Cathy Fooks, President & CEO
The way to get stronger is to let go of power, according to what Helen Bevan of England’s National Health System told a group of leaders in Ontario health care at The Change Foundation recently.
That seemingly paradoxical notion made sense to those of us gathered there once we grasped Bevan’s argument that only by shifting to different kinds of power, finding it in the hands of different people and using it in different ways will health systems be sustainable and provide the care patients deserve.
Bevan, the Chief Transformation Officer for the National Health Service (NHS) was the third speaker in a series on integrating care organized by The Change Foundation with partners from the University of Toronto — the Institute of Health Policy Management and Evaluation, the Health System Performance Research Network, and the Dalla Lana School of Public Health. The goal is to create a learning lab of ideas that will help leaders in Ontario integrate care, and we’re sharing insights from these important conversations more broadly through blog posts, to be followed by more in-depth articles in Healthcare Quarterly.
Bevan, who gave her presentation by video link, had three lessons about introducing large-scale change for the three dozen people watching her from The Change Foundation’s board room. The first was on the importance of the language and narratives we use when proposing change; the second, on shifting power and the new approach to leadership that requires; the third was on the choice between structure and agency as the means of bringing about change.
Bevan did not shy away from using the example of a big mistake the NHS made in the use of language for their current redesign. Their choice of the phrase “accountable care organization,” originally used in Obamacare, to describe new local partnerships of health and social services triggered an immediate backlash. Critics warned of “American-style” healthcare and privatization. Some of their work was put on hold as a result and the new name will be integrated care organizations.
Bevan said the incident was a compelling reminder of something she had long known — that to win support for large-scale change, you need to connect with people’s values and emotions, in this case through language and labels that are meaningful for people.
“You know if we had kind of stood back and thought about it, we should never have used the labelling ACO or accountable care, because it’s got connotations around U.S. health care privatization,” Bevan said, adding “You will smile at this, but the new labelling — rather than being an accountable care organization — will be an integrated care organization.”
I was more inclined to sigh than smile, because the incident was such a prime example of what happens when we don’t involve the public in what we’re doing. That’s a failure we’re often guilty of in health care, whether it’s in how we treat one individual or family, or responding to broader public needs.
The second lesson Bevan offered the meeting was that integrated care requires a different approach to leadership. She began by talking about old power, the norm in hierarchical organizations, including health care. She defined it as positional authority, based on commands and focused on meeting goals and standards. New power, by contrast, is based on collaborative relationships and the sharing of goals and ideas.
Old power clearly leaves little room for public input, or even the involvement of staff and providers. Moreover, since early efforts to reform the NHS actually put health organizations in competition with each other, moving to new power will require big shifts in leadership thinking, but they are essential.
“There can’t be winners and losers,” Bevan said. “The system has got to win.” Integration will only succeed, she added, if it’s built on relationships based on trust, which make it possible for people at all levels to work together to bring about change.
Bevan’s third lesson was that system-wide change is accomplished not only by structural means such as rewriting rules, setting new standards, or imposing top-down plans for restructuring, but also through agency (empowering people and groups to make positive changes).
Public sector reform over the past 20 years has focused on structural mechanisms, but giving people (or groups) agency to make changes is increasingly popular around the world. It’s faster, for one thing. Also, it brings many more minds to bear on an issue — ideally, the minds of people who work on or near the frontlines and know what the real issues are and what solutions make the most sense.
“We know that diverse groups of people will consistently make better decisions than small groups of senior leaders or experts,” Bevan said. “If we start doing things in different ways, if we start opening up our decision-making processes and we have different kinds of conversations with people, I think we can almost talk ourselves and think ourselves into different ways of doing things.”
This was an idea more likely to draw a smile than a sigh from me — because it shows how patients and families, as well as providers, can be change agents, if systems welcome and encourage them. Bevan called it “building power to make a difference,” and it’s done, she told us, by activating people, by improving their ability to make choices and building capability. If we do that, she said, we can build leaders everywhere.