Leading large scale change for integrated care
Dr Robert Varnam PhD MRCGP
Head of general practice development, NHS England
Clinical lead for CCG & primary care delivery, NHS Improving Quality
GP, Robert Darbishire Practice, Manchester
@robertvarnam
robert.varnam@nhs.net

Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Sequencing
 Top tips

Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Sequencing
 Top tips

The story so far

Structure + process = outcome

Structures
Infrastructure
ProcessesBehaviours

The story so far
We have often focused on
structures & provider-led change
… and ended up with integration of providers
(more than care)
… made more improvements than transformations
... and found progress hard to sustain
… which was entirely predictable

So what are we dealing with?

Improvement or transformation?
Improvement Transformation
Doing things
better /
differently
Doing
better / different
things

What is „large scale‟ change?
Depth
of change vis-à-vis
current ways of thinking
and doing; a.k.a
cognitive-behavioural
or paradigm shift
Pervasiveness
of change; does it affect whole or
only portion
of the system?
Size
of system experiencing change; e.g.
geography, numbers of people
Refs: Mohrman A. et. al. Large-Scale
Organizational Change. Jossey-Bass, 1989
and Levy A. Second-order planned change:
definitions and conceptualizations. Org.
Dynamics. Summer 1986, 15:5-20

Large scale change usually fails
Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey of company executives
70%
25%
5%

Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Sequencing
 Top tips

Levers for change
What happens ...

Levers for change
What happens ...

Levers for change
What happens ...

Levers for change
What happens ...

Levers for change
What happens ...

Levers for change
Very few of our „wicked‟ problems will be addressed by believing the health and
care system is a machine.
Our experience shows that it behaves like a complex social organism.
It is time for a different paradigm of large scale change…

Complex Complicated
Chaotic Simple
Emergent practice Good practice
Best practiceNovel practice
Snowden D & Benford RD. The Cynefin Framework.
Cause & effect relationships
exist, are obvious to most people &
predictable & repeatable. Can be
known in advance.
Cause & effect relationships exist, but
not obvious, so require
analysis/investigation +/- expert
knowledge.
Cause & effect only obvious in
hindsight, with
unpredictable, emergent outcomes.
No cause & effect relationships can
be determined.
Probe. Sense. Respond. Sense. Analyse. Respond.
Sense. Categorise. Respond.Act. Sense. Respond.
Knowable
Known
Disorder
Several
options

www.youtube.com/watch?v=ctMty7av0jc
Coordinated, behaviour – thousands of birds moving ‘as one’ – with no external control
How? A small number of simple rules, internalised:
• Separation: steer to avoid crowding local flockmates,
• Alignment: steer towards the average heading of local flockmates, and
• Cohesion: steer to move toward the average position of local flockmates .

Leading in complexity
 A small number of simple rules
 Acting within each unit
 A few well-tested external influences & barriers

Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Sequencing
 Top tips

A different paradigm

What’s the
financial incentive?
Who is
performance
managing?
What’s the
project plan?

“I have some KPIs
for your”
or
“I have a dream”

“You can’t impose anything
on anyone and expect them
to be committed to it”
Edgar Schein
Professor Emeritus, MIT Sloan School

Drivers
of extrinsic
motivation
 regulation
 payment & incentive
systems
 performance
management
 measurement for
accountability
create focus &
momentum for
delivery
Intrinsic
motivators
 connecting to
shared purpose
 engaging, mobilising and
calling to action
 motivational leadership
build energy
and creativity

build energy and
creativity
Internal
motivators
 connecting to
 shared purpose
 engaging, mobilising and
calling to action
 motivational leadership
Drivers of
extrinsic
motivation
 System drivers &
incentives
 Performance
management
 Measurement for
accountability
create & focus
momentum for
delivery

How do we create shared purpose?
Identify shared
values
Create a safe
space
Create a
vision for the
future
Describe why
the change is
urgent now
Amended from work by Roffey Park

[Shared] purpose goes way deeper than
vision and mission; it goes right into your gut
and taps some part of your primal self. I
believe that if you can bring people with
similar primal-purposes together and get
them all marching in the same direction,
amazing things can be achieved.
Seth Garguilo

Using shared purpose
The „why‟ of
your change
A gravitational
force for drivers
The fuel that
won‟t run out
A uniting force
for stakeholders

Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Sequencing
 Top tips

Complex Complicated
Chaotic Simple
Emergent practice Good practice
Best practiceNovel practice
Snowden D & Benford RD. The Cynefin Framework.
Cause & effect relationships
exist, are obvious to most people &
predictable & repeatable. Can be
known in advance.
Cause & effect relationships exist, but
not obvious, so require
analysis/investigation +/- expert
knowledge.
Cause & effect only obvious in
hindsight, with
unpredictable, emergent outcomes.
No cause & effect relationships can
be determined.
Probe. Sense. Respond. Sense. Analyse. Respond.
Sense. Categorise. Respond.Act. Sense. Respond.
Disorder

Sequencing in large scale change
Identifying
need for
change
Framing/
reframing
the issues
Engaging/
connecting
others
Making
pragmatic
change in
multiple
processes
Attracting
further interest
After some
time
Settling in
Possible outcomes
1. sustainable norm
2. plateau
3. run out of energy
Living with
results and
consequences
Maybe later
Repeats
many
times in
hard to
predict
ways
Time delay

Large Scale Change
The emergent process of mobilising a large collection of individuals, groups
and organisations toward a vision of a fundamentally new future state, by
means of:
• high-leverage key themes
• a shift in power and a more distributed leadership
• massive and active engagement of stakeholders
• mutually reinforcing changes in multiple factors
• a focus on changing patterns of behaviour, relationship &
power

Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Sequencing
 Top tips

Conclusions from the evidence
Successful integration requires:
• shared purpose & collaborative
behaviours, more than new structures
• overcoming silos through communication
(leaders & staff talking, shared patient
record, shared performance data)
• much can be done within existing regimes
(eg tariff, Caldicott)
• no silver bullet
bit.ly/RzENMB

Conclusions from the evidence
“Leaders and managers tasked with applying integrated care „at scale
and pace‟ might … focus on driving forward the organisational
solution or introduce various financial inducements in the hope this
will be more effective [than starting with values-based shared purpose].
Such an approach would be a mistake…
A values-driven approach should be a pre-requisite to the
successful adoption of integrated care.”
Goodwin, Nick. “Taking Integrated Care Forward: The Need for Shared Values.” International
Journal of Integrated Care 13, no. 2 (June 24, 2013).

Conclusions from the evidence
• Eventually, successful
commissioners have to adopt
different approaches:
• see the whole system, not just
constituent services
• more relational, less
transactional
• more clinically-led collaboration
with providers, less finance-led
negotiation
• more provider-led innovation &
improvement
• less bound by annual & linear
cycles, more flexible, long-term
& iterative
bit.ly/13Otdyq

Top tips (NHS Academy for Large Scale Change)
1. Moving towards a new vision that is better and fundamentally different from
the status quo
2. Identifying and communicating key themes that people can relate to and
that will make a big difference
3. Multiples of things („lots of lots‟)
4. Framing the issues in ways that engage and mobilise the
imagination, energy and will of a large number of diverse stakeholders
5. Mutually reinforcing change across multiple processes/subsystems

Top tips (NHS Academy for Large Scale Change)
1. Continually refreshing the story and attracting new, active supporters
2. Emergent planning and design, based on monitoring progress and adapting
as you go
3. Enabling many people to contribute to the leadership of change, beyond
organisational boundaries
4. Transforming mindsets, leading to inherently sustainable change
5. Maintaining and refreshing the leaders‟ energy over the long haul

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enquiries@nhsiq.nhs.net @robertvarnam