The Sustainability and Transformation Planning process challenges health and social care to achieve two huge tasks. Redesign and build a new system around the needs of people and communities and do it in a financially sustainable way. To add to the complexity STPs are caught in tensions between central government and local control, long term aspirations and short term crisis and the recognition of the potential to realise huge change against the scepticism that this is just another way to cut budgets and services.   It’s not only the outcomes and environment that are challenging. To succeed the system and the people in it must begin to work in a whole new way. Local leaders have been given joint responsibility to deliver. This demands a refocus from the internal hierarchies and individual organisations to spanning boundaries and building authentic relationships and networks across the landscape. Changing demographics and demands; depleted financial and staff resources; new technology; changing patient, staff and community expectations and redefining of illness, health and well-being all combine to create a complex, unpredictable and sometimes volatile environment for this work.

To work well as systems leaders, thinking beyond the usual focus of one organisation and instead holding what benefits the whole system requires relationships built on trust, shared values and the ability to appreciate contributions from all parts of the system. It also requires a huge change of perspective. We need to move from organisation based discussions focused on acute hospital ward closures to apply generative listening to the people and community who need the services and the staff who are passionate about and committed to providing it.

When we take a step back and look at this challenge, it is obvious that conventional change management alone cannot deliver. It would not be efficient in terms of use of management staff and resources, or effective in terms of facilitating the innovative and inclusive approach that this task requires.  Leaders need to set clear direction, boundary the space with information about standards, available resources and needs and then step back and empower and enable their staff and communities to develop, own and execute the changes. This is an anxiety provoking situation and travelling the road together is always slower than forging ahead as individual organisations or services. So, despite the pressure we must progress at a measured pace if it is to be done sustainably.

It is because leaders are now fully appreciating the situation and achieving the confidence to hold the space and step back that Communities of Practice are becoming a popular way of working. Communities of Practice work first to bring people together around a shared interest or domain. This can be a professional or academic interest and can also be about personal or lived experience. Bringing different expert experiences and tacit knowledge together and enabling people to develop shared stories, collective sense making and shared values develops a group identity and relationships where deep learning and new knowledge and practice can be developed. Communities can bring people together across traditional boundaries, encourage groups to identify their most burning questions and facilitate them to co-create new knowledge and practice in response to the most complex challenges. Staff involved in this way of working have reported a reconnection with motivations and values that they felt had been lost in their work. Patients, service users and carers spoke about being heard and valued as their experiences were validated and aspirations recognised. Perhaps most importantly Communities are generating innovative, sustainable solutions to sticky problems and creating real value for themselves, their organisations and communities.
Proof perhaps that “None of us is as smart as all of us”.

I remember at a meeting, talking to someone working to establish a Teal organisation who told me that the NHS could never be Teal. The NHS is a long way from Teal, for sure. The NHS as a governmental entity is formed of many different organisations. Right now it’s probably more of a rainbow than any particular colour, in terms of the developmental stages of its units. Even so, the NHS and the services it incorporates have made many big changes previously. For example, I was part of the alliance between health and social care staff, families, and service users that worked to move mental health care out of the asylums and into communities. I have worked with some amazing people and I have seen them do incredible things. Maybe they can evolve a Teal NHS; I think so, and this is why.
The Current NHS
Customarily, particular NHS services have been keen to police and protect their own borders, responsibilities, and resources. In the worst cases, people are bounced between different services, and struggle to find their way in a complex web of providers and eligibility criteria. Sometimes they fall in-between services and their needs go unmet or they just give up. For example, when I was pregnant I had pregnancy-related carpal tunnel and needed a wrist splint. I was told by the physiotherapist I saw at my local primary care clinic that she couldn’t provide it to me, as her budget didn’t cover pregnant women. She advised I should travel into the city to the acute hospital maternity unit and see the physio there. I gave up and bought one via the internet.
Institutional Context of the Co-Creation Network of Communities of Practice
I have been working for the past year with a group of NHS clinicians, academics, service users, and staff from charitable and private industry to establish what we call the Co-Creation Network which encompasses a variety of “Communities of Practice” committed to making improvements in the health and social care system.
The Teal characteristic of evolutionary purpose is evident in that these Communities are about making improvements partly by breaking down the traditional boundaries of health and social care services, and encouraging/implementing a community-encompassing approach.
The Network is sponsored by two regional NHS bodies: Yorkshire & Humber Leadership Academy and Yorkshire & Humber Academic Health Science Network. Both regional bodies recognise that the challenges faced by the health and social care system require something very different. Both bodies have struggled to hold the space for this Network and the different approach it takes, against the usual system demands for performance management to justify any investment and direct activity.
Communities of Practice are a voluntary, not delegated endeavour. Some participants are given leave to attend meetings and events in worktime, but most CoP activity is done in members’ own time. Thus, membership in a Community of Practice requires great passion and personal motivation.
How the Communities of Practice Operate
Each CoP is people working together to co-create new knowledge and practice in an aspect of their own field. Communities are varied, focusing on whatever their members see as important. For example, Communities of Practice have been established to consider Sepsis, Medication Safety, and Creating Caring Cultures.
The Sepsis CoP is working on awareness-raising techniques to address an issue that people have not been well aware of previously. The NHS system has given them implicit permission by tasking staff or organisations to reduce sepsis incidents, but has not given directives on how to do this. So the CoP has the freedom to develop and implement some “How’s.”
You might be wondering, how do new “ways” get authorized to be implemented and put into practice in various settings? In some cases, the system has not given permission (versus the implied permission re Sepsis concerns) and the CoP may be challenging received wisdom and practice. Some CoP’s have been formed with the express intention of doing such challenging, as they strongly believe that current practice is not good enough. CoP’s looking at changing the traditional relationship between professionals and patients are often in this position. Part of their learning is how to identify and influence key stakeholders to co-create a new approach.
The Communities of Practice are courageously pursuing new knowledge and new practices that they believe can bring real value to the services they provide.
In an acute hospital, a Community of Practice has introduced mindfulness practices for staff and elderly patients. It is reporting a real cultural shift in the ward environment, and a huge impact on patient safety, with fall rates hugely reduced.
This Community is now turning its attention to how it might extend this ethos of care out into the community to involve everyone who might provide support to their patients.
A Community of Practice was formed by a group of staff developing a new role in primary care to connect services and provide better care for older people with complex health needs. In the UK, locally-based clinics provide access to doctors, nurses and health care support staff as the first point of contact − and principal point of continuing-care contact − for services dealing with ongoing health conditions. It was noted that an older person with several long term conditions such as heart disease, diabetes, and dementia would be in contact with their local primary care doctor and nurses, but would also have links with a huge variety of other health and care organisations including specialist medical services provided at outpatient clinics in acute hospitals, specialist community-based teams such as mental health and dementia care, specialist home care services from a physiotherapist or occupational therapist, nursing visits from charities, as well as support and care workers from not-for-profit care companies. This Community of Practice is noticing early signs of expected success in reduced admissions to hospital for this patient group as all those services work better together to keep the person safe and well at home.
There is also a vast array of other benefits from this CoP’s connecting of services. They include improved understanding and appreciation between different government-provided health and social care services, good relationships between different locally-based clinics, authentic connections between statutory (government-provided) services and community assets and resources, and a commitment from all elements of the whole system to improve the support provided to these elderly members of their local community.
Next-Stage Challenges Faced and Dealt with in CoP’s
I believe my experience provides one bit of clear evidence that the three Teal principles of self-management, evolutionary purpose, and wholeness have been readily adopted as core principles by some NHS staff and those working with them. I am sure there are other examples too. The Communities of Practice established as part of the Co-Creation Network adopted these principles despite the fact that they were challenging and difficult at first.
Self-Management
Communities of Practice are self-managing by definition. They set their own agenda, organise themselves, and also decide what learning they will pursue and how they will use this knowledge.
This was a shock to many NHS staff involved, and it was difficult not to seek permission and direction from elsewhere. Many of us experienced confusion at first. “What is it we are supposed to do?”
Communities moved swiftly from confusion to feelings of liberation and then action. Members gained confidence, established relationships, defined their shared agenda, and organised meetings and “learning expeditions” — our title for the work to answer the questions we have set ourselves.
Wholeness
One of the most unifying and important aspects of the Co-Creation Network is the way it supports wholeness. The Network adopted mindfulness practices to help stressed, overstretched members be fully present in their Communities of Practice.
The opportunity to make authentic connections and pursue work that they identified themselves as important was cathartic. I think it may have even persuaded some members, who were disillusioned and damaged by their working environments, to stay within the NHS and work towards change.
“This work gave me space to connect with that passion again and start to explore what could be possible. Through learning about CoP’s I could see that I wouldn’t make it to the top (of the mountain) on my own, but I could take others with me and we could support each other on our difficult journey. And that the journey itself would make us stronger, through sharing and learning together.” Community of Practice Member
Evolutionary Purpose
Perhaps most inspirational is the evolutionary purpose evident in the Network and its Communities of Practice. Free to pursue their own agendas, Communities of Practice have been established to consider pharmacy, mental health and childbirth, work with older people, the role of mindfulness in healthcare, Innovation, Musculoskeletal Practice, and many other areas. However, it’s not the rich variety of learning and practice being developed that I find so significant; it’s the way this is being done, described in this article. Like for Buurtzorg in the Netherlands, the results can already be termed “outrageous”. (Laloux, 2014 Reinventing Organisations, Chapter 2.2 Outrageous Results paragraph 1)
“There was an absence or at least a much reduced sense of fear about “doing it wrong;” this felt different from much of my previous experience of the NHS.” Community of Practice Consultant
Reinventing the NHS as Teal
Contrary to my own typical experience of “falling through the cracks” of the system, now more new Communities of Practice are focusing on working across traditional service boundaries, and often exploring a geographically-defined approach which reflects the community or neighbourhood experience of the people accessing their services. These Communities of Practice seem to have found a real evolutionary purpose.
They are working towards breaking down traditional NHS boundaries and developing new ways of supporting health and well-being in an environment where it is clear that health and social care needs to radically reinvent itself.
Maybe the person I met was right after all. The NHS as it is now cannot be a Teal organisation. But the NHS that will be, must evolve to become a Teal organisation.

previously published Enlivening Edge 27th October 2015  ​http://www.enliveningedge.org/organizations/uks-national-health-service-nhs-cannot-teal-organisation/#more-1448