*6.1. Suspending Disbelief*

Many of those in health and social care have experienced a lot of change throughout their working lives. They have not initiated much of this change, and sometimes it has not led to better outcomes for themselves as practitioners or for those using services. Integration requires a suspension of disbelief. It means taking the risk to set up a new system in which professionals take up new roles and do things they are not accustomed to doing. It requires some give as well as some take, and it will take some time to see whether the risk will pay <sup>o</sup>ff.

"Will our patients ge<sup>t</sup> a better service at the end of all this? I can see it is a massive amount of work to make it all join up." (GP)

We saw some practitioners willing to suspend disbelief and take the risk. We saw other practitioners, and particularly those who have little experience of interorganizational working, reluctant to take the risk, and quite deeply entrenched in their own system. Sometimes this related to power. Those with the most power, were often the most reluctant to collaborate, because it meant sharing it. Those with the least power, had little to lose by collaborating.

What we found helpful in encouraging people to suspend disbelief and take the risk to establish interorganizational relationships, was to foster a sense that something had to be done, both by looking at what worked currently, but also by exploring honestly the failings in the current system and how they impacted on particular people, both patients and practitioners. This created urgency.

What practitioners valued most in almost every workshop we ran or every event we facilitated was the chance to understand what each other did. As soon as they began to explore each other's roles and each other's organizations in any depth, they almost always found ways of helping one another in very practical ways. These turned into what are commonly known as 'small tests of change'. For instance, GPs began changing their prescribing practices so that home care staff did not have to visit so often, and housebound elderly people could go out to a local lunch club rather than stay in so that a worker could visit them and support them to take their medication. This meant the GP having to spend more of their budget on medications which could be given twice a day rather than four times a day, but they were willing to do it because they could see what a difference it made to the quality of life of their patients. These small practical experiments in doing things differently began to add up to a conviction that maybe things could be better through collaborating across and between organizations.

Suspending disbelief was facilitated by the three elements of the Stretch approach: curiosity, courage and communication.

<sup>2</sup> We use a variety of reflection cycles but they all start with us individually telling stories of our experience and then going through a cycle which includes observing, reflecting, planning and identifying actions (ORPA designed by Research for Real and based on the work of Yolande Wandsworth).

### *6.2. Defining a Shared Purpose, and Getting Everyone to Sign Up to It*

Health and social care integration aims to evidence high-level outcomes, which are achieved for society as a whole and not just for the participating organizations.

The pressure to produce these outcomes as a result of integration is intense and unrelenting. The Scottish Government are expecting more for patients and people who use services, at a lower cost. At a societal level, there is a real reluctance by politicians, and the general public, to accept that the present system is una ffordable and health and social care services will need to be rationed in some way.

In practice this means that di fficult decisions about where to ration are left to local health and social care leaders and managers again requiring courage. As well as improving services, health and social care practitioners are tasked with improving public health overall (as a way of reducing demand), and mobilizing as ye<sup>t</sup> undefined, community resources. Given this context it is no wonder that the task can feel overwhelming and produce both a sense of hopelessness and embattlement. This is compounded by media coverage, which is mostly hostile.

Within this context, we commonly found that people were inclined to 'get on with the job' without beginning with curiosity or communication which could lead to establishing meaningful tasks, roles and responsibilities. Developing a shared purpose enabled practitioners to explore their own role in relation to delivering that purpose and to explore what felt new, di fferent and challenging about it. This makes it sound as if the purpose was fixed and immutable. In Beston it was not. As issues were explored, short term and medium term goals like encouraging the nurses to visit older people whilst they were at the lunch club, rather than in the homes, which meant they had to stay in all day, were constantly revisited and refined in the light of new knowledge. The long term goal of improving the wellbeing of housebound elderly people through improving their services, remained the same.

Ensuring that those who would be working towards the purpose were part of defining it was crucial. We saw several plans written by consultants or managers, which felt at best meaningless and at worst dishonest, to those working on the ground.

### *6.3. Developing Accountability to a Shared Purpose*

Health and social care partnerships are accountable to the Scottish Government for delivering targets. These targets are often imposed from above, can be controversial, are often resented by practitioners on the ground and little understood by the general public. Instead we attempted to develop a sense of accountability to people who were using services and putting them at the heart of the shared purpose was fundamental to this. The ideal way to do this was to ge<sup>t</sup> them in the room as part of defining this purpose. However, this was not always possible. So, we encouraged practitioners to bring their stories into the room and started with those, trying to ensure that those closest to people using services had a strong voice. This worked well in Beston, where we started the process by focusing on 4 case studies of older 'housebound' people; creating in those in the room a sense of wonder, that people had so much unnecessary and conflicting support, a sense of frustration both at the waste of resources and the distress caused to the recipients of the services and an urgen<sup>t</sup> desire for change and improvement.

### *6.4. Exploring Diversity and Building Trust*

Schruijer points out that "successful collaboration means being able to work with diversity ... diversity which in itself gives rise to distrust, stereotyping and conflict" (Schruijer 2006).

Providing health and social care services to the whole population naturally entails a huge range of diverse specialisms and skills. Interdisciplinary working adds another dimension to interorganizational working. It is at its most e ffective when these specialists can work well with one another across organizational boundaries. For instance, when a GP (who works within her own small partnership business) knows enough about an older person's support at home, that she can prescribe medication to be taken at a mealtime when a home carer (who works for the local authority) is likely to be there to administer it.

Exploring diversity could be both an a ffirming and exciting experience in groups when they began to realize the potential of what was on o ffer. However, they could also experience it as threatening, particularly when their own specialism was under threat and when their organizations were competing for scarce resources.

In several interorganizational groups we experienced a real reluctance to talk about the painful and threatening aspects of working together. This manifested itself in conflict avoidance, which resulted in simmering frustration, or at the other extreme a refusal to talk to or work with people from di fferent organizations. Both these behaviors naturally enough resulted in unproductive collaborations in which a lot of time and e ffort was wasted in either avoiding di fficult subjects or not being able to ge<sup>t</sup> the right people in the room to talk about them.

Good solid working relationships are at the heart of collaboration. Building these relationships across organizations takes time, commitment and a willingness to take a risk to notice areas of disagreement and explore di fference.

We have noticed two attitudes to relationship building. The first is the assumption that they are already built, which made us wonder whether participants were 'colluding' in avoiding the discomfort and conflict, which might be inherent in going a bit deeper and working towards meaningful change.

We experienced this phenomenon strongly in one partnership in which we worked, where a real discussion of di fference was seen as very threatening. We were constantly told that relationships were good and therefore coming together was a redundant activity; managers just needed to be left alone to ge<sup>t</sup> on with their work in their way. All di fficulties were blamed on budget cuts and poor leadership.

This entrenched sense of powerlessness and being victims of forces beyond their control, was the view of a minority of group members, but they had a strong voice, and other members of the group found it impossible to challenge them. When we challenged them, we felt more like school-teachers, than facilitators or consultants.

Over time this changed. Two years later, those most resistant to change have moved on, managers have begun exercising their power in more constructive ways and di fference is being confronted more openly. However, there is a deep-rooted power imbalance between the two main parties, health and social care. The split in the senior leadership team is acknowledged but entrenched, so progress is both slow and frustrating.

The second attitude we encountered was that it is not worth taking the time to build relationships because we need to ge<sup>t</sup> on with the work. What we have found is that taking the time to explore what matters to people, individually, what their work experience is, and what their values are, provides a strong foundation for developing a common endeavor, as is demonstrated in the Beston example detailed earlier. It enables people to overcome their instinctive fear of 'the other', and to challenge their assumptions about the other's motivations. It leads to the development of working relationships which are based on respect rather than assumptions; where each partner recognizes the value in, and the contribution of the other. It enables the development of trust, where each partner is confident that the other is committed to the same end; and will put that end before their own organizational or individual interests.

It does not avoid conflict but it does create the conditions in which di fference can be addressed constructively, rather than explosively or covertly. Ultimately it leads to getting the job done quicker and more e ffectively because there is less chance of miscommunication and misunderstanding.

When people have the courage to name either their fears or their suspicions, it often had a transformational e ffect on the group, who were then able to work together in a far more meaningful way. Sometimes this could be as simple as someone saying they felt overwhelmed and unsupported, as the nurse did in the Beston example. That was an experience others could relate to, and it felt true enough that the group immediately understood that we were there to work on the real issues.

Creating safe enough conditions for groups to work in this way was often challenging. Trust takes time to develop and can only be sustained if all parties demonstrate through their actions as well as their words, that they are working towards the same goals. Open and transparent leadership, which modelled a strong collaborative approach was key and is discussed later.

### *6.5. Designing Purposeful Structural Change*

"I might have had this almost mystical belief that the structures and processes we are putting in place will lead to integration, when the hallmark of integration will be relationships and dialogue. It needs to be built on that solid foundation, otherwise nothing else will work, whatever procedure you type up and circulate." (social work team manager)

New structures bridging organizations were often created, before purpose and working practices had been explored, before relationships had been developed and before a new culture had even been discussed let alone defined. The urge to act quickly and concretely without real forethought was strong. One practitioner commented:

"Health and social care integration is not about new structures, but about how we make services work locally. When you make it real and concrete through relationship and dialogue, it makes sense." (participant)

Part of the hopelessness and disa ffection we encountered in our work in integration came from a mismatch between the aspiration and the reality epitomized by structures, which were impeding rather than facilitating collaboration (this was particularly true in IT where it is very di fficult to share data). Structures were also failing to hold people to account for poor performance and to enable and reward good practice.

The most e ffective structural changes followed a clear agreemen<sup>t</sup> on what would support working to purpose and were facilitated by good relationships. This meant that even when structural change meant people either losing their jobs or being redeployed, they could see the rationale and justification for it in relation to the wider outcomes for those benefiting from the collaboration.

"We deliberately didn't focus on structural moves at the beginning—our focus was on working together ... structure would come later and is still coming, we are trying to ge<sup>t</sup> the best fit at this point in time, structural changes create huge tension, leave all of us feeling insecure." (leader within a health and social care collaboration)

### *6.6. Courageous and Systemic Leadership*

The biggest common denominator for successful collaborations was courageous and systemic leadership, at di fferent levels of the organizations. This meant having leaders at the top who were willing to take the risk to challenge the targets imposed on them by government. It meant leaders who showed that they were willing to look beyond their own and their organization's interests to the wider interests of the collaboration.

It meant leaders who were willing to try new ways of working, knowing that they might fail. It meant leaders who took the time to listen and try to understand the whole picture rather than become immersed in one part of it. It meant leaders who were willing to create a structure for the long term rather than something which suited their interests in the short term. One leader spoke about this as designing a collaboration that would work for the next generation of leaders, rather than for himself or his colleagues.

It meant leaders who were willing to listen to the dissenting voices and acknowledge where they were right rather than trying to shut them down.

It meant leaders who were willing to give themselves and others the time needed to explore the underlying issues and complexity rather than reaching for immediate and short-term solutions.

We saw plenty of examples of this kind of leadership. It added up to systemic leadership, which moved from blaming one party or another to a real understanding of how the current conditions had been created and what needed to be done to address them.

We also saw plenty of examples of failures in leadership where leaders modelled putting themselves before the interests of the collaboration often in quite concrete ways. One leader sought a pay rise whilst arguing that he did not have the finance to set up permanent collaborative roles. Whilst there were undoubtedly good reasons for the pay rise it had a devastating effect on the morale and credibility of the collaborative venture.

Although modelling good leadership at the top of the collaboration is crucial, good leadership at every level is at the heart of making a difference on the ground and delivering positive outcomes for people in communities. One leader commented:

"Empowerment of staff helps to ge<sup>t</sup> things happening from the bottom up. There are things happening that they don't tell me these days. It is not out of control but good innovation, it's a trust thing."
