When I moved to work in Greater Manchester in 2017, I started a journey to learn a new language, in a different culture, with thousands of people I didn’t know. And I’m not talking about ‘Mancs’, with their cool dialect, northern soul and grit. I am talking about working in the NHS. I constantly had my hand up in meetings asking what the acronyms meant! My role was part funded by Sport England, the Greater Manchester Combined Authority and the NHS in Greater Manchester and I was to work across, between and within these different sectors, to deliver on their collective ambitions for physical activity across the region.
Greater Manchester was at the start of its health devolution journey. Taking Charge of our Health and Social Care Strategy and the Population Health Plan had been published and our challenge was to create the conditions for the 55% of Greater Manchester residents who had said they wanted to be more active, could be supported and enabled to do so.
That’s a big job. I was one person, in a new job, with a small coalition of the willing across GM Moving partners. Where should I start? How could I work in ways that were most conducive to systemic change? Especially when I didn’t understand the language these people spoke.
This is my story of the journey of working within an integrated health and care system. Trying to find ways to embed ‘moving more’ into the culture, systems, processes, services and approach of people across the system. The reason I am pausing now, in April 2022 to reflect and capture all this is because we are about to start the next phase of this journey. After pandemic-induced delays to the ‘launch’ of Integrated Care Systems (ICS’) across England, they will go live in July, and we will start the next chapter. Along with ICS’s across the rest of England. Each place with a different set of local conditions and contexts, but with a great deal of shared purpose and common challenges. We have a lot of learning from the past 5 years. I’m trying to capture some of my personal learning and our collective learning to support leaders across the region and perhaps around the country, as they start or continue on their own journeys to integrate health, care and physical activity.
Over the next couple of months, the GM Moving embedded researchers from Substance Consortia will be doing a ‘deep dive’ into this area of the work, to draw out evaluation and learning. This feels like the perfect time to pause, learn, review and plan our next phase for Active Lives for All, supporting Good Lives for All.
Phase 1: 2015
The GM Moving Blueprint for Change had been written in 2015, which was the beginning of the journey of the whole system approach to physical activity in the region. This journey has been captured before here. In this piece, I am trying to write through a health and care system lens, although of course a good integrated system can’t draw boundaries around these things.
By 2017 the work had moved forward some more and preparations were underway for the first mayoral elections. I came into post in early 2017, and we developed the GM Moving Strategy. This was informed by a widespread engagement and consultation with people across the region, resulting in the Taking Charge Strategy and the Population Health Plan. The conditions were set:
- Strategic leadership in place.
- The cost of inactivity to the place was understood
- There was a clear belief in the power of physical activity within the health system
- 55% of people in the region had expressed the desire to live a more active life.
- The case for change, the evidence and the will of the people were clear.
The question was what did we need to do? How could we work together across the system to bring about long-term transformational change?
The rest of this article is an attempt to explain some of the ways of working and approaches that we’ve taken so far, so we can reflect on what works and why.
The need for Disproportionate Influence
In a recent conversation with Warren Heppolette (Exec Lead for System and Strategy, GMSHSCP) he reminded us of the disproportionate influence we have managed to leverage for this agenda over the past few years and would continue to need to have.
“There are 150,000 people working in the health and care system but you don’t need to have 150,000 different conversations”
Phase 2: Exploring Approaches to Systemic Change (2018-21)
Over this period, we engaged in multiple ways of working during this time, with a test and learn approach.
There was only an emerging evidence base of how to operationalise a whole systems approach. Systems leadership learnings were emerging throughout this period, and we tried to learn as we travelled the road together. It has felt like we have been operating in the space between two worlds.
In 2018, we didn’t have the models or theories at our fingertips to help us understand what we were experiencing either. So, we explored. Iterative. Adaptive. Emergent.
We have had the opportunity to work with two evaluation teams during this period, which has helped with our understanding of what is making change happen. The first short piece of evaluation resulted in the production of the Pointers for Leadership Practice, which have guided our approach since 2018. These are helpful guide in our daily personal leadership approaches.
The second phase of evaluation has offered us embedded researchers in GM Moving, the Walking Ambition and the Local Pilot work. A realist approach, which helps to find ever-more-likely explanations of how positive change is, or isn’t, happening in a complex system .
Most recently, the team have shared Normalisation Process Theory with us, which helps with understanding the different kinds of work that people do to implement a whole system approach, which I have used as a thinking tool in this article:
- Differentiating it from existing practice- noticing what’s been different from traditional ways of working.
- Recognising my/our role in these approaches as leaders.
- Explaining how I/we have made it workable in our setting.
- Appraising what have been the benefits and risks/costs of each approach.
And I have added this one: Trying to understand what has made a difference so that we can codify and refine our ways of working for the next phase.
With this in mind, I’ve taken some time to remember and write down:
What we’ve been doing, how and why and the array of approaches we have taken and their characteristics. Now, with colleagues I will keep building the picture, reflecting on benefits and costs/risks of each. I want to capture what we have learnt as we have operationalised the strategy, to help guide us with where next.
I’ve also included a section here with further useful resources, articles, links or models that might support learning. I’ll keep adding to this.
Reflective Practice and Data Capture
When I sat down to think back over 5 years of work in this area and wrote as much down as I could, as succinctly and clearly as I could. This turned into a 25 page document that I know no-one apart from me or the evaluation team will actually read! So I then tried to spot patterns and themes, organise it into a logical table and draw together something more shareable. From 25 pages, to a blog and a set of slides with questions for exploration.
Below, I’ll share a summary of the approaches and activities, with some examples that might bring it to life. If anyone is interested in more detail, the risks, costs and benefits, I can add to this.
Questions to start with: Some questions that could be helpful for the next phase of our journey and for anyone who is starting or continuing on their own journey as ICS’s evolve, are:
- Where do we start?
- Is there an ideal order of approaches for us?
- What is the right balance and blend between these activities for any individual or team leading in this area?
- What balance and blend are right for the place at this particular point in time?
- Which activities are right for the different parts of the system or agenda?
And in your place/your part of the system/your role… what needs to happen first/next? What would that take? Is there anything in the way? What would help to remove blockages? What’s your personal leadership role in this and what might you do next?
I hope that what is set out below will prove useful to you and your system. PLEASE tell me what you do with it, how it helps (or not) and what else is needed.
The What and the How
This blog is focussed on the ‘what’ rather than the ‘how’. I write about the how most of the time. The principles, ways of working, approaches to leadership and relationship building are all fundamental to this approach. What I am asked sometimes is for more of a ‘guide’ and for support in deciding what on earth to do and where to start. So that’s what this is about. If you’re interested in the how, there are some blogs linked at the very bottom.
National – Regional – Local – Neighbourhood: What to do at each spatial level
Another important question to bear in mind when planning our approaches to integration, is “what is best to happen at which spatial level?”. Those of us working at national, regional and locality levels are here to create the conditions for health equality in neighbourhoods. This is the spatial level that most people live their lives at. Learning about what is worth doing the same way across England or Greater Manchester is key. Then, there are ten localities in GM and 240 neighbourhoods. Each is unique, but there are also things that they all need, which can be supported at scale.
If we work by the principle of ‘locally led, GM supported, nationally enabled” it raises some specific questions:
- What can be done differently at a national level that creates better conditions for EVERYONE working locally?
- What makes sense to do the same way across the whole of GM or the whole of a Borough?
- What is so unique that it has to happen differently in a neighbourhood? (and how do we ensure the learning from this is drawn back out to support others?)
We have been testing and learning in our neighbourhood, locality, GM level work for some time and have some evidence about what is needed. This is for another blog, but I will finish this by saying that no matter which spatial level you are working at, the approaches described above are translatable to your place and your work. Please test them and use them.
Where Next for Greater Manchester?
Phase 3 (2022-5)
Last year we refreshed the GM Moving Strategy, launching GM Moving in Action in September 2021. One of the Commitments is Integrated Health and Care. During and following the launch of the strategy, there was a process of system-wide engagement to develop a deep understanding of progress and set priorities for the next phase, ready for the launch of the ICS. We have a bigger coalition of the willing now, and a set of local and national conditions that should better support transformational change. And we know that physical activity has a role to play on every agenda and in every place.
Now, we need to be clear, effective and impactful in our ways of working, drawing on the learning so far and ensuring collective and distributed leadership for change. Which is I did the exercise above and why we are now conducting an immersive piece of evaluation into the physical activity and health integration work with our embedded research team.
The next phase of core co-investment from the ICS is for GM layer leaders to play a systemic role, building on what we have learnt. A set of priorities and deliverables have been agreed for a transition year (2022-3). During this year we will continue to learn, adapt and plan for the next phase. Together we will:
- Continue to operationalise the whole systems approach.
- Seek to ‘codify’ the ways of working that best effect change.
- Develop further clarity about where to lead, support and connect the system.
- Focus on how we can create the conditions for ‘disproportionate influence’ across the system.
- Keep learning how to measure, evaluate and learn in a systems approach.
What kind of leadership does this take?
At the beginning of this article, I mentioned the Pointers for Leadership Practice. The importance of these can’t be overstated. They are fundamental to operationalising a whole system approach. They were developed in 2018, and are standing the test of time well. Use them, share them and notice the difference!
Useful Reading and Follow Up
Approaches with a few examples