creative practice: facilitated workshops by iriss - … · web viewas demonstrated through a recent...

Creative Practice: facilitated workshops by IRISS

Background

In January 2015, IRISS hosted two day-long sessions to support key stakeholders in Shetland to consider their progress on integration and to consider ways to work more collaboratively. Our role during these sessions was to independently facilitate and guide conversations, highlight the evidence base where possible, and to provide processes to support action moving forward.

Overview

Each day had a different flavour; the focus on day 1 was supporting strategic managers to consider their shared vision for the Shetland partnership, particularly focusing on the crucial role of localities, and to explore opportunities of similarity and difference. The focus on day 2 was to support Team Leaders to ‘imagine the future’ and to consider their own leadership role in creating their preferred vision for integration.

Headline findings

There is much to be positive about. The commitment to make integration work and the enthusiasm to work together was clearly apparent throughout the session. There are key areas of success to be celebrated, and key actions to take forward. It was clear that people had appreciated the ability to stop and reflect on progress and to learn that they are ‘better than we think we are’.

1. Articulating the overall transformation that Shetland seeks to achieve through integration

A range of people felt that the outcomes of integration need to be more clearly articulated. For instance, it was apparent that some were seeking improved outcomes for people whilst others may be seeking reduction in cost, and at times these two agendas may conflict.

Attached to the need for overall clarity of vision is a very powerful dynamic around trust and permissions within the workforce. A key barrier identified, throughout the two days, was that staff did not know if they had permissions or the trust of leaders to effect change, within their own sphere of influence, guided by an overall vision.

learning • partnership • creativityRegistered Office: Brunswick House, 51 Wilson Street, Glasgow. G1 1UZ [T] +44 (0)141 559 5059 [W] www.iriss.org.uk

Registered in Scotland No. 313740 • Scottish Charity No. SC037882

2. Developing visible leadership at all levels

Many commented on the need to work on developing a safe, open and honest culture to allow leadership to emerge. That being said, it is an interesting observation that anyone within senior positional power, very visibly, left the group half way through the session on day 1. Although many could have considered this appropriate to free up discussion for those in less senior positions, it instead perhaps sent the message to those left in the room that leadership is still perceived as hierarchical.

3. Developing a sense of a collective identity – “becoming ‘we’, not ‘them and us’

It was felt that creating space to build on these conversations throughout the different levels of the organization would encourage this identity to grow, and solutions to be developed together. There were many examples, for instance of people working on similar priorities but using different language to describe the activity (duplication).

4. Understanding of different roles, responsibilities and priorities

It was recognised that there is a huge amount of work being undertaken across different teams and it was thought that communication of these would help staff navigate their way to shared opportunities and interests.

There were articulated concerns that high profile projects being led by one agency (without representation from the other) could give out the wrong message and be seen as a barrier to integrated working. Similarly, it was considered that all parts of the system were not yet engaged nor represented in the integration agenda (GPs, for example).



Context: what’s driving change in Shetland?

Although each day had a slightly different focus, both groups were encouraged to consider the local drivers for change in Shetland. This was important to ground the discussions in the reality of what currently exists to determine key action areas for development. It was interesting to note the similar themes that emerged across the two days, as follows:

Theme Day 1Supporting information

Day 2Supporting information

Capacity “retention – single handed practitioners or generic services… how to create a dynamic structure?”

“shortage of staff – recruitment to key posts and retention”

“capacity to meet the increasing demand on services”

Communication “conflicting priorities”

“where is the mandate”

“strategic plans –must set out a commitment to positive change”

“where is our mandate for action?”

“effective inter-agency communication”

“Are we speaking the same language?”

Infrastructure “model of service provision needs to change”

“service models not necessarily meeting need of service users (e.g. more people admitted to hospital)”

“outdated service delivery model – doesn’t provide the flexibility we need to keep people close to home”

“Geography! Providing ‘equitable services across the isles’”

Leadership “Staff must be enabled, and must have professional respect for one another”

“this requires communication from above”



Public perceptions

“culture of unrealistic public expectations”

Local delivery“a need to get the right information available to the right person at the right time’

Trust/Permission “pity that senior managers had to go out… would’ve been good to validate our direction”

“we need to work on a culture that it safe, open and honest”

Process overview

Day 1

Integration and locality planning: working together to deliver local integrated services

Process Overview

The focus of the first day was to support the group to consider their progress specifically looking at locality planning as one of the key mechanisms for change towards an integrated model.

The group received two inputs in the morning session; one delivered by Peter Macleod, IRISS Chair (slides attached) designed to set the national context for integration. This focused on the need to adopt an outcomes focused approach (through commissioning, predominantly) and to focus on localities as the vehicle for the delivery of integrated care and support. Peter shared some of his own experiences and reflections about the implementation of integration at a locality level.



The second input was delivered by Edna Mary Watson who has been leading the locality strand of work in Shetland (slides attached). Edna’s presentation gave an overview of the key stages of the localities’ work to date and gave an honest appraisal of the challenges and opportunities that this project has presented.

Edna’s input was extremely helpful in outlining the legacy of locality working in Shetland. We discussed that Shetland has a reputation of excellence in developing models which support locality working and that this should be recognised, built upon and celebrated. In particular, the following were noted:

- local health centres providing local primary care services- rural care centres with devolved budget to adapt to local needs - With You For You – a process that puts people at the centre of the design and

delivery of support

The group reflected back to Edna their support for this piece of work. There was a concern that this needed to be communicated more widely in order to keep others informed and in order to ensure that linkages were made appropriately. This gap was considered to be a product of a key member of staff (joint lead) on the project being on a period of absence.

What’s our vision?

Using the input from the first two presentations, the group was split into five groups and was asked to think individually and collectively about their vision for integration that would respond to some of the pre-identified drivers for change.

Each group was provided with some prompt cards and a blank newspaper template. They were asked to imagine themselves 5-10 years into the future reading a newspaper when a headline catches their eye because it is so positive with regard to the integration of health and social care. As a group they were asked to collectively choose one driver for change, and to create a headline and accompanying story that would highlight their vision and first steps towards that vision.

Theme: TrustHeadline 1: Marriage made in heaven: staff agree that 5 year relationship is an

unqualified successActions:

1. No more mixed messages from above (clarity of position and vision)2. Genuine outcomes are identified and agreed3. Trust that motives are shared (support to develop customer trust)4. Develop staff champions for integration



5. Work on developing a shared language to avoid mixed messages and working at cross-purposes

Theme: Capacity and resourcesHeadline 2: Right info, right skills, right tools deliver the right outcomesActions:

1. Roles are redesigned to be fit for purpose – recognizing the impact of shared/integrated posts

2. Investments are followed through3. Stop waiting for permission, and start doing. Trust ourselves4. Write a collaborative business case (including stakeholder engagement) in

support of new actions and to justify the spend5. Everyone to use the same system (EMIS or other)6. Use data sharing partnership group to communicate changes

NB: this topic was primarily focused on sharing information about the person to ensure that the right people were able to act on it at the right time

Theme: InfrastructureHeadline 3: They are all ‘one’ to usActions:

1. All staff to have the same name badges2. Move towards a matrix management structure which will support the

removal of silo working/thinking3. Create a shared induction process and join key policies together4. Work that is completed at a locality level to be reflected on and lessons

learned shared5. Recognise that may of the issues that arise are collectively shared. Work

together better to ensure the experience is right for people living in communities.

Theme: LeadershipHeadline 4: Dispersed leadership takes hold across Shetland to deliver outcomes

to the peopleActions:

1. Create more action learning sets to build leadership capacity2. Effectively evaluate the action learning sets to ensure justification for

capacity to be released3. Create a process to ensure decision making is devolved – linked to quality

assurance process



4. We will know this is a success when we have the tools, skills and frameworks that support devolved leadership and when decisions can be justified due to processes in place

Day 2

Imagining the future together, supporting local leadership: an exploration for practitioners

The focus on the second day was to work together with the group to help them imagine the future of health and social care in Shetland. We used the four Imagining the Future scenarios to think through some of the issues facing the practitioners locally and to consider the opportunities that may arise.

Session 1: Imagining the future (www.content.iriss.org.uk/2025 )

IRISS’s Imagining the Future tool was used in the morning of the second day to encourage debate and to flush out different (and equally legitimate) perspectives on how to develop the integration agenda in Shetland. ITF is a powerful tool and it was striking that the main feedback session, which was planed for 30 mins, had to be extended to three hours. It became apparent that there had not previously been much by way of opportunity to speak so openly in a trusted space.

Most evident from that session was the fact that different languages between health and social services still proved to be a barrier. Some delegates did not favour an enablement approach for communities or individuals to codesign and deliver their own approaches to care. There was still an explicit and implicit attitude from some delegates that integration should only be concerned with professionals speeding up processes and making them more efficient.

Similarly, there was no great passion or fire around integration being a single public value proposition. Delegates, through discussion, did start to recognise the importance of this and acknowledged there is work to be done but that everyone was on that journey to creating an overall vision with strong shared values.

Over the course of the morning, the conversations moved away from ‘how are we going to fix this’ to appreciating the complexity of the system dynamics at play and considering how to make meaningful, practical progress within the overall system in Shetland.

Developing leadership capacity



http://www.content.iriss.org.uk/2025

The afternoon session involved the use of various exercises and demonstrations of tools to allow delegates to start to make sense of the morning discussions and consider how to practically apply what they had learned in meeting their strategic barriers. These exercises involved delegates learning how to use (and identify) different conflict styles, consider the emotional dynamics of change and the importance of political intelligence in a period of change (see slides attached).

Outcome

Throughout the session each individual was given the opportunity to identify a key action that they would take forward, based on the discussions that they’d had. These were as follows:

Implement small tests of change A few attendees talked specifically about trialing a change or experiment and then assessing impact, in order to develop evidence to take ideas forward.

“apply concepts discussed in my day to day contexts. Use small tests to try this out”

Stay positive!The group had the opportunity to explore areas where health and social care integration could improve outcomes for people. This action was to remain focused on those elements, rather than to focus on the challenges.

“Positive approach – take the change forward”

Exercise leadershipDay two exposed attendees to a range of different tools to support them to exercise their own leadership and to manage change. Many of the respondents pledged to use these with others to help them make sense of the changes that the integration agenda may bring.

“use the materials and discussion to improve my leadership skills in current role”

Revisit previous plans/business casesA few attendees commented on having renewed energy to push for their ideas to be implemented in practice and pledged to refresh business plans and/or create more evidence to support their case.

“I’ll continue on the same path, but with renewed vigour and enthusiasm”

Become more informed



Many attendees had learned a lot through the first session of the day about the drivers for change and had had the opportunity to explore what integration might mean for Shetland. There was a sense for a few people that they would like to be better informed before they could commit to any concrete action.

“find out more about colleagues in SIC and their views, to be better informed about how integration can benefit all”

Overall recommendations and way forward

As articulated in Petch (2011), structural integration itself will not deliver improved outcomes for people and communities, unless equal or greater attention is paid to a range of other key factors such as demonstrated below:

Interestingly, these are the key factors that have been highlighted as drivers for change and areas for future work by staff in Shetland.

The staff group themselves have influenced and designed many of the key recommendations and are able and willing to take these actions forward. This has been justified by supplemented evidence.

VisionThere was voiced frustration that there was not sufficient clarity around the overall vision for health and social integration from the key leadership. Staff felt that they were able to take on the role, but that many elements of control were outwith their



own sphere of influence. There was a clear sense that permission was need to encourage the group to prioritise strategic thinking and test out new approaches to care and support delivery.

As demonstrated through a recent evidence review (Petch, 2011; IRISS 2012), successful delivery of integrated care and support requires a commitment to and a belief in a goal to be achieved. The first step in this process is to set a vision for integration and to work with a wider group of staff to plan how this vision can be communicated, shared, reinforced and embedded.

It was clear that although staff feel that there is an overall direction of travel, that there is a need for a vision for integration to be articulated to enable the ‘golden thread’ to permeate throughout the partnership.

Recommendation

1. Create the space for the right people to be freed up to work together to consider their strategy. Build on the themes identified on day one and use these to reinforce the overall direction of travel.

Enablement – risk/permissionA theme which continued throughout both sessions was the need to engage both staff at all levels throughout the organisation, as well as people in communities to help them take on a leadership role and to engender a culture which would be permissive and tolerant to risk.

This dynamic between trust and permission is one of the key drivers for change that was explored in the Imagining the Future scenarios (see: http://content.iriss.org.uk/2025/yesterday.html). Brown and Osborne (2013) have produced a recent paper that argues that existing approaches to risk and innovation are not sufficiently developed and as such propose a framework of risk governance that may be helpful to explore.

Recommendation

1. Provide support for practitioners with ideas (through a variety of different staff) to incubate their idea from initial stage, to develop a proposal into pilot testing and embedding.

CapacityOverall it is felt that there is limited capacity for additional work, or space to create new actions going forward. Indeed, it was commented on that this is where the previous action learning sets ceased to become effective. An important role in the context of integrated working is what has been termed the ‘boundary spanner’



(Williams, 2011), key individuals who have a pivotal role across organisational boundaries, who can make connections between key activities and thus seek to avoid replication and enforce synergies.

Recommendation

1. As a group, we discussed the need to identify activities that individuals would stop doing in order to free up time to prioritise new areas of work.

2. Identification of boundary spanners as champions for integration who can support flexible use of human resources across agencies and projects

Being genuinely responsive to people in localities

There were different attitudes displayed in the group around how to support local people to be involved in decisions about the strategy for delivery of health and social care integration. Despite this, in the afternoon there was an emerging sense that people in localities and users of services would need to be part of the overall conversation.

Coproduction of care and support is a key challenge for many agencies; however there is a wealth of experience in Shetland to be capitalised on, as was evidenced and celebrated throughout the two sessions.

Recommendation

1. Build on and champion the history of effective locality work in Shetland2. Build on Edna Mary’s work on locality development

Key issue: developing integrated health and social care teams

There is a fairly well developed evidence base on what makes for effective integrated team working (see Maslin-Prothero and Bennion, 2010). Overtveit (1997) suggests that inter-professional teams can be described in terms of four key dimensions: the degree of integration, team membership, team process issues and team management. There is no evidence to suggest one form of team management is inherently superior; however it is essential that there is a structure and process for team accountability.

A key area of consideration for the majority of people present was the proposal to move towards matrix management. There was consensus that the move towards virtual teams would hinder effective communication.

Recommendation



1. Establish a pilot, which will test the matrix management model that will include virtual and actual teams to establish the evidence for best fit. This should include clarity of team structure, clear lines of management responsibility and accountability and mechanisms for resolving areas of conflict

Conclusion

Overall, there was a great deal of consensus in the room around direction of travel for the vision for integration. In essence, this was to ensure that:

- Outcomes are met for people supported by services- Staff and people who use services are supported to influence decision making- Spaces are created to support staff to support each other through the change

process, to influence it and to take action



Appendix 1: evaluation

Day 1

What inspired you from the session?

Overall, the majority of attendees had been inspired by the engagement and discussion with colleagues during the session. People remarked on how it important it was to have the opportunity to clarify the thinking (collectively) about the challenges and opportunities that lie ahead with integration.

The level of engagement, understanding and enthusiasm in the room appeared to take many by surprise! Comments focused on how positive it was to see that there was a) good foundations to start from b) shared sense of purpose and views on actions and future plans to achieve outcomes for the people of Shetland.

What have you learned through the session?

It was clear that people felt that there was greater shared understanding of the current position in Shetland and a better indication of the future direction of travel. People commented specifically on:

- the clear and informative presentations from Peter Macleod and Edna Mary Watson

- the areas of shared interest for development and action - the momentum to continue to explore a range of issues collectively

What could’ve gone better through the session?

The majority of comments centred around:1. trying to cover too much in a short space of time (focusing on one key point

in order to fully discuss and explore actions and opportunities)2. having senior leaders stay in the room for the whole discussion3. with more planning available, there could have been potential to engage

more people in the session

Day 2

What inspired you from the session?



Again, the group enjoyed the discussion openness and encouragement from other colleagues. Many commented on feeling ‘re-energised’ and ‘comforted’ by having had the opportunity to explore areas outwith the day to day routine of their roles.

What went well?

Overwhelmingly, participants noted how the open conversation, participation and honest dialogue had been the most positive experience from the event. The group had enjoyed particularly the opportunity to explore their own leadership potential (through using tools such as ‘The Change House’ and scenario planning).

What could’ve gone better?

The majority of comments centred around:1. allowing more time to specifically look at commitment for next steps2. more senior management present from NHS to allow an effective mix of roles

and experience



Appendix 2: reading list

Integration evidence base: http://www.iriss.org.uk/resources/integration-health-and-social-care http://www.iriss.org.uk/resources/delivering-integrated-care-and-support-

insight http://www.iriss.org.uk/resources/marriage-divorce-or-civil-partnership-

evidence-integration-alison-petch http://www.alliance-scotland.org.uk/news-and-events/news/2013/07/all-

hands-on-deck-locality-planning-paper-published/

Imagining the Future: http://content.iriss.org.uk/2025/

Leadership: http://www.ssireview.org/articles/entry/the_dawn_of_system_leadership http://www.sparc.bc.ca/the-art-of-powerful-questions

Democracy: http://www.westminster.ac.uk/about-us/our-people/directory/mouffe-

chantal



http://www.westminster.ac.uk/about-us/our-people/directory/mouffe-chantal

http://www.westminster.ac.uk/about-us/our-people/directory/mouffe-chantal

http://www.sparc.bc.ca/the-art-of-powerful-questions

http://www.ssireview.org/articles/entry/the_dawn_of_system_leadership

http://content.iriss.org.uk/2025/

http://www.alliance-scotland.org.uk/news-and-events/news/2013/07/all-hands-on-deck-locality-planning-paper-published/

http://www.alliance-scotland.org.uk/news-and-events/news/2013/07/all-hands-on-deck-locality-planning-paper-published/

http://www.iriss.org.uk/resources/marriage-divorce-or-civil-partnership-evidence-integration-alison-petch

http://www.iriss.org.uk/resources/marriage-divorce-or-civil-partnership-evidence-integration-alison-petch

http://www.iriss.org.uk/resources/delivering-integrated-care-and-support-insight

http://www.iriss.org.uk/resources/delivering-integrated-care-and-support-insight

http://www.iriss.org.uk/resources/integration-health-and-social-care

Appendix 3

Monday 26th January: attendees

Mark BodenVaila SimpsonLaura SaundersShona ThompsonJane ClunessChris NicolsonRalph RobertsChristine FergusonSarah TaylorKathleen CarolanSusan LaidlawBruce McCullochCraig ChapmanElizabeth RobinsonShona CarterDenise MorganJo RobinsonAnne RobertsonJan RiiseDenise BellLawson BissettColin Marsland

Tuesday 27th January: attendees

Christine EunsonElaine MaguireMichelle WilkinsonRobbie SimpsonMark BodenLaura SaundersMary McFarlaneEleanor StewartRosemary BlainIain MacBrideNick McCaffreyGeorge MartinSteven McCulloch



Gillian GoverJune PorterJo McPhersonJulie KidosnLawson BissetJane ClunessJordan SutherlandChris HamerJane PembrokeClare BurkeLawrence HughesLorraine AllinsonJan Riise



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