AYRSHIRE & ARRAN HEALTH BOARD

TRANSFORMATIONAL CHANGE PROGRAMME

TEC EXEMPLAR RESPIRATORY PATHWAY

April 2019

Page 1

Foreword This report sets out an approach to designing and implementing a whole-system TEC Exemplar Respiratory pathway for the citizens of Ayrshire & Arran, using a transformational approach. It provides an open and informative account of the work and learning to date and also the experience of key stakeholders involved in the programme. It has been a collaboration with the national TEC Programme and a significant contribution to our national aims as set out in the Digital Health and Care Strategy on service transformation. We expect that this work will continue to facilitate the implementation of a person centred respiratory pathway in Ayrshire and Arran but also make a significant contribution to other pathway re design work across health and care services elsewhere in Scotland. Dr Margaret Whoriskey John Burns Head Technology Enabled Care Chief Executive, NHS Ayrshire and Arran and Digital Health innovation, SG Chair, Technology Enabled Care Board

Page 2

Table of Contents 1 Introduction 3 2 Service Transformation 5 3 A taste of each phase 7 4 What’s worked for us 10 5 Conclusions at this stage 12 Appendix A Theory of Change, Theory of Organisations 14 Appendix B: Transforming the system 18 Appendix C: ‘Deep immersion’ 19 Appendix D: TEC as an enabler 21 Appendix E: A framework for understanding and working with passivity 23

Page 3

AYRSHIRE & ARRAN TRANSFORMATIONAL CHANGE PROGRAMME

TEC EXEMPLAR RESPIRATORY PATHWAY

OUR LEARNING SO FAR

1 Introduction

1.1 The Scottish Government believes that the use of digital technology is central to fulfilling Scotland's potential as a nation. Within the context of health, housing & social care, digital technology offers new opportunities for transforming the outcomes and experience of patients and citizens – and of supporting those who care for them.

In order to ensure that NHS Boards, Local Authorities, Integration Authorities and their partners are fully equipped to maximise the value of these types of solutions and services, the national Technology Enabled Care (TEC) Programme was launched in 2015. The main focus of this programme is on ensuring that outcomes for individuals, in home or community settings, are improved through the application of technology as an integral part of quality cost-effective care and support. The Programme sets out two important aspects that need to be promoted, namely:

(i) TEC should support person centred care within a broader range of support and care services with the focus shifting from the technology (the means) to the care outcomes (the ends); and

(ii) TEC should support the focus on preventative and anticipatory care, recognising that while TEC can be appropriate at all levels of need there is greatest scope to make an impact at the high volume, lower care needs level.

1.2 In response to an opportunity created and initially funded by the TEC Programme, Ayrshire & Arran formally committed in the summer of 2017 to developing and implementing a whole-system TEC Exemplar Respiratory pathway for the citizens of Ayrshire & Arran, using a transformational approach. This work pulled together and built on a range of discrete improvement projects already under way with respect to Respiratory, each of which was generating data, learning and recommendations for improvement. It was considered that developments in Respiratory had reached a potential ‘tipping point’, and that a different approach was needed for real and lasting change to occur.

1.3 At the time of writing teams are deep into the implementation phase of the

work, with much achieved, and much still to do. Learning so far clearly shows that each local context is unique, and so a ‘drag-and-drop’ approach to transformation is not realistic. With that said, the work at Ayrshire & Arran has generated an overarching approach, structure, interventions and learning points that could richly inform the trajectory of comparable programmes elsewhere. These will be headlined in this paper, with the intention of inviting deeper curiosity, enquiry, dialogue and collaboration between colleagues and

Page 4

partners as best serves their aims and contexts. As part of ongoing spread of learning and good practice it will be possible to share more specific information about the impact of the work on service delivery and patient experience.

1.4 Section 2 below outlines the overall framework underpinning Ayrshire &

Arran’s approach so far. This is followed by a ‘flavour’ of each phase in Section 3. Detail of what has worked well and might help other boards and partnerships follows in Section 4. Section 5 offers some conclusions that can be drawn at this stage.

Additional detail or context-specific information from Ayrshire & Arran’s work that readers might find useful are attached as appendices.

Page 5

2 Service transformation – Ayrshire & Arran’s framework

Our commitments What we delivered How we delivered it Phase 1: Create the Conditions

To generate commitment to and accountability for the need for profound change in Respiratory - at pace

To pull together and build on existing work in Respiratory, and to crystallise what a transformational shift would look like

To shift the existing conversation from silos and discrete projects to whole-system, citizen and pathway

To embed TEC as a way of thinking, not as a set of products

To embody the desired culture and ways of working from the start – ie the process is

the change, rather than leads to change

To co-create a prototype of a TEC Exemplar Respiratory Pathway for A&A

An observable shift in the positioning, pace and visibility of the work organisation-wide

A whole-system shared picture and reflection on current thinking, approaches, learning and sticking points in Respiratory so far, accounting for diverse and multiple ways of seeing the world and resulting in a more inclusive dialogue

Shared commitment to a radical change in pace and focus, via a ‘deep immersion’ event – plus full prioritisation of and participation in that event

Co-design of the 2-day event, during which the definition and principles of a transformed pathway emerged

Whole-system co-creation of a prototype TEC Exemplar Respiratory pathway, and associated priorities for next 3 years

Commissioning of a Clinical Leadership Group charged with leading the work in Phase 2

CEO overarching leadership and unequivocal commitment to delivering change

Transparent, shared approach and methodology for working transformationally

Short-Life Steering Group to lead, participate in and act on learning from Phase 1

One-to-one and group learning conversations with stakeholders across the system

Whole-system 2-day ‘deep immersion’ pathway development event, co-designed by short-life Planning Team in 5 x fortnightly meetings

Clarification of interface and communication with Respiratory MCN

Whole-system external OD support emphasising contemporary experiential and embodied approaches, co-production, and emergence

Phase 2: Build Capacity & Capability in the System

To establish CLG mandate and presence as a pan-system leadership team, and the TEC Exemplar Respiratory pathway as an organisational priority

To build leadership capacity and capability to deliver the pathway on a whole system basis

To align / integrate pathway work into other organisational priorities where appropriate

To continue whole system conversations following the 2-day immersion event, including the culture that was created at the

CLG transitioned to a high-performing transformational leadership team

Sustained shift in the visibility, prioritisation and significance of Respiratory work in the organisation

Participation of CLG members in relevant pan-system strategic groups, thereby enabling greater integration and prioritisation of the work into existing priorities, and re-calibration of existing priorities where appropriate

Commissioning and participation of strategic leads in taking forward pathway priorities

Development of practical implementation plans for

CEO delegated overarching leadership of the work to Clinical Leadership Group, whilst maintaining a Sponsorship role

Sustained CLG leadership development ‘on the job’

Designated CLG Sponsor / Strategic Lead relationships for each priority

Fortnightly scheduled CLG action / reflection / development conversations,

Bi-monthly scheduled whole-system action / reflection / development conversations, designed to meet emerging need and

Page 6

event – thereby building engagement, capacity and capability, participation and ownership of the work in the wider organisation

To notice what works, recognise it, and build on it

To build resilience, adaptability and ‘can-do’ in the organisation with respect to perceived blocks, setbacks and failures

each priority, together with metrics

Begin drafting strategy for Digital/TEC that aligns with organisational and national strategies

Resolution / progress on some long-standing blocks to progress, greater awareness of how some deeper cultural patterns feel and play out, and strategies developed for intervening / behaving differently

Ongoing engagement with national TEC colleagues to support learning and development

including education and input from national TEC leads and specialists

TEC Sub-Group of the CLG to develop TEC/Digital Strategy

Ongoing external OD support as above

Phase 3: Implementation and spread (ongoing)

For the CLG and Strategic Leads to maintain pace and focus as work becomes complex, messy and emergent

To sustain regular reflection / action based organisational conversations in the CLG and Strategic Lead events.

To keep pressure on the ‘how much by when?’ question and build capacity to think pragmatically and flexibly with respect to different kinds of measures, data and evidence

To face in to any cultural habits / blocks / behaviours that impede progress, and find new ways to address and hopefully dissolve them

To crystallise plans for pragmatic changes, interventions and developments

To embed use of Pentana as a system-wide tool for learning, observation, tracking and joining things up

To begin to spread learning from Respiratory to other parts of organisation

Plan-Do-Study-Act – ongoing: what difference are we making, how do we know and so what? Much greater level of spontaneity, proactivity and action to test things out

CLG sustaining ‘helicopter view’ and capacity to make decisions and act promptly regarding a constantly emerging, changing and multi-dimensional picture

Detailed action plans for each priority developed, and Strategic Leads supported to use Pentana to capture, track and join up an increasing spread of work, tests of change and initiatives

Metrics for pathway and priorities

Respiratory TEC strategy, implementation plan and business case for invest-to-save proposals, aligned with background ‘digital pathway’ for A&A as a whole (in progress)

Conversations with other parts of the system with respect to spreading the approach, methodology and learning in Respiratory.

A visibly more relaxed, collegial ‘I’m OK-You’re OK’ culture across the system IRO pathway work, and readiness to act on challenges as well as talk about them

Ongoing scheduling of regular CLG action / reflection meetings, inviting specialist input where necessary

Ongoing scheduling of bi-monthly whole-system action / reflection / development conversations

Holding the spotlight on measures/data/evidence, action plans in support of final business case

Series of learning events scheduled to support other pathways at A&A who are actively seeking to learn from Respiratory and deliver similar change in their own areas.

Targeting specialist support as needed – OD, improvement, TEC etc. CLG developing and clarifying its own mentoring role within the organisation.

Implementation of interventions and changes as and when possible (eg Respiratory App)

Page 7

3 A taste of each phase – what does delivering a programme like this mean in practice?

3.1 Phase 1 – Creating the Conditions

The deep purpose of this phase is to light the touch paper of transformation. This means shifting energy from circling around what’s wrong or missing with things or people, to alignment behind an unequivocal, overarching shared purpose and direction. Somehow, participants need to see that what’s been created thus far has the potential to become something radically better and beyond everyone’s expectations – and that they are the ones to lead it forwards. This isn’t because what has been done so far has failed, it’s because the work has outgrown the conditions that are currently supporting it. This work can be done at pace, yet at the same time it cannot be rushed. You can only start from where you are, with whatever is going on, and however people currently see things – and act on whatever emerges as it emerges. Pace is achieved through a disciplined structure of frequent and consistent reflective conversations and resulting decisions and actions. This can feel extremely messy and challenging, and at times, as if things are getting worse before they get better. Phase 1 culminated in the 2-day whole-system ‘deep immersion event’, a learning conversation with the purpose of co-creating a prototype TEC Exemplar Respiratory Pathway for A&A. The following reflections express something of the profound shift that this event generated: “I was deeply cynical when I heard about it. I didn’t think we would achieve very much. I was wrong. It was not like any experience I had before and we genuinely moved forward in a way I didn’t expect”. “When I heard that my attendance was mandatory, I was really annoyed. I don’t like being told what to do. I now know why it had to be mandatory. I was expecting a repeat of what’s happened before, and I didn’t believe this would be different. I wouldn’t have turned up. Yet it was only by coming that I realised everything had changed”. “It was fun! We moved around all day and everyone took part in everything. We had cakes and coffee and got to chat and get to know each other. It really felt like the whole system working together”. “A lot of the pathway we ended up with was what we had already developed. What really changed was that everyone owned it – the whole thing, end to end, no matter where they were in the system”. “When I first heard it was 2 days, and that you had to attend the whole 2 days, I thought how will I find the time for that? I thought it was unreasonable and unrealistic. But it was amazing, the amount we achieved, and there were not the distractions of everything else going on. I enjoyed being able to get right into it”.

Page 8

3.2 Phase 2 – Building Capacity and Capability in the System

The deep purpose of this phase is to build a clinical transformational leadership team that sustains and builds on the pace, energy, and delivery achieved in Phase 1, and empowers and mandates others to lead and deliver. Much like Phase 1 this relies on a disciplined structure of regular meetings which balance reflective dialogue with pragmatic action, and a willingness to be open to, yet challenge as appropriate, existing narratives and behaviours in the organisation. The work goes through significant ups and downs, and building the resilience to stay on course notwithstanding this has proved fundamental. Experience within CLG, mirrored in wider teams, showed that early discussions inevitably become overwhelmed with fears about capacity, ability to deliver, the complexity of the task, anxiety about pace, and perceptions of blocks and barriers that seem too big to overcome. As one member later put it, ‘the only way out is through’! By being willing to ‘stay with it’ and really observe how sticky organisational patterns play out, the CLG was able to make decisions about where and how to act differently and change the flow of things. When it realised its own power to do this, the team literally ‘didn’t look back’! The mechanism of the CLG Sponsor / Strategic Lead relationship borne out of just such an impasse, and surprised everyone in how quickly and simply it cut through the overwhelm. “The most effective things are sometimes so simple you can’t see them straight away”, one member observed later. CLG also discovered that meetings can be generative, creative, fun and enjoyable even when they include disagreement, struggle to decide what to do about something, or challenges that come left field and seem to tip everything over. “Never under-estimate the power of cake and coffee”, says one member, who ensures this is a feature of all meetings and conversations. “Enjoying ourselves and providing nice things for everyone makes even the most difficult conversations so much more do-able!” “I hated 2-weekly meetings to start with”, says another. “I couldn’t imagine finding the time. It seemed just another talking shop. I look forward to them now. We get so much done! But that’s not all. I love the fun, humour and above all the trust we have built. We really are there for each other, and no-one is left on their own to struggle with something”. The joy, ‘can-do’, honesty and willingness to act and deliver that the CLG has built is infectious. A series of wider development events with Strategic Leads and their teams has met with consistent participation, and people have openly appreciated the opportunity to learn and share informally. “We achieved more in the last four hours than we achieved in four years”, observed one participant after the first event. “I love the fact that we’re all here in the room together, and can act there and then to join things up. It’s so obvious when you think about it!”

Page 9

3.3 Phase 3 – Implementation and Spread

The deep purpose of this phase is the nuts and bolts implementation of what is needed. This plays out as multiple and proliferating tests of change, an increasing spread of involvement and relationships and spontaneous initiatives to meet a need or to generate information, and pan-system work such as development of the Digital/TEC strategy and business cases for whole-system investment. Different priorities move at different speeds and require qualitatively different input and support, and at the same time, the CLG starts to think ahead to the next swathe of priorities. All of this is held together by the ongoing discipline of regular conversations, a balance of reflective dialogue and pragmatic action, clear accountabilities, and the willingness to respond and re-prioritise wherever necessary.

It is during this phase that the work rapidly spreads beyond any one group’s capacity to hold the complete picture in detail, and support systems like Pentana come into their own. Tenacity and a willingness to persist with jobs that can feel mundane, detailed and bitty are core skills in this phase, and the CLG relies on teamwork and combining each other’s strengths to stay on course. Everyone has learned that proliferating drafts, endless emails and sprawling timescales leak energy and waste time, and it has become more natural and appealing to get round the table where possible and bring collective energy to bear on things. Spread had previously been talked about as ‘selling’ and ‘buy-in’, and interestingly this has not been the experience in this work. Instead, the touch-paper is spreading beyond Respiratory with an energy of its own. The last three months in particular has seen several parts of the organisation knocking on Respiratory’s door expressing curiosity and interest in the work and wanting to learn more about how it could be applied in other areas. Respiratory has also become energised at the potential for their learning to make others’ lives easier, and has initiated a series of learning events solely for this purpose. As everyone is humbly aware there is a huge amount of work still to be done, and the ups and downs will continue. “We have to keep talking to each other and doing what needs to be done next”, said a participant at a recent development session. “Sometimes you can’t see beyond the next hour. Maybe you don’t need to! Just do the next thing. And keep your sense of humour!”

Page 10

4 What’s worked for us – some pointers for others on this journey

4.1 Establish and maintain clear, unequivocal leadership The commitment to co-create a TEC Exemplar Pathway is a deliberate, planned process of whole system transformation. Within this work people are required to move beyond existing ways of thinking and working, to tolerate uncertainty, ambiguity, messiness and stuckness, and to balance ongoing action and reflection in order to bring about lasting change.

In order to sustain clarity of direction and for people to feel safe to take risks, the work needs to be experienced as a non-negotiable priority, and the ‘deliberate, planned’ intent actively and visibly held and asserted at the highest appropriate level. Due to the number of pieces of work already under way relating to Respiratory at A&A, and the span of authority required to bring them all together, this role was initially taken by the Chief Executive. It was then delegated to the Clinical Leadership Group in Phase 2.

4.2 Work with an integrated theory of change, OD approach and OD methodology The purpose of OD is to co-create the conditions in which profound change can emerge and be sustained. It is therefore essential that work is supported by a compatible, contemporary whole-system OD approach and methodology. (Detail of that applied at A&A is set out in Appendix A).

4.3 Inject pace and momentum from the start This was achieved by:

a) Focusing on a specific pathway as a catalyst for profound change. In system transformation terms the concept of fractals supports and legitimates this approach (see Appendix B); b) Working in phases, which ensures that work is time bound with objectives and deliverables that are relevant and achievable. This prevents irretrievable overwhelm and passivity the perceived scale of the task; c) Investing in a ‘deep immersion’ event in Phase 1 (See Appendix C for how we did this at A&A). d) Short-life groups and regular, scheduled conversations.

4.4 Invest in building a shared foundation before moving to solutions

Transformation is a shift in culture and meaning, and the saying goes that you cannot create something new from within the existing way of thinking. The primary goal in Phase 1 is therefore to find out what is relevant and significant for those already and potentially involved in the work, and to surface and share the patterns and themes in how they currently see things. It is particularly important to give space and time to any issues that are playing out as stuck, inflammatory or personalised, to see what relevance they might have beyond the individuals they affect or are attributed to.

Page 11

4.5 Be it, from the start - don’t just talk about it People often manage uncertainty by situating change in the future and disappearing into their heads. This shows up in intellectualising, generalising and over-detailing, and frustration with the behaviour of others. Transformation, however, is ‘the future emerging in the present’, ie what happens now creates the conditions for what is desired. This means that the work is the change, rather than solely leading to change.

This was enabled primarily by a) reflective practice, built into regular scheduled conversations, b) interactive, co-creative experiential working and learning on the job c) noticing and working with parallel process (see 3.1.7 below).

4.6 Don’t separate TEC/Digital out – focus on the whole pathway See

Appendix D for A&A approach to TEC. 4.7 Notice what happens in real time and take swift action as needed This

has been one of the most critical factors in sustaining pace, momentum and delivery throughout this work. It is facilitated mainly in two ways: a) structurally, via regular, scheduled reflection/action/ development conversations and timely decision making, and b) by surfacing ‘parallel process’ – namely when the patterns of transformation work begin to replicate outdated patterns in the organisation’s culture. These patterns generally emerge out of awareness – ie people regard them as ‘the way things are’. Part-way through Phase 2 the Clinical Leadership Group encountered one of the most ingrained cultural patterns observable in public services – organisational passivity (see Appendix E for understanding of passivity applied at A&A). This ultimately played out in a near-breakdown of attendance and participation in meetings, overwhelm and disbelief that change was achievable, and a strong belief that there was not the individual capacity to do the work required. The Group’s willingness, capability and courage to acknowledge what was happening, share responsibility for the pattern and experience the intense discomfort this involved, and then to change their behaviour, took the work to an entirely different level almost overnight. As one CLG member put it after that point ‘we have achieved more in the last four months than we have in the last four years’.

Page 12

5 Conclusions at this stage

A pathway approach is a highly effective mechanism for achieving whole-system engagement, participation and learning;

A transformed pathway emphasises quality of life and independent living. This is demonstrated by an empowered citizen taking control from the beginning, and maintaining this all the way through to any specialist hospital support at the end. The beginning of the pathway therefore emphasises prevention and the options for self-management as early as possible in a person’s journey. This is where transformation truly lies, and creates the conditions for radical shifts in future outcomes;

Deep pathway work as outlined above links directly into local care models, and drives their development and delivery;

Transformation of one pathway serves as a vehicle for transforming others in the system, through generating:

o Specific, tangible vision and intended outcomes; o Clarity as to what transformation is and looks like; o Identification of common needs and features across all pathways, for

example shared data accessible to citizens, single point of contact etc; o Modelling the weaving of TEC throughout the pathway as a way of

thinking, not as a slotting in of products; o Creating mechanisms for whole-system leadership and thinking, and

translation of this into practice; o Recalibrating the role and impact of clinical leadership; o Strategies for meeting and progressing constructively through

organisational and cultural challenges.

A small Clinical Leadership Group is a highly effective mechanism for whole-system leadership of the programme. As a microcosm of the overall system, this group will inevitably experience and embody the very cultural patterns the programme seeks to transform. The group’s ability to see these patterns, tolerate the challenge / discomfort they can generate, make new choices and act differently creates a living model of the future within the organisation. Support and development of the group to work in this way is important.

Note from an external OD perspective

No written report can do justice to the experience of this work at Ayrshire and Arran. There have been several palpable and at times inspirational shifts in how people relate to this piece of work, and the risks they are prepared to take to do something differently. People are responding to the opportunities and complexity of challenges with dynamism, creativity, humour and ‘can-do’, and are facing and addressing embedded cultural habits and patterns that are no longer fit for purpose despite the difficulties this brings. There is greater spontaneity and proactivity in simply doing what needs to be done. And there is a visible esprit de corps and supportive

Page 13

honesty in how the CLG functions. Many individuals have flourished and achieved things they didn’t think were possible in a relatively short time. To put it in one sentence, the pathway ‘ignited’ during Phase 2, and the work now has a life of its own. It is a privilege to support and witness what is happening, and to see that participants are now initiating contact with other parts of the organisation in order to begin sharing what has been achieved so far.

Page 14

Appendix A Theory of Change, Theory of Organisations and OD methodology applied at A&A by Helen Ross Associates Transformation – a supporting theory of change

Broadly speaking, change can be thought about in two ways: first order, and second order1. First order change is when reconfigurations or reorganisations take place within the system as it currently is. That is to say the current frames of reference, associated assumptions and ways of thinking, and how these shape communication and organising, can be taken as read. Work at this level often starts with solutions. Second order change (transformation) is when the system itself is changed. This means that people are making new meaning of what it is they’re doing, why they’re doing it, how they’re doing it, how they know they’re doing it, and what success looks like. By definition it is not possible to achieve this via old ways of thinking and organising or by drawing on old assumptions, because it is these that the new approach seeks to change. Paradoxically, however, this is unavoidably the context in which change is sought. The work of transformation, then, is to co-create the conditions in which new conversations take place, through which new meanings emerge and new solutions can be shaped, implemented, reviewed and evolved. When sufficient work is done at this level, options, possibilities and solutions can emerge ‘swiftly, with a natural flow’2 – and change is irreversible. In a solutions-driven culture, multiple and often conflicting demands are often articulated / understood in first-order terms. There can therefore be a temptation / pressure to ‘hurry up’ and ‘do stuff’ without sufficient conditions for the work to be meaningful. This relieves anxiety and gives the appearance of productivity, but in reality ‘digs in’ the status quo. People can find themselves further down the line busier than ever, with no real evidence of change. Transformational work relies on investment in creating the right conditions. These include leadership, shared alignment around outcomes, meaning-making, engagement, positioning and governance, such that new thinking and solutions become possible. What can get missed in linear ways of thinking is that creating these conditions is the work of transformation – not a delay of it! And also that ‘doing’ and ‘productivity’ include meta-level and seemingly less tangible activities such as reflection, dialogue, evaluation and frequent returns to the ‘so what?’ question.

1 Watzlawick, P et al (1974): Change: Principles of Problem Formation and Problem Resolution, W W Norton & Co, USA

2 Senge, P et al (2005): Presence: Exploring Profound Change in People, Organisations and Society, Nicholas Brealey

Publishing

Page 15

OD and Transformation All OD practitioners work within a preferred philosophy and approach. I take a systemic approach, grounded in contemporary thinking from complexity theory and emergence, as set out below. This is the context in which methodology, design and process sit. I hold that fundamentally, OD is about co-creating the conditions in which profound (second-order) change can emerge and be sustained. Becoming a TEC Exemplar Board is about how the system needs to change, not just the individuals within it. A systemic approach to OD is therefore essential, and needs to inform the ways in which people are engaged and involved from the start. In other words, the OD programme is an experience of the desired future it is there to facilitate. Systemic theory of organisations (Berne, 1963; Napper, 2010)3 Typically, a focus on individual and group dynamics is viewed as the starting point for a piece of development work. This usually includes descriptions of patterns of the following:

Observations and stories of what people talk about, how they talk about it, and what these patterns are considered to mean;

Observations and stories of certain ‘personalities’, groupings, professions etc and how they do or don’t work together, particularly those who are considered ‘difficult’, ‘challenging, or ‘resistant to change’;

Patterns of communication and interpersonal behaviour, and examples of how this plays out and the effects that have been observed;

Individual styles and proclivities, who appears most visible and why, and the impact of these individuals. Equally significant are who are ignored or considered ‘background’ – albeit they are equal participants in ongoing patterns;

Reports of individual thoughts and feelings and what they might mean;

Hypotheses as to the possible ‘whys and wherefores’ of particular behaviours and what might be under the surface;

Narratives about what constitutes ‘good’ or ‘bad’ behaviour. In a systemic way of thinking, however these dynamics are not considered in isolation, or understood solely in terms of individual style or personality. Rather, they are considered to be shaped and contained psychologically by the context – i.e. by organisational structures. Such structures include, for example:

Vision, purpose and direction, how these are articulated, and the extent to which organisational design supports their delivery;

Levels / sections / groupings of staff, and the interfaces between them;

3 Adapted by Helen Ross from ideas by Eric Berne (1963) by Rosemary Napper in The Individual in Context:

How do I fit in around here? In Erskine, R G (ed): Life Scripts: A Transactional Analysis of Unconscious

Relational Patterns, Karnac 2010

Page 16

Models of care and delivery, their historical context or otherwise, and how they are currently configured;

Approach(es) to leadership;

Accountability and decision-making;

Role design, role boundaries, authority and power;

Policy, procedures and processes;

Resources and resource allocation. Organisational culture emerges through the continual interplay between organisational structures and organisational dynamics, as described above. Each continually impacts on the other. In order to change culture, it is therefore essential to explore what is going on in the structure and the dynamics, and to intervene in both at the same time.

Page 17

Methodology In order to find new ways forward it is first important to engage key leaders and stakeholders in taking a whole-system ‘helicopter view’ and surfacing the thinking and assumptions that shape current approaches, perspectives and experience. Many of these will be out of conscious awareness. This process also engages stakeholders in reflecting on where and how these patterns are playing out, the impact they are having and their purpose; what changes are therefore important and necessary; and the conditions needed for these to occur. This learning provides a wealth of current organisational information, and a platform for a new, shared, open and equal conversation that is not personalised. Without this work any new solutions are inevitably created within existing ways of thinking, and are very unlikely to sustain. The OD approach is therefore broadly underpinned by four stages4: 1 - Existence: What’s relevant to those involved? Identification of any and all factors considered relevant by key stakeholders regarding the presenting situation, how it is playing out, and the resulting impact(s) and consequences; 2 – Significance: What does it mean? Reflection on, and exploration of, the meaning made of these factors by stakeholders, both individually and collectively - and the light this sheds on the situation in hand and the desired direction / developments; 3 – Solveability: Options and possibilities - Where do we go from here? Options, parameters, intended outcomes, responsibilities, accountabilities 4: Capacity and capability - Who needs what, to do what, when, where and how, how will this be supported, and how will results be evaluated and sustained? Although these stages are cyclic rather than linear, it can be expected that early OD interventions will emphasise stages 1 and 2 in order to create the conditions for 3 and 4. Experience has shown that when sufficient investment is made at levels 1 and 2, solutions can often emerge swiftly and easily, together with a context for experiment, evaluation, learning and spread. Thinking and working this way is an important feature of working in complex adaptive systems.

4 Adapted by Helen Ross from Macefield, R and Mellor, K: Awareness and Discounting: New Tools for

Task / Option-Oriented Settings, Transactional Analysis Journal 2006, Vol 36 No 1

Page 18

Appendix B: Transforming the system - Where to start? Transformational work in organisations means that the approach is whole system. This is not necessarily the same thing as working with the whole system at once. Thinking whole system means recognising that a ‘part’ – such as a service - is not an isolated entity operating in its own right which can be intervened in without consequence elsewhere. Rather it is a microcosm or fractal of the system as a whole, the patterns of which reflect that whole system. Change in a microcosm is change in the system, and it will therefore be a catalyst for influence and change in both deliberate and unintended ways. What is experienced and learned in microcosm is therefore an asset that can be drawn on to influence, develop and transform other parts of the system. With this in mind A&A decided that a realistic, practical, and timely way to become a TEC Exemplar Board was to develop one particular part of the system from a whole system perspective. And why did we pick Respiratory? In view of the range of improvements it had already delivered, the Respiratory Service was considered to be poised to become an exemplar pathway as above. In addition:

It is a core service – a ‘backbone’ care pathway, working with and linking in widely across the system;

In terms of its function, it parallels any care pathway in the system – ie it must enable prioritisation of self care, self management, quality of life, staying out of hospital and so on. Learning from Respiratory is therefore learning for all;

There is already huge demand on this service, which is predicted to increase and become more complex as population need evolves. This means that some ‘burning platforms’ are already evident, which are powerful levers for second-order change;

The centrality and volume of demand in Respiratory will surface and highlight key issues, questions and opportunities for TEC. Responding to these will have a wide reach in terms of impact and benefits and improve quality of care for those users at the same time as generating learning for other pathways;

One of the respiratory consultants has an in-depth background in service development and improvement, a considerable asset in this kind of work;

The Respiratory MCN is a vehicle for the development of all MCNs, and needs to shift beyond its current ways of operating and communicating.

Page 19

Appendix C: ‘Deep immersion’ – how we did this at A&A ‘Deep immersion’ is a highly effective way of achieving pace, momentum and shared ownership of outcomes, as well as a radically different style of organisational conversation. Most of the effectiveness of this intervention is in creating the conditions for it. How you go about this will depend on the local context, stage of development of the work and the approach to design.

1 CEO mandated a series of externally facilitated ‘learning conversations’, aimed at engaging key stakeholders – including the Steering Group - in reflecting on the current state of developments in Respiratory. This generated an initial ‘helicopter view’ of the status quo which served as the vehicle for the first in-depth pan-system collective conversation in Phase 1

2 Having engaged in this piece of work, participants agreed that the existing

Respiratory pathway needed to be crystallised into a well-developed prototype with a set of priorities to be delivered over the next three years. This work needed to take place in a whole-system way, and at pace;

3 Given that existing projects had been progressing for months and not arrived

at this point, it was recognised that to continue working incrementally would not provoke a deep enough challenge to current practice, let alone quickly. The decision was taken at the first collective session to run a 2-day immersion event 8 weeks later, at which invited stakeholders from across the system would be supported in a conversation aimed at co-creating a transformed pathway and identifying 3-year priorities. In addition, the event would support stakeholders to participate and engage with each other in ways that embodied future values and ways of working;

4 A Planning Team was set up, drawn from the first collective session, to co-

design the event with the external OD consultant. This group met for 5 meetings of 2 hours, and during that time a profound shift in thinking occurred with respect to the principles underpinning a transformed pathway. From this point onwards the shape of the event was obvious, and the team was dissolved.

5 Further one-to-ones were held between OD consultant and anyone who was

unsure about their role and participation in the event. This built trust, engagement and confidence of participants to be in the ‘driving seat’ of their own event – a mirroring of one of the principles of the pathway.

6 Delivery of the event focused on experiential, embodied learning rather than

giving and receiving information, and people were active throughout. The design of activities made it inevitable that people worked pan-system and talked cross-functionally, that TEC was embedded as a dimension of the pathway, and that everyone could see what was emerging as it emerged. People were briefed in advance to know that it is normal for ups and downs and messiness to occur, and that they might even get stuck or want to give up and that this is OK - and that their job was simply to speak out. This injected freedom, flexibility and shared ownership into how the event unfolded.

Page 20

The event delivered on its aims and people were engaged and involved throughout. The mandating of the CLG by the CEO at the end was a visible commitment to following through, and to maintaining pace and momentum into Phase 2. The event also made it easy to continue collective pan-system conversations during Phases 2 and 3.

Page 21

Appendix D: TEC as an enabler, not a set of products The everyday language of TEC tends to focus on what it is and what it does in a practical sense. There is an endless array of possibilities, many with endless potential. Experts / enthusiasts can be inspirational and passionate in their descriptions of what particular pieces of kit can do and the impact they can have. This enthusiasm gets people to ‘do stuff’ and makes things happen, and is a valuable asset. The risk, however, is that work to introduce or implement TEC proliferates rapidly and local results appear positive, yet transformation does not happen. This is because the thinking in which the work sits has not changed, and the speed / extent of implementation increasingly becomes the focus rather than the speed / extent of real improvement and change. In transformational terms TEC is not a thing, or a collection of practical interventions. It is an enabler – an integral dimension of a whole system approach to designing, delivering, evaluating and evolving contemporary care pathways. To focus on it as separate and distinct from everything else is to unwittingly reinforce current ways of thinking – ie TEC as a ‘body part’ that can be assessed, diagnosed and treated in isolation and in its own right rather than as an integrated dimension of a whole, living system. In OD terms, then, transformational work to shape a TEC Exemplar Board cannot focus exclusively on TEC, or treat TEC as separate from other dimensions of the care pathway. Work needs to focus on the system, such that the intended impact, priorities and strategic direction for TEC become clear. How we are enabling the TEC conversation TEC/Digital presents a challenge in that levels of knowledge, experience and grasp of it are very varied. This means there is a need for education and knowledge sharing about TEC/Digital itself, alongside provoking new ways of thinking and working of which it is a part. We are building this by: a) Embedding TEC into ongoing conversations about the pathway:

Focusing on the intended outcomes of an exemplar Respiratory pathway, and how these will be enabled, including with TEC rather than just with TEC;

2-day ‘deep immersion’ event facilitating a conversation in which TEC was – by default – experienced as a way of thinking, rather than a set of products;

A TEC/Digital leader on the CLG – currently the eHealth Lead;

TEC embedded into overarching templates for action plans, encouraging Strategic Leads to demonstrate how it is linked to the principles and deliverables of the pathway and their priorities;

Inviting national input into conversations when helpful. b) Providing education, guidance and specialist input on TEC to meet need:

Page 22

Weaving TEC education on a needs-led basis into ongoing collective development events, as requested by participants and suggested by action plans;

Inviting specialist/expert input both nationally and locally when needed;

Setting up a TEC Sub-Group during Phase 2 to pick up the emerging TEC/Digital themes from priority plans. This Group will integrate the Respiratory pathway priorities with local and national priorities, and support participants as required to develop their thinking and implementation plans.

Page 23

Appendix E: A framework for understanding and working with passivity (adapted by Helen Ross from The Cathexis Reader, Schiff et al 1975) Passivity is when a person or group engages in activities, behaviours and ways of thinking that are avoidant of the actual situation(s), problem(s) or challenge(s) in hand. The following escalating levels can be observed:

Doing nothing in response to a problem (rather than a conscious decision not to act). A person uses all their energy to inhibit their responses, and will report ‘not thinking’ or that they ‘can’t think’. A common example is middle managers, who often complain at length about senior managers whilst sidestepping invitations or opportunities to communicate with them directly.

Overadaptation Individuals who are overadapting often seem co-operative, and so their behaviour may unwittingly be praised and reinforced. However overadaptation occurs when a person or team do not identify a specific goal when solving a problem. Instead they try to achieve someone else’s goal, or fantasise generic, non-specific goals without thinking of their relevance or significance. In so doing they may project their grandiosity onto another person’s / the organisation’s expectations, defining them as unreasonable or the problem unsolveable.

This happened in the Clinical Leadership Group in Phase 2. They began over-adapting to a non-specific, idealised notion of a transformed pathway rather than the specifics of what had been generated in Phase 1, and began saying that they had no vision or direction. This played out in endlessly circular (highly articulate and intellectual) conversations, after which no-one took action. The Group began to fragment. The direct naming and exploration of this pattern led the Group to realise that it was not lack of vision but lack of structure for their task that they were struggling with. It was from this position of extreme discomfort that they generated the highly successful mechanism of the CLG Sponsor/Strategic Lead relationship, and made a profound shift in how the CLG works together which has sustained notwithstanding ongoing challenges.

Agitation is described as ‘repetitive activities which are purposeless and non-goal directed’ (Schiff et al 1971, p74), accompanied by confused thinking and feelings of inadequacy. If pressured to ‘do something’ in this state, an individual’s agitation will escalate and may be harmful to themselves, others or the environment. One of the ways organisations express agitation is by ratcheting up meetings, reports, measurement mechanisms, targets, models, concepts and so on, without assessing their meaning, relevance or impact. This can sometimes get such a life of its own that it can be extremely difficult to interrupt, particularly if facing what is being avoided has profound consequences.

Incapacitation/violence is the discharge of energy built up from passivity. The individual accepts no responsibility for their behaviour. After the energy is discharged, they may be in a position to re-contract. In organisations, incapacitation often manifests as long term sickness.

Page 24

These levels are chronological. This means that if you hypothesise that a person or group are agitating, for example, you can expect that they will move back through Over-adaptation and Doing Nothing before truly engaging with reality again. This comes about through skilful leadership and facilitation – eg use of questioning and listening skills; mirroring and reflecting; confrontation and boundary setting; follow through on deadlines and d requirements and focusing on evidence of delivery or otherwise; careful consideration of individual / group settings for interventions and so on.

David Sword, Consultant in Respiratory Medicine – David.Sword@aapct.scot.nhs.uk

Gail Caldwell, Director of Pharmacy (Gail has now left Ayrshire & Arran)

Lorna Loudon, Clinical Nurse Manager

Paul Kerr, Clinical Director for North Ayrshire Health and Social Care Partnership

Andy Grayer, Assistant Director – Digital Services

Alison Anderson, Respiratory MCN Manager

Billy MacLean, Head of Community Health and Care Services

Helen Ross, OD Consultant