BLOG: The eight conditions for rapid change in health and care

Sarah Robens, Evaluation Lead for the South West Academic Health Science Network (SW AHSN), describes some of the key themes captured from the learning processes the South West AHSN has been running during COVID-19.

With the arrival of the COVID-19 pandemic, we planned a rapid process of capturing learning about how the health and care sector in the South West was responding to the crisis. Nearly 300 contributions have been made to this process by health and care teams across the region since April 2020.

This insight gathered to date indicates that there are eight conditions that have most frequently facilitated rapid change during lockdown. Individually and combined, these provide useful insight for ongoing efforts to make our health and care system more resilient. Our aim is that this knowledge, shared across our network, can be useful as the South West region continues to adapt, and build its resilience and capacity for patient care. 

During the first phase of COVID-19 we have experienced extremely swift change within the health and care system in the South West. We have seen rapid:

• Implementation of new systems and structures
• Uptake and adoption of existing innovations and technologies
• Progress of pipeline programmes and projects.

As we collectively move to longer-term planning, there has been a shift from crisis planning to consideration about how to become more resilient to future challenges facing the system.

A resilient system is one that is not only able to respond to shocks and stresses, but one that can do so whilst maintaining positive outcomes more widely across the system.  It is also one that learns from challenges and emerges out the other side stronger than before.

At the SW AHSN we have been listening to our network, feeding back into systems to aid their reset and recovery work.  Most recently, we have been looking at:

1. What conditions have led to rapid change, and what practical examples evidence this change? You can see examples of these in the chart below.
2. How can we identify those elements that are useful to maintain beyond the immediate crisis? We have examples of care pathways, new reporting structures, and technology adopted during COVID-19 that could support the system into the future.
3. What have these individual and collective conditions and examples taught us about how to build resilient health systems going forward? For example, identifying a particular partnership that has helped ensure quality care during COVID-19 can help establish the potential for collaborative working ongoing.

What we have been finding highlights the importance of organisational culture and ways of working in ensuring rapid change, but also in providing the structure for a resilient system going forward.

What have we discovered about the conditions for change?

From listening to people working in the health and care system through interviews, focus groups, surveys and collaborative conversations, we have identified not only what has changed but how it has changed. Understanding how change occurs can particularly help inform future systems development, supporting further adaption or the spread of new approaches.

By asking about how change has happened, we have helped our partners to identify eight conditions for rapid change in health and care. Each have individual characteristics, but they also overlap and combined provide particular scenarios where resilience is most likely to develop.

The eight conditions for change are:

1. Adaptability: Finding ways to change what is already working to meet needs in a crisis.
2. Shared purpose: A unifying driver for change – in this case protecting against COVID-19.
3. Psychological safety: Permission to try, ‘give it a go’ without fear of blame, build things through trial.
4. Removal of organisational barriers: Moving beyond existing systems to promote solutions-based activities.
5. Resourcing: Providing money, redeploying staff, freeing up time and space.
6. Development of cross-organisational systems: Moving away from silos because success was sometime only possible between teams.
7. Communication: Using information across teams to plan and deliver urgent changes.
8. Collaborative Mindset: Finding new or strengthening existing partnerships to swiftly build services or amplify availability of support.

How do conditions for rapid change combine?

As you will see some of these conditions relate to the culture within which we work: shared purpose, collaboration, permission, communication. Others address the systems and processes which shape how we work: adaptability, removing barriers, resourcing, cross-organisational systems.

To further explore how teams can adapt and apply this evidence-based theory of change we have been using an iceberg systems model. This model helps us to understand how these conditions help even in very complex contexts.  What we know is that we need to look beneath the obvious indicators of success or stress in our system to understand where we can affect ongoing and systematic change.

What we see on the surface is that, for example, a structure such as a new community-based system for assessment of frailty can provide clues to understand what it is that has enabled the change. In this case, adaptability of existing plans, resourcing, permission to try something without risk of failure, better communication between community and secondary care and a shared purpose have combined to make change possible and for Community Assessment and Treatment Units to be up and running within a very short space of time.

Evidence of the eight conditions for rapid change

We have seen a large range of actions, behaviours and processes that relate to these eight conditions, with the following being some of the most common:

In many ways, these eight conditions are not that surprising. They are conditions that have been linked to successful outcomes in the health and care sector, as well as other sectors, for many years. However, what is interesting is not only how they have become so apparent and so important in such a short space of time, but also how people throughout the system are recognising them, valuing them and considering how to keep them in place going forward.

This suggests the opening of an ‘adaptive space’, as described by Mary Uhl-Bein, which is allowing people the opportunity to try new ideas as usual structures flex to the needs of the pandemic. At the SW AHSN we are providing opportunities for teams to reflect and respond to their own and collective learning.

Not just rapid, but resilient change

These eight conditions are also evidenced in the ‘resilience dividends’ that have emerged as a result of the COVID-19 pandemic. Resilience dividends are the new approaches, innovations, and processes that were either put in place or reinforced as a response to the crisis, and which will give added value to the health and care system going forward.

So, how do we use an understanding of the conditions needed to create resilient change to help design how we work together in the future? There is a need for a new approach, a new agreement in how we work, to enable our system to be resilient. We will be exploring many of these themes in the months to come.

Sarah Robens is joined by Jon Siddall (CEO, SW AHSN), Hannah McDonald (Partnership Development Manager, One Northern Devon/One Ilfracombe), Dr. Tamsyn Anderson (Interim Joint Medical Director, Cornwall Partnership NHS Foundation Trust) for a participatory webinar: Learning from COVID-19: The conditions for change in building resilient health systems. To register click here.