I spent today at an Open Space event organised by NICON, the Northern Ireland branch of the NHS Confederation. There were about 80 people there, representing different aspects of health and social care work in NI, as well as people from other government departments, consultancies, the private sector, the community and voluntary sector, health charities, and two of us from local government. We were considering the theme “How can leaders in the HSC and in partner bodies help shape and drive change to meet the health and social care challenges ahead “, with the purpose of building a wider understanding of the challenges and to propose solutions. Participants proposed topics for discussions, which were then self-managed in smaller groups.
The first session I took part in involved a discussion on collaborative working, focussing on reasons for and barriers preventing joined-up working, and looking at the potential for central-local working within the community planning process (due to be legislated in NI very soon).
Three key themes soon emerged:
• The need for a collaborative approach and shared outcomes
• The need for a political mandate
• The need for permission to be innovative, particularly in use of money and resources
There was broad agreement that collaboration hasn’t worked across the public sector in NI to date, never mind involving business and communities. The Total Place approach and single outcome agreements were discussed as potential positive ways forward, and as a means of looking at what we are collectively spending, which is currently very disjointed. To use our resources better, it was agreed that we should have shared themes and agreed outcomes on health across the public sector. There was lack of consensus on who should lead, with a particularly worrying comment made by a senior official, who believed that local government shouldn’t lead on community planning.
There was agreement that the way budgets are allocated needs to change, to reward the right work in the right place, and to achieve an agreed end vision, with collective agreement on the good we are trying to achieve. Building a shared understanding of the long term aims was agreed to be vital, with partner organisations being able to see and show the benefits of collaborating.
A serious barrier was identified in the lack of ability to pool resources effectively and to synchronise on time and it was acknowledged that, no matter how good the concept, to date NI has failed on implementation. There are particular difficulties at local level.
It was agreed that sometimes we need to bend and break rules to achieve. We need to rewrite the rule book if this is the case, and to negotiate with DFPNI to obtain their support for and action on financial innovation.
We need to look at the targets we are working towards, examine our corporate plans, and rethink them, to ensure an integrated approach and an outcomes focus. There needs to be permission for integrated working, and a move away from over-management of Trusts.
A further barrier was identified as the changing nomenclature for policy and practice, within a changing political context, e.g. Total Place now known as community budgeting. This confuses the issue, and is an unnecessary complication. Political maturity is preferable to rebranding.
It was strongly agreed that the mandate for a new way of working, with a cultural shift from delivery of services to delivery of outcomes, needs to come from the Assembly. A new set of agreed outcomes should be contained within the new Programme for Government. Local councils currently suffer from the need to implement a constant drip-feed of cross-cutting, yet unlinked government strategies, pulling us in many different directions, with a short termist funding provision (obtained at Christmas, spend by June). We need the NI Executive to ‘join the dots’.
It was noted that devolution to a regional assembly with local accountability, has increased risk aversion. Public servants need to be trusted to make decisions and to change priorities when needed, particularly if different departments and partner organisations are to work together to overcome silos and reduce duplication. The politicians and policymakers should focus on the ‘what’ not the ‘how’.
We are beginning to take on greater responsibility for education area planning, community planning and commissioning, but these all need to be joined up, without fear of paralysis or protectionism.
At the moment there is no space to acknowledge that change is necessary and to work out what is needed, to “call my baby ugly”. A cultural change is required, with a safe conversation on outcomes, working in a forgiving context. We need freedom, to be given permission to take risks, and to get things wrong occasionally. As my dad says; “anyone who never made a mistake, never made anything”.