**2. The Context**

In 2016 the Scottish Government legislated to bring together health and social care in to a single, integrated system, joining up services and thereby improving the experience for those using support. An ageing population and the impact of austerity on health and social care budgets introduced another driver for collaboration—a decline in financial resources, which looks set to continue.

Although new integrated boards were created in 31 areas across Scotland with responsibility for large parts of the health and social care budget, the original National Health Service (NHS) Boards and local authorities, with statutory responsibility for social care, remained, and most sta ff are still employed by them. So, health and social care 'integration' is in fact mostly a process of (multi-party) collaboration by which two large organizations, made up of many di fferent departments, and large numbers of smaller organizations, attempt to work together to provide a better and more seamless service to people with health issues; in e ffect, almost the whole population.

The Scottish Government realized that developing interorganizational relationships to enable such collaboration would need support, and as part of that support, funded three national health and social

care organizations, NHS Education for Scotland (NES), the Scottish Social Services Council (SSSC) and the Royal Scottish College of General Practitioners (RSCGP), to design a support and development program, Collaborative Leadership in Practice (CLiP) which drew heavily on their own experience of dialogue, coaching and action research methodologies and practice. They contracted with Animate, and another consultancy organization, similar in size and approach, to deliver it.

Through CLiP, we were commissioned to support collaboration in 10 partnership areas. Two members of our team, Jo Kennedy and Ian McKenzie, and one associate, delivered the interventions, whilst the third member of our team, Joette Thomas, supported our learning. The exact nature of the interventions we delivered was determined in collaboration with the partnership itself but it always involved either team coaching or facilitation.

### **3. Using an Action Research Approach**

The program was managed by leadership development practitioners or project managers from the three national agencies, to whom we reported regularly in action research meetings, facilitated by a 'learning partner', who supported us to use an action research approach1. The idea was that we could encourage those who were part of CLiP to see what changes they were experiencing in themselves and their teams as they began to develop interorganizational relationships, which then resulted in changes across the wider organization(s) or system resulting in improvements for people in communities.

This action research approach meant that as we took action, we sought to understand the impact of that action together. It also worked on a number of levels. Firstly, and most importantly, it helped us to articulate a theory of change. This was that working on one's own attitudes, behaviors and assumptions about the other, and subsequently on our relationships with our fellow practitioners from other agencies, spreads better practice in our teams, changes the relationships between our organizations and ultimately can lead to positive outcomes for those using services. This theory of change made sense to practitioners. We used graphic tools to map it quite specifically, and practitioners then felt more legitimized in spending time exploring their own assumptions, their own understanding of collaboration and their role in relation to it, rather than immediately rushing to action. Secondly, it helped us to define a sense of common purpose, identify the changes we were seeking and evaluate whether we were achieving them. Furthermore, it helped us to track small changes over time in relation to the overall change we were seeking.

### **4. Developing Our Interventions**

In all honesty, before writing this article, we had never considered in any depth, how our intra-organizational approach di ffered from our inter-organizational approach. We just knew from feedback from our clients, and from evaluating the impact, that the approach worked in both contexts.

Writing this article forced us to ask the question: how do we determine the interventions we use to support interorganizational collaboration? We also revisited the theoretical underpinning of our practice, which could best be described as eclectic. We draw on a range of organizational development theories and have trained in systems, psychodynamic and gestalt approaches to working with groups and organizations. When we began working interorganizationally we drew on many of the same theories and approaches we used in our intraorganizational work. We learned over time that there were three sources which made most sense to our clients, in the interorganizational collaborations in which they are currently working. The work of Heifetz (2009) on adaptive leadership helps us to support people to: navigate complexity by taking the time to stand back and look at the whole; be more comfortable with not knowing the answer straight away and understand the value of bringing di fferent views and di fferent approaches to an issue and indeed the absolute imperative to do that

<sup>1</sup> For further information on the approach we used to learn and on action research more generally c.f. www.research-for-real. co.uk.

when faced with 'adaptive challenges' (Heifetz et al. 2009). Interorganizational collaborations, like health and social care integration, are set up to address 'adaptive challenges', like how do we improve the health and wellbeing of Scotland's population; the answer to which is not within the 'gift' of any single organization. We find that making the distinction between a technical fix and an adaptive challenge, language pioneered by Heifetz, is very useful for the practitioners we work with, who are extremely familiar with the pressure to provide quick solutions to complex issues, without taking the time to consider who needs to be involved, and how, in developing a new approach.

We have found Wilber's Integral Theory equally useful. The simple four quadrant diagram which we discovered originally in an article on Resistance Free Change (Klein 2009) supports us to explain the aspects of intraorganizational and interorganizational working, systemically. In his book on Integral Psychology (Wilber 2000), Ken Wilber defines Network Logic as follows: "A dialectic (dialogue) of whole and part. As many details as possible are checked; then a tentative 'big picture' is assembled; it is checked against further details, and the big picture is readjusted. And so on, indefinitely with ever more details constantly altering the big picture—and vice versa. The 'whole' discloses new meanings not available to the 'parts', and thus the big picture will give new meaning to the details that compose it." We do not go into such depth in working with practitioners, but we do highlight how easy it is to pay attention to the 'objective' and tangible systems, processes and competencies within an organization or between organizations, and ignore the 'subjective' aspects which are less easy to see, such as values and beliefs, individual hopes and aspirations, culture, informal working practices and unwritten rules. When explaining it we often cite the old adage 'culture eats strategy for breakfast' attributed to Peter Drucker. This often elicits a weary laugh from the practitioners we work with, who are used to multiple strategies, plans and protocols which are never embraced or enacted. Explaining how paying attention to the 'whole system' including individual aspirations, values and beliefs and the cultures which have grown up in teams as well as the more familiar external process in organizations, can provide a way to move forward and makes sense to practitioners in both intraorganizational as well as inter-organizational contexts. However, in interorganizational contexts it is even more meaningful. Practitioners are used to starting with developing new structures, new roles and new job descriptions, to promote interorganizational working, rather than seeking at the same time to explore how to make it possible for individuals and teams to work in completely new ways, ways which often threaten their sense of identity; and to understand and value the approach taken by another organization, without feeling threatened by that di fference.

Finally, Kegan and Lahey's (Kegan and Lahey 2009) work on Immunity to Change, enabled us to provide practitioners with a way of seeing resistance as something to be understood rather than something to be overcome. The Immunity to Change process introduces the idea of the 'hidden competing commitment' which could be underlying the resistance to change and needs to be both honored and understood. It also challenges practitioners to explore the assumptions they make about what might happen as a result of making a change and encourages the testing of such assumptions. This process, again is useful in a wide range of contexts, not just interorganizational working, but we have found it particularly useful in that context, because interorganizational working always necessitates change and often provokes fear, which leads to untested assumptions about what might happen as a result of that change. The Kegan and Lahey approach gives practitioners a simple process to help them really understand their own and others' resistance, rather than deny it, ignore it or fight it.

Being eclectic in our theoretical approach sometimes makes it hard to explain exactly how we work in both an intraorganizational and interorganizational context. So, over the past two years we have done some internal work to try to clarify and define our distinctive approach, and have come up with a working approach, which we are calling 'Stretch'. Stretch is not based on our understanding of Heifetz, Kegan and Lahey and Wilber. Instead it draws on a whole range of theory which has influenced us and is firmly rooted in the learning we are generating from our current practice. As such, it is a work in progress rather than a finished product. Currently, it has six elements (or imperatives) which as consultants we try to adopt ourselves and to use to support the development of intraorganizational

and interorganizational relationships. The elements are be curious, be appreciative, be proactive, be courageous, be thinkers and be communicators.

We use Stretch when working within organizations and between organizations; but we find that in our work on interorganizational collaboration, particular elements come to the fore namely: curiosity, courage and communication.

Working interorganizationally necessitates being able to tolerate a high level of di fference without finding it threatening or overwhelming. We know that from our own experience and from our coaching practice, that raising individual's levels of awareness and insight into the impact of their own behavior, particularly when fearful or under threat, can have a transformative impact on groups and organizations. We know from our psychodynamic training that, as individuals and groups we are naturally threatened by 'the other' and often find ways of excluding them. We seek to raise awareness of this in our interorganizational work by exploring the assumptions which naturally arise about 'the other' and examining the ways in which we both consciously and unconsciously exclude. Encouraging curiosity is one of the most accessible ways we have found to express this. To support curiosity, we use 'light' psychometric processes in the room to enable people from di fferent organizations to gain more insight into themselves and others, and to grow in understanding of their own 'working style'. Sometimes, we consider the 'working style' which might be dominant in their own organization and encourage them to be curious about the working style that might be dominant in other organizations too.

Drawing on our understanding of the work of Kegan and Lahey in particular, we encourage individuals and groups to identify their assumptions about others and about the work they are doing, and to ask more questions of themselves and one another. Some of these questions involve taking risks. We acknowledge and support di fferences and potential conflicts to emerge, drawing attention to them in the room and opening up the space for conversations about them. These conversations often take courage on all sides. Clearly courageous conversations are necessary within organizations as well as between organizations, but we find that interorganizational working requires a particular kind of courage, which often means people stepping outside their 'comfort zone', being willing to question their own professional identity, taking the risk to share resources and sometimes giving up working practices or aspirations which have been dearly held.

Finally, we spend a lot of time exploring how and what to communicate both within and outside the room. Again, this is as necessary within organizations as it is between organizations, but it is even more complex interorganizationally. Organizations develop their own ways of communicating internally through formal and informal systems, which are often impenetrable to those from other organizations. The same words may be used to mean di fferent things in di fferent organizations. Rather than just examining communication systems, as we would when we work intraorganizationally, when we work interorganizationally we support both informal and formal communication processes to be dismantled and rebuilt to suit a new entity and a new purpose.

Running through all the Stretch elements is a relational, purposeful approach. This means that we work hard to ge<sup>t</sup> to know our clients as human beings, and we prioritize giving them the time to ge<sup>t</sup> to know one another too; believing this knowledge will support them to take up their roles more purposefully and e ffectively together. We focus on defining purpose at every stage, from every perspective, and try to keep the purpose at the forefront, seeking to clarify it throughout our intervention.

### **5. Interorganizational Working in Practice**

As part of our work on one of the national programs mentioned earlier, our team has worked with ten health and social care partnerships across Scotland, over the past two years, all at di fferent stages of integration. All face the same challenges, which can be summarized as: greater demand, which has to be met with fewer resources. The pressure just to 'get things done' is huge and mitigates against the time it takes to establish a common vision, clear roles and truly e ffective working practices.

To describe the context of all ten would mean getting into a level of detail, which is beyond the scope of this journal article. However, our approach, although tailored to the individual context, was broadly similar in all of them. So, the description of the one below gives an impression of our work across the whole. Names have been substituted to protect anonymity. The consultant working in the site was one of the three authors of the article.

Beston is a small town on the edge of a large city in Scotland. It was chosen by the Health and Social Care Partnership (HSC) as a site in which to launch an inquiry involving practitioners from across disciplines. George, the 'strategic program manager' asked Jo, a consultant with Animate Consulting, to attend a startup meeting with him, and several other senior health and social care managers, to scope out an approach to promote better joint working for the benefit of housebound elderly people. The initiative was seen as a way of trying out 'locality working' in practice, with the aim being that we could devise a process, which other localities could learn from.

General Practitioners (GPs) are the first point of contact for many patients; they are also the most likely to be working in isolation. The HSC partnership decided to focus the project around two GP practices. They invited the GPs to attend six meetings with other health and social care practitioners who were also supporting housebound elderly people. The intention was to see how together, the group could improve the lives of elderly housebound people by ensuring that they received more of the right kind of services at the right time. Crucially, the HSC gave Delia, the 'integration manager' time to support the initiative, inviting people, organizing rooms and following up actions in between meetings.

Meetings were held monthly over a six month period. Each meeting lasted three hours. Fifteen–twenty people attended each meeting. No one (except Jo) attended all six meetings, although most people were present for at least four out of the six meetings. They included: two GPs (from di fferent practices), district nurses, a social worker, a day center manager, a mental health specialist, a community librarian, several people from voluntary sector organizations who were providing community support or support to carers, a pharmacist, an occupational therapist, an IT specialist and one or two senior managers. In all, 10–15 organizations were represented. Jo's role was to design, facilitate and support the inquiry process.

Setting up the first meeting required courage on the part of Delia, who issued the invitations. It was an unusual meeting because: it was long; there was no fixed agenda; it took place in a community setting and the practitioners had di fferent levels of experience and of status within their own organizations. What they had in common was a clear intention to work together better to support housebound elderly people in their geographical area. The first meeting began with a focus on communication. Jo invited people to say who they were and why they were there. The GPs in particular found this useful. They had not met most of the other practitioners, and they were immediately curious about all the support that was available from the voluntary sector organizations. Already many people in the group were beginning to question the assumptions they made about those who worked in other organizations being in some way 'less skilled' or 'more informed'. Almost everyone found it strange: hardly anyone had had the 'luxury' of three hours to sit together and discuss how to tackle the issues they had in common. They started by considering what worked currently about the way they worked interorganizationally, taking time to ge<sup>t</sup> to know one another (rather than just read each other's name badges) and getting clear about the purpose of their work together.

They were invited to identify the kinds of changes they wanted to see as a result of this process. Aspirations included: more trust, stronger relationships, more community involvement, better use of technology and a stronger focus on personal outcomes. During the second half of the meeting we focused on four stories of real people who were using support in Beston. Four small groups worked to distil the learning from each of the stories. Several interesting conclusions emerged: Three out of the four people receiving services were overwhelmed and confused by the amount of support they received from di fferent organizations; people were afraid to change their 'care packages' in case they could not ge<sup>t</sup> them back again if their needs increased and information recorded by one practitioner in one organization was inaccessible to others in a di fferent organization.

Telling stories of the present engendered a desire for immediate action and practitioners highlighted things they wanted to do (like sharing information) or questions they wanted to ask (such as 'what is a wellbeing clinic and how might it work?') before they met the following month. During that first meeting one of the nurses was visibly angry and upset, fed up with the ever-increasing volume of work, and the ine fficiency of the systems and structures. Jo encouraged her to speak out and the group members respected the courage this took by listening to her. By the end of the meeting she had agreed to take a lead on researching the wellbeing clinic. Although Jo did not explicitly use Wilber's integral theory she was encouraging people to think systemically, drawing on their own values and aspirations, considering the culture of their organizations, examining the systems they used and most importantly beginning to create a new interorganizational entity to support housebound elderly people better.

In between every meeting Jo met with Delia, to debrief, discuss progress and plan the next meeting. Delia communicated with individual group members between meetings and nudged actions. She was always able to keep Jo abreast of what was going on, highlighting underlying issues and ensuring that the agenda was really focused on moving forward. Jo and Delia quickly developed a format for the meetings, which encapsulated an action research approach. Each meeting began with a short recap, using a visual plan which was pinned on the wall, and an update on actions in the whole group, which took the best part of an hour. This was followed by an in-depth focus on two or three key areas, in smaller groups, which led to agreemen<sup>t</sup> on actions in the large group. They always finished by checking out how people were as they left.

The second meeting began with more introductions as new people joined. By this time the existing members of the group were able to explain that the group provided 'an opportunity for trial and error in a safe environment, a place to share enthusiasm and frustrations, energy and honesty, a place where we can learn, a chance to identify and talk about the big issues'. They caught up on progress in relation to the actions identified in the previous meeting. In addition, they focused on three areas: tapping into the lived experience of users and carers; medication and information sharing.

During the third meeting Jo used a visual scenario planning tool to identify the future they wanted to create, where they were now in relation to that future, and the key areas they wanted to work on. That provided them with six clear priorities to focus on. By this time the group was appreciating the distinction between technical fixes and adaptive challenges (Heifetz). They identified some 'quick wins' such as telling pharmacists which of their patients attended the day center so that they could drop o ff medicines there, to avoid getting overwhelmed by some of the more intractable issues, such as integrating di fferent information systems. At the end, group members reported that the meeting generated 'lots of little things that will make a big di fference' and provided 'a forum that works towards integration that we can't find in the day to day'.

And yet, Delia and Jo were beginning to ge<sup>t</sup> impatient themselves, and were sensing that group members might be too. Group attendance was irregular and actions agreed at the meeting were not always being carried out between meetings. They were struggling even to ge<sup>t</sup> started on developing integrated systems across agencies, because the individual systems were not functioning themselves. Some practitioners had competing priorities and were not able to give the work the attention they wanted to, and others, found the cross-sector approach threatening to their sense of identity and professionalism, and stopped attending. The GPs were attending but were still skeptical and although positive in meetings were struggling to prioritize taking action in between.

During the fourth meeting they talked about some of these di fficulties, using the Kegan and Lahey insights on resistance to examine what was underneath some of the barriers. The group had still not managed to identify how many housebound elderly people the GP practices supported. Nor had they managed to coordinate support around them. Getting to the bottom of who was 'housebound' and considering how to surmount the legal obstacles to sharing information, was tedious and taxing work. Having had the courage to acknowledge this, they recharged their energy by turning their attention to making the best use of the voluntary sector day center. They developed ideas for 'small tests of change', expanding its use by statutory sector agencies. By the end of the meeting the GP was

commenting: 'I am learning more about how other organizations work—these small tests of change are very important—I see my role as information sharing—I will ask the district nurses to pop into the day center'.

Delia and Jo were conscious that there were only two meetings left and during the fifth meeting they focused on what group members felt should become 'business as usual' in the HSC partnership, with a particular focus on developing flexible care packages for people (so that they did not feel the need to hang on to any support they were o ffered) and devising e fficient ways of sharing information between agencies.

Delia and Jo met with senior managers to consider the results of the initiative before the final meeting. They were both anxious, aware of how slow progress had felt in relation to some of the key issues they had identified at the outset; however, the managers were very positive. They recognized a strong foundation for future collaboration. They saw that giving sta ff time away from the frontline had been valuable. Four ways to continue the work were identified: monthly multi-disciplinary team meetings in each GP practice, focusing on particular patients; continuing to work on far more flexible review process which really put the person at the center; developing the role of the voluntary sector day center and continuing to tackle the obstacles to information sharing.

During the sixth and final meeting they agreed plans to take forward the four initiatives. We ended by checking back against the outcomes agreed at the beginning. Group members identified that they had improved communication and understanding of each other's roles, made new partnerships and found out how to help one another to provide better services. They spoke of practical integration on the frontline. One member said 'we have gained traction' whilst another spoke of 'inspiration, enthusiasm and commitment'.

### **6. The Six Practices**

The Beston story typifies our approach to supporting interorganizational collaboration. Using the three elements of Stretch: be curious, be courageous and be communicators, helped us design our interventions. We invited all the relevant partners to be in the room together; we took time to ge<sup>t</sup> to know one another, and one another's roles; we agreed a shared purpose, which mattered to all of us; we acknowledged diversity and recognized and worked on frustration; and we tried out small tests of change, building those that worked into 'business as usual'. Although it worked well enough, we only really scratched the surface in terms of being able to talk openly about some of the tensions and power imbalances between partners. This was largely because the group was fluid as most practitioners could only a fford the time to attend some of the meetings. Prioritizing time to think remains very hard for practitioners delivering services, which means that developing adaptive solutions to complex issues is a real challenge.

However, Stretch really only defines our approach. The group created practices together which enabled their interorganizational relationships to develop and true collaboration to take place. These practices were facilitated by Stretch, in particular the support of courage, communication and curiosity and most importantly a clear and unequivocal focus on purpose and outcomes for people using services. In the rest of this article we explore the six practices, adopted in Beston, and in other areas, which for us have become the hallmarks of interorganizational collaboration. We identified the practices through reflection. Jo and Delia reflected first, in between each meeting in Beston, discussing what they had learned from the meeting, which interventions had worked well and what could be improved, and designed the approach to the next meeting together.

The authors also reflected as a team, telling stories from Beston and the nine other partnerships which made up our part of Collaborative Leadership in Practice, and drawing learning from our practice,usingareflectioncycleandwiththesupportofourlearningpartner.<sup>2</sup>

 The practices are:


• Developing accountability to a shared purpose;

