It’s hard work setting up a business. Research shows moving from start-up to scale up presents new and equally demanding challenges. High growth organisations face challenges in recruiting the right talent to meet their growing needs, developing the leadership to continue to inspire and steer the organisation, the perennial access to finance issue and the need to create the right structure and culture capable of delivering the vision.
As more businesses become clearer about their vision and commitment to values, so more start-ups seem to reach a situation where a choice needs to be made. Many make the decision to stay small so that they do not compromise their values. Others sell out to larger organisations, checking out before the original vision is compromised. But there is another way.
I have recently been working with a small company committed to sustaining great relationships and flexibility for its staff and delivering high-quality services for its customers.  Supporting people with disabilities at home, and in hospitals and schools; this company also wanted to make its services accessible to everyone it could it make a difference to.   Growth was in line with its values and essential to delivery of its purpose.  This company could not stay small and align with its values, it could not limit its growth and fulfil its purpose. On the other hand, the co-founders were adamant that they did not want to develop into a hierarchy with layers of management, bureaucracy and tomes of policies and procedures. This was not what they were about.
They were at a crossroads and took the brave decision to find another way that would promote sustainable growth, align with their values and help them live the meaning of their organisation. Taking a new approach to developing an operating system and organisational design that intentionally creates the culture you want and promotes the values you founded your business on, is a realistic and prudent option. There are now thousands of organisations adopting self-managing techniques and creating their own non-hierarchical organisational structures. Asking new questions, they find answers to attracting, growing and retaining the right people, being agile and remaining relevant to their customers, staying true to the original purpose and therein delivering the real value of the business. They found that all can be more successfully delivered by adopting these new ways of working and growing their organisation.
Entrepreneurs are by nature innovative problem solvers, adept at creating new opportunities. It’s vital to embrace innovation and seek new solutions in all aspects of your enterprise. There is a huge opportunity for growing businesses to exploit by adopting these new operating systems and agile structures. Time to ask the new questions, how can I stay true to my values and grow a successful business?  Lots of growing businesses are already finding out.
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​​When we consider the current challenges and approaches in Health and Care the reasons to “Take it Teal” become self-evident. The challenges are big and complex and making what we already do more efficient will not help. Indeed, there is evidence that some of these previous initiatives have been counterproductive and have disengaged staff and left citizens dissatisfied with the service they received.
The programme to develop Integrated Care Organisations is already underway. Based on subsidiarity, there is no central blueprint, local health and care systems are designing what can improve health in their own neighbourhoods and across their own systems. Moving towards self-organising systems and self-managed teams requires a similar approach. There is learning and experience that can be shared but each system and organisation will need to make it their own. It makes sense to align subsidiarity in the systems and neighbourhoods with subsidiarity in the services that support these neighbourhoods to give them the agility to meet local needs.
Health care used to provide treatment for episodes of illness. Its task was to fix the problem and discharge people back to their usual lives. It now needs to deliver long-term support to growing numbers of older people and those living with long-term conditions. This means enabling self-care and self-management of long-term conditions. To be successful health staff need to focus on what’s important to the citizen they are supporting and provide person-centred care. The educational, coaching and developmental techniques used to support citizens to step up and take control of their health and wellbeing are the same approaches that can support staff to take control and manage their own work. Working in this way restores the autonomy removed from workers in recent times and gives them back the ability to make a difference. The improved job satisfaction and customer satisfaction which results improves recruitment and retention rates, another key issue in today’s health sector.
Our current approach to health, treating our illnesses and conditions, is not sustainable. We need to work upstream, promote wellness and prevent illness. Health is social, there is a physical element to this and a great contribution that medicine can make but we need a broader appreciation of what makes us healthy and feel happy and well. We recognise that our neighbourhoods and communities play a vital role and we are developing towards being able to value them and work in ways that respect this. In organisations we know that the culture in which we work has a dramatic impact on our performance and our staff wellbeing.  Creating organisations and working in ways that maximise the health and wellbeing of our staff and respect and value our communities is a moral imperative. These new ways of working enable us to do this.
In health care we are now more accepting of the emotional and spiritual aspects of health, we can prove the benefits of compassion and more holistic approaches to care with patient outcome data.  It therefore makes sense that we should view wellbeing and wholeness for our staff in the same way. Creating workplaces where we welcome the whole person allows us to address issues of equality and diversity in context, not as a separate issue. It allows us to value and harness all the talents and passions of our staff to their work, not just the slither of person that might be reflected in a job description.  It enables us to model health promoting approaches for other organisations in our systems and treat our staff in the way we hope they will treat the citizens they support and care for.
Safety, quality and continuous improvement have long been a focus of healthcare with varied success. Self-organising approaches release the energy of staff and teams committed to doing their best for the people they care for. These staff are best placed to spot the dangers, experience the frustrations and identify the improvements that will deliver the biggest advantages for the people they support. Continuous improvement is an integral part of the self-management team approach. Adopting self-organising approaches in teams and supporting them to pursue their own improvement agenda rigorously will produce the safety and quality we aspire to.
Adopting this approach allows organisations to align their operating process with their approach to delivering to their purpose and providing care and support to improve the health of their communities.  Whether we look at NHS values, the 6 Cs or the 7 principles of care, this way of working enables us to live them. If we are serious about preserving these values and principles and creating a way for them to not only to survive but thrive into the next 70 years, this is the way forward. 

Some new organisations are set up with the intention of being self-organising but for many the challenge is a different one. The way an organisation that exists within a traditional management and hierarchical structure can reinvent itself is a focus of Laloux’s current work. This is the reality of most organisations in health and social care. How can it be possible to take a traditional health and social care organisation and move it towards being a self-organising entity? As the Reinventing Organisations movement emerged four years ago, I remember conversations with leaders of new self-managing organisations in the private sector who told me it was quite impossible. They were wrong.

Self-management is the aspect of this new way of working most focused on. The reports of significant savings in the costs of corporate functions, coupled with the ability to re-engage staff through autonomy and improving the quality of services provided, are very attractive.  In the health and care world, which traditionally values doing, there is a temptation to focus on re-organising and how we “do” self-management. Ignoring the other elements that make this approach successful, the culture we create, our purpose, the values and beliefs we hold and how it feels to work or receive services are a vital part of this approach and must demand our equal attention.

There are various possibilities when considering a transition to this way of working. Some organisations create teams to pilot this method, working as part of but distinct from the larger organisation. To protect this new way of working many projects build a firewall between the pilots and the existing organisation. All communications and interactions are channelled to the new team via a small group of staff and the workload and resources of the team are protected from processes that are used in the wider organisation. It is not yet clear if this approach can successfully transition the host organisations to a new way of working. Indeed, in several organisations hosting these pilots, it is not clear that the organisation itself intends to make this move.

There are examples in private industry, perhaps Zappos being the most famous, where leadership has taken the decision to move the whole organisation in this direction and issued an ultimatum. For health and care organisations, who need to ensure safe continuous service, this is not a practical option. Customers may be inconvenienced by lack of new shoes but people and communities would suffer if health and care services are badly disrupted. This adds a whole new dimension to the challenge of change. There are several examples where action by staff groups and communities have halted or seriously disrupted change initiatives in health and care and organisations. Organisations making this move need to be mindful but not paralysed by this awareness.

An alternative approach is to work with a whole organisation and support it to evolve in this direction. Some organisations may dismiss this as too complex, too risky and too slow. Indeed, it is not a journey that should be embarked upon without significant consideration, energy and courage.  Perhaps because of this, I believe this approach is more likely to deliver successful and sustainable results.  When working in the field there is often a request to supply a route map or a project plan to “roll-out” the approach. People want a set of instructions, that if followed will get the organisation to where it wants to be. Herein lies another challenge. This methodology is founded on the belief that rigid long-term plans are not helpful in the VUCA world our health and care organisations inhabit. Every organisation must be alive to its purpose and constantly responding to the needs of the people and communities it serves. The route followed by one organisation, or even a service area in a large health and care organisation, will be different from another. It needs to be, or the organisation will not be taking full advantage of the intelligence, talent and passion of its frontline and the communities it works with. There is no one route map and organisations should beware of anyone that tells them there is.

On the other hand, there is a growing and generous community of health and care organisations who already work in this way. They generate learning and advice that can be taken and built upon. From this we can identify some useful foundation stones on which we can base our work. (Read more about these in part 2). We can use this learning intelligently and intentionally to evolve an organisation. Using methods that align with the self-management approach is important in achieving the cultural shift needed for the work. Used skilfully it can provide the pace and assurance of usual project infrastructure and will provide more successful and sustainable results.  When we step back, this method is not so different from the work being done to create Integrated Care Organisations. There is no blueprint for this either but a commitment to move in this direction, courage and a willingness to learn together is driving this forward. The content of the work and way the principles are woven together in the new way of working may be new, but health and care has been evolving new approaches, breaking new ground and achieving the impossible for decades. It’s time to rediscover those abilities. 

1.   Self-management means no management​In traditional organisations the tasks of decision making, providing expert clinical advice, allocating work and resources and monitoring and assuring the work being done are often all part of the managers role. In a self-organising team these tasks still exist but are done in a different way. Teams that work successfully adopt processes to help them manage themselves and hold each other accountable. The process of peers holding each other to account about their practices and efficiency can be much more powerful and effective than traditional management methods. Common techniques teams use to help them do this are tactical meetings, integrated decision making, regular consideration of statistics and stories that enable the team to know where they are at and plans to continuously improve.

2.    There is no hierarchy​
There is no power hierarchy, no-one is given power over their team mate. Natural hierarchies do arise and are encouraged by building an environment that welcomes the whole person to work. Someone who is considered efficient and fair is an obvious choice to fill the role of organising the rota or can be the “expert” that supports others who want to develop the skills and aptitudes for this task. Similarly, a colleague who is an expert in a clinical aspect of work will naturally take a lead in discussions and developing practice in this area. She may even find she is asked for advice and input by other teams.

3.    Teams are left alone to get in with it
Teams are supported to self-organise by coaches or facilitators. Coaches and facilitators have no power in the team. Their role is to provide advice, information and support the team to make decisions and resolve issues. Depending on the type of team or organisation, some teams are also supported by business managers who handle contracts on their behalf or carry out other specialist functions.

4.  Teams act independently and do as they please
Teams taking decisions often use integrated decision making and the advice process. This ensures that they take advice from any experts and talk to anyone who may be impacted on by their decisions. The decision is the teams to make but they will be taking the decision having integrated any views and objections they encountered. Teams may also link with other teams to consider issues they have in common. For example, teams may send representatives to a meeting that they have empowered to make decisions about staff training. The meeting would be accountable for planning the programme and spending the budget on behalf of all the teams. Systems and processes based on holocracy or sociocracy are often used to connect teams and their decision making across larger organisations.

5.    There is no leadership​
There is distributed leadership. Many people taking different roles will be required to take decisions as defined by their role, instigate action, resolve problems and monitor quality and outcomes. Especially as an organisation establishes itself or makes the move to become self-organising leadership is key. Leaders need to create the spaces for the self-organising behavior they wish to encourage and keep inviting people to step up and take part. They need to have courage and hold a steady course as the organisation encounters its first problems and setbacks. They need to articulate the purpose and values frequently and clearly so that teams can make decisions and check they are in alignment. Leaders need to create the environment in which the teams can flourish. They need to collect and provide information to teams to make great decisions and to external regulators and stakeholders to assure them that the services provided are safe, effective and compassionate.

6.    Only highly skilled senior professional staff can work in this way​
Anyone in a health or care organisation can work in this way. We already have many of the skills and self-organise in non-work situations all the time. There are examples of the lowest paid, lowest grade staff working successfully together in self-organising teams. There are also examples of the highest paid, highly trained and educated staff who have not been able to work successfully in this environment. The approach is about working as part of a team. Being able to give and receive feedback, being accountable, being supportive, being humble, being proactive in identifying and solving problems and being trusting and trustworthy are all attributes of successful self-organising team colleagues.
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7.    There is a blueprint about how to do this
The teams and organisations working in this way are very generous. Both inside and outside health and social care they will share their experiences and knowledge with you.  There are lots of shoulders to stand on to see the way forward for your team or organisation.  This way of working is so successful because it enables every individual to contribute their best to their team. Similarly, it enables every team and organisation to offer what is most useful to the people and communities it supports. As a result, each organisation will be different. Indeed, each team made up of different team members and serving a different community in an organisation will be different. The thing that unifies them and serves to measure their success is that they can fulfill the organisations purpose for the people and communities they serve. There is no blueprint but there is a lot of knowledge and experience that you can use to plan your own journey.
 
Jane Pightling www.evolutonaryconnections.co.uk