More and more health care providers are embracing the idea of cross-sector working but what can we learn from those that have already tried? This week, I speak with David Relph, the former Director of Bristol Health Partners, a cross-sector initiative across the city of Bristol in England. David left the Partnership in April 2018 after four years in the role and I caught up with him to find out what went right and what went not-so-right.
Pritpal S Tamber: Hi David. So, why was Bristol Health Partners set up?
David Relph: The partnership was set up after a collective realisation that the city wasn’t really punching its weight when it came to winning major research funding in health. Bristol has two large teaching hospitals, a medical school and a nursing school, plus a range of local health business and community groups, and yet it wasn’t making itself attractive to national funders. Over time, however, the driving force changed to become all about better collaboration across the health and care sectors and the challenge of translating research into practice.
Pritpal: Normally, these kinds of entities have clinical leaders at the helm but you have a military background. Why were you appointed?
David: I’d done some work on how outcomes are defined by place more than by just the systems that serve that place. For me, health is an outcome shaped by one’s experience of place, the wider social context. Accordingly, the challenge – and opportunity – for the partnership was in trying achieve change in a place and not just in an arbitrarily defined ‘health system’. That caught the appointing committee’s attention and they wanted to bring that perspective into how the partnership functioned. I aimed to convince them they needed a city partnership, rather than just a clinical one.
Pritpal: Interesting. So, how did you go about making it more about the city?
David: As Director I advocated for the partnership to have a greater focus on fostering city-level collaboration. One aspect of that was to have the Council (local government) at the table. It was a funder of some of the partnership’s work but not a full active participant. I sought to change that but it wasn’t all me. I found that there was also momentum from within the Council. Its leaders were interested to better connect with the health and care system, which I think they saw as an opaque mass of organisations. So, although I was able to get the Council on board – and we were the first health partnership in the country to do so – it was also the case that the Council, in some sense, came to us.
Pritpal: So, what went right?
David: Lots. Overall, we improved relationships between system leaders by creating a forum where they could genuinely think and act jointly – for the city, not for their organisations. We also pioneered a much more emergent and collaborative way of working than you find in most of the UK, in the public sector particularly. For example, we didn’t set strategic priorities like ‘cancer’ or ‘cardiac services’. Instead, we made better and more effective collaboration the strategic priority and then supported communities of practice as they came forward with often very diverse ideas. This approach allowed us to unlock and mobilise a whole range of expertise and capability from across the city – all with very little money. The ROI (return on investment) case for working in this way is very strong because we weren’t focussed on creating lots of new investment or resource, but on using what the city and system already had in much better ways. It turns out this is also a way to attract lots more investment (research funding in particular), but the key focus was on using what we already had in a more effective way.
Pritpal: Well, that sounds good. But I know that some other things didn’t go so right; when you look back, do you have a sense of why?
David: The leaders in the partnership were all under intense budgetary pressure, which made them focus on what returns they were getting by investing in the partnership. The answers they sought were framed in very traditional, short-term ways – cost savings within their budget, often in-year. It’s very hard – essentially impossible – to make the case for the benefits of cross-sector collaboration within that timeframe. We made the mistake of trying, and effectively spent 12 months wrangling with multiple £500m organisations about how our work might have saved them £10k. In retrospect, that cost us a lot of time and credibility with the Board. It also – because this discussion was implicitly framed in terms of organisational interests – made it more difficult to do the work of building the relationships needed between leaders in different sectors to enable cross-sector work.
Pritpal: Fascinating. Did you try to get the Board to look at ‘return’ differently?
David: Yes, although with varied, and often unsustained, success. The discussion of ‘returns’ is almost always abstract; there is a disconnect between systems and the places they’re in. Systems, like health care, all too often see themselves as ‘black boxes’, effectively service providers without any link to the place they’re in. We have to find ways to think about institutions and systems within the context of places they’re in and, crucially, whether the activity of that institution or system actually make those places better for the people living there. If we were able to do that, we’d be able to think differently about value they create and hence what the core business of these institutions and systems is.
Pritpal: What do you mean by that?
David: When leaders talk about their ‘core business’ they’re just describing what the system does. For me, this concept is increasingly unhelpful, even indulgent. What matters is what’s achieved, not what’s done, but what’s done is what’s focussed on as though efficient services and savings are the ultimate end. For me, the ultimate end has to be to better identify and mobilise the capabilities needed to deal with the factors that really shape health and health inequalities. Given that health is defined by place, it’s about having the capabilities to use the resources available across that place. Within that frame, collaboration is the only way to do this.
Pritpal: So, does that mean that a system’s core business should be fostering collaboration?
David: Precisely. Mobilising capability across institutions and systems is the only way to achieve something ambitious across a place, such as reducing health inequalities. The only way we can identify and mobilise this capability is by collaborating. I’m not interested in what institutions or organisations are doing or trying to do by themselves because whatever they do alone isn’t likely to make any real difference to the place they’re in. When leaders talk only about their own organisations, it’s a sign that they don’t understand the complexity of the environment in which they are operating or the importance of place. Leaders who only think in terms of their own organisation are potentially harming the places we all share; an organisational focus creates a societal opportunity cost, which we all have to bear, not just the organisations themselves.
Pritpal: That’s a pretty strong contention. Looking back, what would you have done differently?
David: I took away three things from time in Bristol. First, I think it’s important to frame health challenges as ones that are dealing with inequality as much as standards of delivery. This is important because framing it in this way makes you start from the social context of health – and makes collaboration essential if you want to have any impact.
Pritpal: Nice. The second?
David: You have to know why people want to collaborate. Motivation ranges from ‘the boss said I should’ to ‘I have a deep-seated desire to change social outcomes and this work is a vehicle to achieve that’. Unless you understand the motivation of the people you’re working with, collaboration is likely to be both superficial and short term. It might start well but if the participants are there for fundamentally different reasons it will likely grind to a halt after a few months. You have to help the person you’re working with to get what they want as part of getting what you want.
Pritpal: Interesting point. Third?
David: You have to understand how people think of value. All too often in collaborative work we assume that a better structure will deliver the outcomes we seek. It’s natural because structures are visible. What’s invisible – or at least often hard to see – are the frameworks of value that shape our decision-making day-to-day. These frameworks are what shape our systems, often unquestioningly.
Pritpal: Tell me more about ‘frameworks of value’.
David: The way we allocate resources is based on some idea of value. For instance, in the business case template in a hospital you have to justify any new spend usually within a two-year frame. What that implicitly means is that we prioritise things that can be achieved within two years, rather than things that might take longer. Given that reducing health inequalities might take two decades, not years, what that template is communicating is that inequalities don’t matter. Of course, no health care leader would say that but it’s being communicated loud and clear through the template. There are numerous examples of this in our everyday processes and decisions.
Pritpal: That’s troubling.
David: Right. And if we’re going to be serious about both inequalities and collaboration we need to find and change these processes and decision points otherwise it’s just all talk.
Pritpal: I suspect that’s both true and challenging. So, what’s next for you?
David: I now work with people who want to understand and deliver change across whole places, not simply within organisations. I don’t want to dismiss the challenge of leading an organisation but I don’t think single organisations will help us address issues like health and health inequalities. I’m developing some tools based on my work to date to help people collaborate better and to think about their role and their impact in a broader way.
Pritpal: What will the tools help people do?
David: Fundamentally, I’m trying to help people in senior roles be more much more ambitious, to try to change places not just help their organisations survive. In practice, this means getting them to reset their relationship with ‘the system’. Rather than be subjects of, or commentators on, the system, they need to become activists. Doing this requires thinking deeply about the frameworks we all carry around with us and shape our everyday decisions. These frameworks need to be challenged.
Pritpal: That sounds like a big but important work. Good luck.
David: Thank you! And thanks for the chance to share some of this. I’d love to talk more to any of your readers who are interested in these issues.
Talking to David reminds me of talking to Andrew Harrison– you start in a recognisable place and end up somewhere completely new and challenging. That’s a good thing but it occurs to me that challenging one’s conceptual frameworks takes time and requires space for reflection. These two things – time and space – are in short supply in health care, a sector that seems to have normalised fighting fires. In my own work, I’ve seen the need for vehicles buffered from the constraints of existing systems (see principle 10) but then watched health care leaders wrangle over the organisational minutia of these vehicles, a thinly-veiled power struggle. Quite what the solution is, I’m not sure, but I am sure that people like David, with front-line knowledge of why cross-sector working often fails, need to be listened to if we’re ever going to embrace the idea that health and place are deeply entwined.
The photo behind the title is by Alina Grubnyak via Unsplash.