outcomes.

To summarise, I believe that current systems leadership approaches can help us. The key is to start by seeing ourselves as systems leaders. We are not on our own. We are not just our organisation. Start with behaviours and value and shared ambition, build a shared endeavour. Make the connections. Build the relationships. Listen to the voices of all. Most of all keep our patients at the centre. Understand it’s going to take time. It’s going to feel messy. There are going to be setbacks. If we keep going, if we take that scenic route, if you look for progress rather than solutions, it is possible to see a change in that will benefit all.

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