Knitting from the middle out

First, you’re a government minister. Or a chief executive of a national statutory body. You’re announcing a nationwide change programme to help safeguard the future of the NHS, our most beloved institution.

You want it to sound suitably impressive, capable of making headlines and winning plaudits. What do you say? A pot of money? A new ‘thing’ – an institute perhaps? Probably a number (containing many zeros) of new clinicians to spearhead your charge. The creation of a new acronym certainly.

Ok? All sorted? Great job.

Second experiment. You’re back to being you. Reflect on a change programme you’ve been involved in which worked. And let’s be flexible about scale – it could be the eradication of a disease, or getting everyone in your office to reliably fill in a leave chart. What made the difference? A clear sense of what you were trying to achieve, maybe. Everyone understanding what was expected of them, perhaps? Potentially, the protected time among a sea of other priorities to do what was required.

Anatomy of change

How do your two lists compare? If you’re anything like me you’ll have ended up with two quite different approaches; and the press announcement and the practical experience don’t have much in common.

Kaleidoscope recently facilitated discussions on this anatomy of change for a group of national and regional health and care leaders on a sunny Somerset afternoon. The question in front of us was to reflect on the progress of the Richmond Group’s (a coalition of 14 charities) project to support better collaboration between voluntary and community groups and statutory bodies such as the local authority and the NHS.

The aim of the project has been to test a hypothesis that better collaboration, both internally between voluntary and community groups, and externally between those groups and statutory bodies, is beneficial for a population’s health and care outcomes. The project has been running for 18 months to significant appreciation, further validated by a recent evaluation by New Philanthropy Capital.

How do we invest our limited time and money in an approach to change that will actually work?

However, there were different, bigger, questions lurking at the back of our discussions. How can we fix a health and care system many see as broken? How can we move beyond knowing something needs to be done to actually doing it? How do we invest the limited time and money at our disposal in an approach to change that will actually work?

What came out of our discussions were not initiatives from the guide to ministerial media-friendly announcements. In fact, the concepts that resonated barely make sense at all without a bit of a context: knitting from the middle out. What does that even mean?

Let’s start with the knitting. A large part of the project’s success was attributed to the tireless role of a local programme manager spending the time to meet everyone involved, understand why and what they were doing, and knitting these divergent threads together.

The tools of the trade being the art of conversation, convening, and tolerance of spending inordinate hours on the road. Let’s try that as an announcement: a new bureaucrat for every area! Unfashionable? Maybe. Effective when done well? Definitely.

Locally owned

And the middle out? Participants agreed the approach taken in Somerset couldn’t be classified as top-down nor bottom-up, being instead a hybrid ‘middle’ approach. The evaluation made clear that the cachet of having a number of national, respected charities involved had certainly helped – as had the additional support of national policy bodies such as Public Health England. But equally, the priorities chosen for the programme were picked and owned locally, not as a result of top-down diktat.

Yet while these two ingredients were identified as important, maybe even necessary, for effective system-wide change, no one thought they were sufficient. Conversation came back time and again to demonstration of impact. This was in part to validate their belief that better collaboration was leading to better outcomes for patients. But it was also being able to demonstrate to the wider world that faith in collaboration is not blind, but a legitimate, evidence-based approach that would help those in ‘spreadsheet world’ see the change they wanted to see.

This appears the next step both for Somerset, and also for advocates of collaborative approaches across the country.

Knitting on its own is not in vogue. Showing that the knitting is fixing a hole in a much-loved sweater, or producing a whole new garment people actively want to wear, becomes a far more attractive proposition. It could even make the headline in a press release.