As promised, here are my reflections on “how to make #peoplepoweredhealth stick”, which I shared at Nesta’s People Powered Health event. For context, I was given one minute and was speaking alongside some terrific speakers, so decided to offer a particular angle on what I thought might work…
There are limits to progress that can be made through hard levers, like policy, regulations, guidance, draft contracts
Policy makers, commissioners providers, practitioners – i.e. people – are rarely motivated by efficiencies and technical
They are motivated by good relationships, happiness, positive contact, seeing the difference they make, feeling like they are good at what they do
My reflection on making people powered health stick is to support people to come together as people, rather than in the roles they have, so that they can directly and personally experience what it is that motivates people
Part of making it stick is trying to move beyond our protective labels and roles, and emphasizing our common human bond.
I wonder why there was such a big delay between the web and Google, and then Google and AirBnB, Uber etc., and then a subsequent delay in their reaching a tipping point in terms of awareness and use by the general public?
I ask this because there have been a very wide number of approaches and initiatives for improving public services, not least health and social care, through technology and particularly the web. For example, there have been care comparison sites a-plenty, much talk of open data and suggestions of location-based services to replace off- and online directories. And yet we see relatively little evidence of these approaching a tipping point, let alone being used regularly by local authorities, providers and the general public when it comes to health and social care.
In it Beth Simone Noveck (former United States deputy chief technology officer and director of the White House Open Government Initiative) takes as a starting point another area of public policy – citizen engagement – and notes how the obvious opportunity to improve public services and local communities hasn’t been taken in the way it could have been.
Citizen engagement isn’t just the equivalent of technology: it’s clearly bigger than that. Beth makes clear this point by showing how better harnessing the interests and expertise of citizens can help both bridge the democratic divide and make the most of people in contributing to their local communities and society.
The internet is radically decreasing the costs of identifying diverse forms of expertise so that the person who has taken courses on an online learning platform can showcase those credentials with a searchable digital badge. The person who has answered thousands of questions on a question-and-answer website can demonstrate their practical ability and willingness to help. Ratings by other users further attest to the usefulness of their contributions. In short, it is becoming possible to discover what people know and can do in ever more finely tuned ways and match people to opportunities to participate that speak to their talents.
But she also notes the most significant barrier to this: the continued dominance / monopoly of policy- and service-elites in the work that they do:
[There is a] long-held belief, even among reformers, that only professional public servants or credentialed elites possess the requisite abilities to govern in a complex society.
Why? Because it is believed
Citizens are spectators who can express opinions but cognitive incapacity, laziness or simply the complexity of modern society limit participation to asking people what they feel by means of elections, opinion polls, or social media.
The shifting of the cause of the problem of a lack of engagement onto citizens themselves rather than the professionals asking the questions is a familiar refrain. We regularly hear laments about “the usual suspects”, limited response rates or adversarial consultation processes that create more problems than they solve.
But this characterisation of this situation only makes sense for one set of players: it suits both the technocratic elites who dominate public policy and services, and the other well-embedded elites with (vested) interests who can mobilise quickly to respond to consultation/engagement that affect their organisations.
It is, of course, a characterisation that doesn’t really stand up to scrutiny. For example, we know that (proper) co-production in health and social care has a solid evidence base in the difference it makes. But we also know it continues to be at best a nice-to-have rather than a must-have.
Thus we come back to the questions kicking about in my mind at the start of this post: if the ability to do this sort of thing exists (be it citizen engagement or technology), why hasn’t social care and the like made the most of this opportunity?
It’s largely because elites aren’t yet comfortable with distributing leadership and expertise.
One of the ways to overcome this discomfort, then, is to make it valuable and rational for the existing elites to engage in effective citizen engagement by ensuring a ‘good’ group of people are engaged and involved in public service reform in the first place.
Noveck rightly says:
To make all forms of engagement more effective, we need to increase the likelihood that the opportunity to participate will be known to those who need to participate. If a city really wants to improve the chances of crafting a workable plan for bike lanes, it should be able to reach out to urban planners, transportation engineers, cyclists, and cab drivers and offer them ways to participate meaningfully. When a public organisation needs hands on help from techies to build better websites or data crunching from data scientists, it needs to be able to connect.
To do this:
[I]nstitutions [must] begin to leverage such platforms to match the need for expertise to the demand for it and, in the process, increase engagement becoming more effective and more legitimate.
This is appealing. Citizen engagement may not be valued by elites because there hasn’t been adequate effort or ability to engage sufficient citizens to make it worthwhile enough.
As Noveck concludes:
This is about chances for civic participation; to be a member of a local community and to make a contribution based on this… It has everything to do with what it means to be a citizen in a contemporary democracy.
This is why I particularly like this: this isn’t just about technical changes around the edges of public service economies, but the broad meaningful difference it could make.
Most [of] the profound and important changes we need to see in public services, we describe as ‘culture changes’… What do we mean by ‘culture change’? Generally, it’s code for a change we don’t think will happen and that we don’t think is our fault when it doesn’t.
Though I can see the point, I don’t think it is right.
Before looking at Alex’s central points and so exploring why I don’t think the above is right, let’s briefly try to answer the following: “What is culture?”
There are many ways or frameworks for defining or understanding culture. McKinsey & Co famously defined it as
Culture is the way that an organisation survives. It is a way of being, believing and feeling that gives consistency and stability. It gives a way of surviving internal and external threat and disruption. It is how a place makes sense of the world. It is how it does things and how it chooses to be seen.
What this gives rise to are three levels of culture: tacit (what is assumed), espoused (what is spoken of) and observable (what is done in practice):
How then, does culture – the way an organisation or system does things, survives and makes sense of the world – manifest itself? One of the more common ways of seeing this is through the Cultural Web (see pp.134-137 of The Art of Change Making). This sees culture as the result of the wonderfully Kafkaesque
The paradigm is
the core beliefs of [an] organisation about themselves. The paradigm and the organisation’s behaviours, actions and thoughts are interlinked, they are a complex web and are inseparable. Every thought, behaviour and action feeds into the paradigm and the paradigm in turn influences every thought and action.
There are then thought to be six cultural influences that inform this paradigm and which are themselves informed by the paradigm (all of which exist at each of the three levels noted by Schein: tacit, espoused, observable).
With these common definitions of culture (and so culture change) in place, we can therefore explore the two central points of Alex’s post.
Just so you can see where I’m going with this, I’ll say now: we’ll see that culture change is precisely the sort of change Alex is rightly looking for.
The first main point in Alex’s post is this:
[I]n reality culture is always, always trumped by the hard levers and incentives in any system.
I think there is a grain of truth in this, but I think it underplays two issues.
The first is that hard levers and incentives themselves are part of the culture. In the Cultural Web they are examples of “Control Systems”, which
are the ways that an organisation controls how things are done, from things such as quality control and financial control, through to reward and punishment… People will behave in ways that they think will please the control system.
That is, what the organisation or system values is what leads to the creation of hard levers or incentives in the first place.
The second issue is that in any complex system the “hard” and the “soft” interact with each other in complex and possibly unknowable ways. (This is true even if you don’t think hard levers and incentives are part of the culture.) What this means is that for successful change to happen we should have both changes to the law, policy and financial flows that govern how systems are structured (the “hard”) and to the culture that governs how/why they work (“soft”).
The second main point in Alex’s post is about power:
Power on the other hand, is not elusive, and rarely dispersed… So next time someone in power suggests a culture change is needed, perhaps the appropriate question is, “[H]ow are you going to give your power to someone else, to start that happening?”
This point and related question about power are exactly right. From the definition of culture, though, we can see that power and power structures are part of the culture of an organisation or system. Or put another way: for power to be moved from one person to another is exactly to require a culture change.
It’s rare for me to disagree with Alex but I hope this post has explained why, on this occasion, I do. To summarise: if people use the phrase “culture change” as code for things they don’t think will happen, I’d suggest they probably don’t understand definitions of culture (at either a system or organisation level), how it manifests itself, and so what culture change might actually entail.
Human nature has provided us with a suite of emotions that encourage rule or norm following that is independent of the norm’s rationality. Sometimes… we follow rules simply because they are old and traditional. We are instinctively conformist and look around at our fellows for guidelines to our own behaviour.
Instead of reason, human behaviour is grounded in emotion and resulting biases (pace Kahnemann) like pride or shame.
Such human behaviour aggregates to institutions, and there are two main reasons institutions don’t adapt either.
The first is because they’re made up of humans, who follow rules for reasons that aren’t rational – see above!
The second is that institutions contain groups who have a vested interest in keeping things as they are:
Political institutions develop as new social groups emerge and challenge the existing equilibrium. If successful institutional development occurs, the rules of the system change and the former outsiders become insiders.
This is encouraging for those who seek and are successful in change.
As the institutions update themselves, though, so we have to be wary about the new elites within them:
But then the insiders acquire a stake in the new system and henceforth act to defend the new status quo. Because they are insiders, they can use their superior access to information and resources to manipulate the rules in their favour.
As each baddie in Scooby Doo notes they’d have gotten away with it if it weren’t for those pesky kids, so we’d achieve every public policy aim we could ever wish for if it weren’t for those pesky humans.
Goodness knows there are many legitimate points to be made about the quality and nature of public policy at the moment.
Nevertheless, I feel it is incumbent on those who want to see positive change to public policy to do so in ways that are effective. I say this because I’ve seen a couple of examples recently that were, in my view, pretty ineffective.
The first is on a topic I agree isn’t right: the limbo in which the Access to Elected Fund finds itself. A source of funding that makes it more accessible for disabled people to stand for elected office is absolutely needed, and the ongoing uncertainty about whether it will be continued isn’t right. This said, there are better ways to make the point than to (a) call it
or (b) propose making a formal complaint to the UN about the breach.
The second is on a topic I am personally very supportive of (and indeed am part of the team working on it): Personal Health Budgets. In response to the scaling up of Personal Health Budgets from the current 4,700 to 100,000 the criticism is that this:
does not fit well with our politics of austerity.
It’s equally possible to say that the scaling up of Personal Health Budgets doesn’t fit well with England’s chances at Euro 2016, with Donald Trump’s continued presence in the Republican Party’s presidential nomination race or with the mystifying popularity of Strictly Come Dancing.
The point being that it’s an odd and wrong premise, and so a criticism that doesn’t make any sense.
(To expand: if the politics of austerity is wrong (the inferred conclusion) then Personal Health Budgets shouldn’t fit well; if the politic of austerity is right, then Personal Health Budgets are a means by which to get better outcomes, most often for less, from a system that doesn’t currently work as well as it should. Either way, the premise is a false one.)
It’s absolutely right that people are critical of public policy. The quality of debate and policy, though, only improves if interventions are effective, by which I broadly mean:
They make sense
They are in ways that are more likely to make the people who could effect the change engage with the issue
They perhaps offer options as to how to address the focus of their criticism
They maybe get involved in working towards a solution
They fundamentally recognise that it’s people on the other end of their criticisms – and so that it’s only by understanding how people change that decisions and public policy change.
I was lucky enough to be invited to a discussion about the project and hear a wonderful summary of the literature on both constructive conversations and wicked issues from ICFI, and wanted to quickly reflect here two key parts of the useful information that was shared.
(I stress that the information below is taken directly from the really excellent work by ICFI, to whom all plaudits should absolutely go!)
First, what is a wicked issue?
The concept is taken from social planning (Rittel and Webber, 1973) referring to problematic social situations where: there is no obvious solution; many individuals and organisations are involved; there is disagreement amongst the stakeholders and there are desired behavioural changes. Public policy problems are ‘wicked’ (Clarke and Stewart, 1997) where they go beyond the scope of any one agency (e.g. health promotion strategies) and intervention by one actor not aligned with other actors may be counter productive. They require a broad response, working across boundaries and engaging stakeholders and citizens in policy making and implementation (Australian Public Services Commission, 2007).
Wicked issues therefore have the following typical characteristics:
Are multi-causal with connections to many other issues
Are difficult to define – so that “stakeholders understand the problem in different ways and emphasise different causal factors… The way the problem is approached and tackled depends on how it is framed, so there may be disagreement about problem definition and solution.”
Are socially complex – “Decisions about how to tackle them are unavoidably political, values based and may raise moral dilemmas. They cannot be tackled as technical challenges with scientific solutions; there is no point at which sufficient evidence will be gathered to make a decision.”
Require a whole system, multi-agency response – they do not sit within the control or authority of a single organisation, making it difficult to position responsibility.
Have no clear or optimal solution – they are not right or wrong, but better, worse or good enough
Have no immediate or ultimate test of ‘success’.
Against these characteristics, questions of social care, health, promoting disability equality, and public service reform are all obvious wicked issues.
Second, what is a constructive conversation?
The phrase “constructive conversation” itself is perhaps not well known, but its attributes are becoming increasingly familiar since they reflect much of what the approach to system leadership calls for.
A constructive conversation engages in what area known as “clumsy solutions”:
Questions not answers: seeking a deep understanding of the problem
Relationships not structures: engagement as the primary vehicle of change
Reflection not reaction: resisting the pressure for decisive action at too early a stage
Positive deviance not negative acquiescence: ignore, or look beyond, conventional culture and wisdom
Negative capability: the ability to remain comfortable with uncertainty
Constructive dissent not destructive consent: seeking consent is often destructive and illusory
Collective intelligence not individual genius: WPs are not susceptible to individual resolution
Community of fate not a fatalistic community: collective responsibility to underpin action which is likely to involve risk-taking
Empathy not egoism: seeking to understanding how other people see the problem, and the wider context”
As a result, a conversation is constructive if the following are in place:
A commitment to be open and honest
A conscious effort to foster and maintain trust
Clear information, provided at the right time
A focus on relationships not methods, underpinned by the goal of collaboration
Well-defined roles and clear expectations
The involvement of all stakeholders, fostering a whole-system approach
The ability and willingness to be flexible, wherever possible”
What a wonderful though subtle rejection of “heroic leadership” or CEO-itis this is, and what an obvious parallel with co-production it produces!
As I read through the slides of the summary on wicked issues and constructive conversations I found myself scribbling “YES!” and “Absolutely!” all the way through, so well did the findings tally with my feelings about what’s needed for change, especially in health and social care, and disability equality. They clearly tally with the ideas of system leadership and collective impact we’ve written about here before on many occasions (1, 2, 3). Though I could understand it if people were to tire of yet another set of terms that could be used and abused, for me the value of the above is in having something further to point to, consistent with what we’ve been talking about before, that further articulates the how I feel we need to go about change.