In early July, alumni participants of The King’s Fund’s Advanced Organisational Development (OD) programme met to share their experiences and explore the role of OD during some of the most complex times the health and social care system has ever faced. In the same week, the Health and Social Care Select Committee identified acute shortages and high turnover of staff across the sector; the stories that afternoon came to life against this backdrop.
The system of health and care through the eyes of the OD practitioners
What is the current reality for people working in health and care? Participants spoke of endless cycles of overwhelming busyness, papering over the cracks by solving difficult system-wide issues with short-term local fixes.
While many formal approaches for implementing change reference certainty – knowing ‘the answer’, reaching an intended outcome – the work of Ralph Stacey examines leaders’ experiences of working with uncertainty and complexity. He suggests that, where levels of agreement and certainty about the right way forward are low, engaging with a diverse range of views about what’s possible, exploring and experimenting may be more helpful than launching another wholesale change programme (see Figure 1).
We used Stacey’s grid1 to map where participants’ current experiences lay and they spoke about the complexity of the issues and relationships in their systems, the interplay of power, hierarchies and interdependencies. In talking together they paused the anxious roller coaster, if only for a few hours, and were able to consider different ways of moving forward, freed from the tyranny of right and wrong decisions. They took huge restoration from this time together and wished the leaders they work with could have the same opportunity to reflect. They discussed their perceptions of leaders’ experiences and considered how they might better support them.
The experience of health and care leaders through the eyes of the OD practitioners
'Participants speculated that the speed and semblance of certainty serves to contain the anxiety of others – and self. The pattern of relentless activity offers no space to think too much or think differently about issues.'
The alumni participants were struck by the inherent strain they witness in leaders as they try to navigate a way through workforce issues, growing waiting lists, pressures on general practice, the lack of funding for social care, and so on. They noted that this creates tension at every level of the organisation. As a result, there is constant pressure on leaders to ‘show up and shape up’, and a desire from everyone – from staff to national bodies – to heap responsibility on one clearly defined person or group of people, who take all the praise and all the blame. They agreed that not much is spoken about in terms of the emotional toll of this on leaders.
Operational delivery also takes precedence, resulting in leaders taking tough decisions quickly to get something done, needing to demonstrate that they can keep the system afloat against all odds. As Philip Streatfield said in his book The paradox of control2 , to suggest that you are not ‘in control’ is the worst thing you can do. Participants speculated that the speed and semblance of certainty serves to contain the anxiety of others – and self. The pattern of relentless activity offers no space to think too much or think differently about issues.
Holding the line: OD practitioners working in support of their leaders
'Yet perhaps this is the work: not giving in to quick wins to address immediate pressures and instead holding the line on what will bring about real change.'
What struck the alumni was just how hard it was to hold the line with leaders, particularly beleaguered leaders whom they wanted to support. They discussed the courage it takes to say no to the next initiative, another workstream, in exchange for something which may appear ambiguous, such as thinking more widely with different people. Yet perhaps this is the work: not giving in to quick wins to address immediate pressures and instead holding the line on what will bring about real change. Stacey would argue that human relationships are continually forming and changing, creating new meaning and new possibilities. OD can support the creation of space for leaders to hear new perspectives, to think together with others. Early examples of the alumni working in this space included:
connecting with counterparts in different parts of the system, eg, from acute hospitals out into local government, GP practices, social work, building networks to think differently and role-modelling this within the system. ICS OD communities of practice are now developing, sharing projects and resources on behalf of the system
re-instigating activities to encourage conversation or a new perspective. Schwartz Rounds and Gemba Walks were proving successful, enabling different combinations of people to be heard, connect and generate ideas that would not otherwise surface
supporting staff networks in gaining a greater voice at the table, highlighting and addressing problems for under-represented or disadvantaged groups and individuals within organisations
undertaking individual inquiry meetings with senior leaders in an integrated care system, aiming to give leaders space to pause, notice, consider the influence of their role, and their needs for support in a newly formed system.
It is said that humans are naturally ‘cognitive misers’ who use familiar beliefs and routines to save energy3, but that can produce very rigid thinking. Operating differently requires courage and ‘intellectual humility’, a willingness to revise your views. Pausing also risks being seen as indecisive. Yet there is no evidence that quick decisions to complex issues reap any rewards beyond the short-term comfort of the illusion of certainty. OD practitioners can help by challenging this mindset and bring to life possibilities for liberation from the need to know the unknowable. They just need to hold the line.
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