People keep saying to me “you have been very quiet lately”. That’s deliberate. I’ve had my head down, helping to lead efforts to deliver productivity gains through quality improvement. The focus is how to mobilise people who use NHS services, people who work in the NHS and people who support the NHS for the cause of Quality, Innovation, Productivity and Prevention (QIPP).
Through this work, we are blending powerful change methods from community organising with more “mainstream” approaches to leading improvement in the NHS. Although it is still early days, we are learning greatly about a) how to really build commitment to change, b) how to shift the power in the system towards service users and those who give care and c) how to organise to deliver change. So I’m committing myself to writing a series of pieces over the next few weeks to share some of the emerging knowledge. The first couple of pieces are on the theme of “strong and weak ties”. This is the topic that is creating the most “light bulb” moments for senior NHS leaders. Bear with me and we will get to this topic. But first I want to provide some wider context.
Most of the methods, strategies and tools we use for change in the NHS come from a powerful body of “healthcare improvement knowledge”. We utilise a range of approaches and labels, including “service transformation”, “organisational development” and “process and system redesign”. This knowledge has been derived from experience in other industries and adapted for healthcare. It has been built over the last 100 years.
There is an additional body of knowledge about how to create change, which has been built over a similar timescale. This knowledge, however, is rooted in the tradition of community organising, campaigns and social movements, learning from popular, civic and/or faith-based mobilisation efforts. It is only in recent years that organisational leaders (such as those in the NHS) have started to recognise that the philosophy and methods of community organising has massive potential to help formal organisations and systems to achieve their goals. It isn’t necessarily an alternative to existing healthcare improvement knowledge but it enhances our ability to make change happen and challenges some of the ways that we, as NHS leaders, have gone about change up to now.
Much of the conventional wisdom of NHS improvement is based on a model of “strong ties”. We have strong ties when we interact with “people like us”, people with the same life experiences, beliefs and values. Until I learnt community organising, I was an advocate of “strong ties” as the most effective method to enable change to happen at scale in the NHS. I believed that the best spread methods were “peer to peer” based on strong ties; GP to GP, nurse to nurse, gynaecologist to gynaecologist. I recognised that strong ties didn’t just relate to professional groups, they related to organisations; change spread most easily from hospital to hospital, from primary care practice to primary care practice and from ambulance trust to ambulance trust. I saw very few examples where ideas spread from say, a hospital setting to a community health or social care setting. My views were reinforced when, time after time, I observed that people were far more likely to be influenced to adopt new behaviours or ways of working from those with whom they are most strongly tied. The most successful NHS change projects were those built on strong ties, where people who were strongly connected to each other, liked each other and trusted each other, made the most timely and effective changes.
Whilst I could see that working through strong ties led to change, I could also see the drawbacks. When we base improvement processes on peer to peer spread, we reinforce silos and “groupthink” and restrict our ability to spread change or information beyond the professional group or organisational identity. As a result, the amount of knowledge that gets circulated round the system is severely restricted and the likelihood of innovation is limited.
The opportunity to learn and apply community organising principles to NHS changes has given me additional perspective and some new tools for change. Strong ties will always be important in an NHS context but I now appreciate that “weak ties” are at least as important as strong ties to deliver change at our current stage of NHS reform.
When leaders of change build weak ties, they deliberately seek to build bridges between previously disparate groups and individuals, creating relationships based not on pre-existing similarities but on commitments that people make to each other to take part in and deliver change. When, as leaders, we organise in weak ties ways, we aim to mobilise all the resources in our community or system that can potentially contribute to our cause. By organising these resources, we can shift the power in the system to deliver the outcomes we seek. This is the basis on which the great social movements, the community organisers and the civic campaigns have delivered the changes that have, in many cases, changed the world (or a key part of it).
History suggests that a weak ties strategy will probably give us the best chance to deliver the scale of improvements we seek in quality and cost in a challenging timescale. Weak ties are typically a more effective starting point for influence at scale because they enable us to access large portions of the population, with fewer barriers than strong ties. In addition they give us the greatest insights to think differently about the future.
There is a particular risk for the NHS in this time of transition. In situations of uncertainty, we have a tendency to revert to our strong tie relationships, to stick to what and who we know and who we can trust. Yet the evidence tells us that weak ties are much more important than strong ties when it comes to searching out resources in times of scarcity. Only in times of plenty are close associates likely to have access to what we need. Our best new ideas about how to deliver more effectively with less - and the most breakthrough innovations of the NHS - will come when we tap into our weak ties.
My own understanding about the power of a weak ties strategy is growing as I see local campaign teams starting to organise as part of our quality and cost improvement efforts. In the past, I invited service users and community groups to be part of NHS improvement projects because I thought it was “a good thing” but often their involvement was marginal. Now I understand that their engagement and commitment is critical if we are going to shift power to service users and communities and deliver our goals.
For instance, one of our campaign teams is focused on improving end of life care for people who live in care homes. The team is mobilising a wide range of people and resources for its cause. This includes people who live in care homes and their families, care home managers, GPs, family liaison co-ordinators, community leaders, voluntary sector organisations, community and hospital based clinicians. This campaign group is organised around weak ties. This means that the campaign leaders are concentrating on building relationships amongst this whole “constituency” to create commitment to a common purpose and deliver its goals. This campaign team is learning new skills to help deliver better end of life care through weak ties. As a result, they are going about change in some very different ways to what is typical in the NHS. They are creating powerful narratives for change that bind people together in a common purpose and an explicit call to action. They are seeking out the people who have the resources that the campaign needs and are asking them for commitment to action that will take the campaign forward. They are building effective leadership teams that are based on commitments through relationships rather than “top down” hierarchy. Finally, they are creating campaign strategies that are based on turning the resources they have into the power they need to deliver the outcomes they seek.
I hope I have demonstrated the potential of a weak ties strategy to complement strong ties in the era of QIPP. In my next piece, I will describe some practical ways that we, as NHS leaders, can build on the power of weak ties.
Carolan, B and Natriello, G. (2005), Strong Ties, Weak Ties: Relational Dimensions of Learning Settings. Available at http://edlab.tc.columbia.edu/files/EdLab_Strongties.pdf
Ganz, M. (2007) Relationships: Notes, Charts, and Questions. Harvard University student notes
Granovetter, M (1983), The Strength of Weak Ties: a Network Theory Revisited. Sociological Theory (Blackwell) 1: 201-233
Malone, E and Edgerton, S. (2001) The Strength of Weak Ties: The Influence of Horizontal Research Ties on National Environmental Policies, Institute for Climate Impact
Wilson, D. (2010) Building Bridges for Change: How Leaders Enable Collective Change in Organizations”, Development and Learning in Organizations, Vol. 24 Iss: 1, pp.21 - 23