"We have to change the National Health Service into a National Health System. We need Shared-Care and Self-Care. We all need to understand what health means - more than the absence of illness. And everyone needs to contribute - every school, every public service, every employer, every faith group, every citizen. Everyone.”
I wanted to put in the public domain what I have learned in the past 28 years about facilitating complex collaborations for health and care. Many of the things you have to do are not immediately obvious. You have to set short-term actions inside long-term processes - like a gardener cuts the grass edges firmly while waiting for the seeds to grow. You also have to think about the whole garden.
I started large-scale collaborations in healthcare in 1989 when I set up the Liverpool Primary Care Facilitation Project. We formed a grand alliance for health and care throughout the city. This had an extraordinary transformational affect. We got general practices in multidisciplinary teams working in localities with specialists, Trade Unionists, Arts groups, voluntary groups and many others. We trained local multidisciplinary facilitation teams to lead large group interventions that engaged loads of people in collaborative projects. Without realising it at the time we were using theories of whole system learning and change (I learned the language afterwards). I have been doing this kind of thing ever since, mostly in London, mainly to make a local difference and to satisfy my own curiosity.
Now, everyone wants to make collaboration happen in healthcare, both to contain costs and to improve quality – New Care Models, Integrated Care Pilots, Accountable Care Organisations and so on. I know how difficult it is, both practically and theoretically; and I know how easy it is to doubt that it will work, especially when things get turbulent (it seems that turbulence is a necessary part of it, unfortunately). And I know how much it REALLY works when you get the processes right, and fails when you don’t. It seemed important to me to write down what I have learned. Hence the book.
Anyone who wants to integrate care and health promotion, and anyone who is interested in local participatory democracy. Different Parts of the book are targeted towards different kinds of reader.
Part One is for policy makers – those who have to design and evaluate integrated care. In the UK this includes general practitioners, Sustainability and Transformation Partnerships, GP Federations, Clinical Commissioning Groups and Accountable Care Organisations. The chapters show how the right kind of infrastructure can support multiple-way, long-term collaborations.
Part Two is for leaders of individual organisations such as general practices, schools, pharmacists and community services. The chapters show how to develop as a learning organisation.
Part Three is for leaders of clusters of organisations within geographic localities of about 50,000 population. The chapters show how to engage large numbers of people in annual cycles of collaborative reflection and coordinated change.
Parts Four and Five outline theories that are mentioned in the previous chapters. They show how to think in whole system, learning–oriented, connected and co-creative ways.
I am almost more excited about that picture than about the book itself! My son drew it, to accompany Part Four of the book. Much later the publishers thought it summarises well one of the most challenging ideas in the book.I said: “David, I need a picture that shows three aspects of the world. When you look with the idea in your mind of a machine you will see mechanistic links. When you look with the idea in your mind of a complex, alive situation you will see organic potential. Thirdly, we need to look with the idea that these insights need to challenge each other to make good next steps. Do you think you could draw something that shows that?’. This is what he drew.
The picture reveals three different paradigms that help us to understand moving pictures as well as static photos. I call them post-positivism, critical theory and constructivism. The first sees linear, mechanistic things; the second sees multiple connections; the third reveals creative interaction between these different kinds of insight that we use to move real-life stories forwards. Each paradigm makes a different assumption about how the world behaves and so illuminates a quite different aspect of reality. If we use all three paradigms we see more of the whole moving picture.
My new book describes models to support collaboration at scale. The models are not prescriptive. They are what Charles Handy calls ‘Empty Raincoats’ – they provide a basic shell that you fill with whatever suits you locally.
My first book focused more on gaining acceptability that a connected view of the world is more valuable than a fragmented view. This reflected those days when systems thinking was an eccentric pursuit. When I left Liverpool in 1995 I did not believe that in my lifetime the NHS would consider applying at scale the ideas of collaboration and connectedness that I think are essential in a healthy society. So convinced was I about this that I left and accepted a post in South Africa to set up a national training and research unit to support the Mandela reforms. As it happened the funding for that post fell through and I ended up working in West London, first at Imperial College, then Ealing Primary Care Trust, then Ealing Clinical Commissioning Group. Between 1996 and 2006 I pulled together the literature to make sense of what we did in Liverpool and presented this in my first book. It was in the following decade – 2006-2016 - that I piloted the models that I describe in this book that show how to apply this kind of thinking at scale.
We have to change the National Health Service into a National Health System. We need Shared-Care and Self-Care. We all need to understand what health means - more than the absence of illness. And everyone needs to contribute - every school, every public service, every employer, every faith group, every citizen. Everyone. We need to create geographic areas of about 50,000 population with mechanisms to build local communities for health. Public health and primary care need to work together inside these localities to coordinate efforts for treatment of illness and promotion of health. This is what the World Health Organisation (WHO) has long advocated - they call it ‘community-based coordinating hubs’.
There are some pretty obvious reasons why we need to do this. 30% of the population has a long-term condition, and as the population ages this will increase. Simply to provide minimal support for these people we have to, as a society, develop systems that help teams to form around people and around complex issues. Networks of leadership teams need to build a culture of collaboration within communities that help people to help themselves, learn how to be team-players, value diversity, and care about others beyond their own self-interest. We also have to remember that we live in very individualistic times and it can be hard for some to understand the point of collaboration and how to go about it. In particular, fragmentation of the extended family means that new parents and children often lack role models, so we have to find new ways to help parents to parent well, and children to feel vital members of vital communities. Health and social care must contribute to all of this.
Health care is increasingly under pressure. Budget crises are making collaboration and smart thinking essential, while increasing numbers of people with multiple long-term conditions make specialist models of health care increasingly inefficient – patients too often go from one specialist to…
Paperback – 2017-12-01
Paul Thomas is a general practitioner in west London, professor of primary care research, education and development at the University of West London, UK, and honorary senior lecturer at Imperial College, UK. He is editor-in-chief of London Journal of Primary Care a Taylor and Francis Journal, which is an international, Pubmed-cited journal that publishes case studies of integrated working in primary care and local communities.