Deep dialogue

Dialogue is probably a word like inclusion which we all use and may never unpack and seek it's authentic meaning. It is also something we all are in favour of. Yet this doesn't prove we know what it is or even practice it! So what is dialogue? Is it discussion? Is it listening? Or something more?

I attended the first session of the Leeds Indaba Programme last week. This is a leadership, ideas and innovation fellowship in Leeds based at the Centre for Innovation inHealthcare Management. Based at  the University of Leeds, CIHM is a centre of inspiration, idea generation and testing, community outreach and teaching in innovative and creative forms. To my mind, CIHM is both an assett of and gift to the city of Leeds.

The Indaba programme is a joint partnership between the Centre, the University of Stellenbosch University in South Africa and the VU University in Amsterdam. Becky Malby, director of CIHM, Professor Erwin Schwella and Professor Goos Minderman were the facilitators. Indaba is a word meaning an important conference held by members of the Zulu or Xhosa people of South Africa. The Leeds Indaba was a meeting of a number of leaders from across the country from business, the NHS and the Third Sector. Its aim was to allow a discussion about leadership, positive passions, the NHS and its future and new fresh thinking.

I learnt many things. There was a large number of times when my mind lit up at comments made as they made sense of other things or connected them. In this post I will focus on the concept of dialogue. At the beginning of the session we each went around and spoke of who we were and our roles and interests. This was very different from when this is usually done. Usually people say their name, role and place of work. This was deeper. Those who attended spent some time talking about themselves and their journey. Throughout the day the honesty, depth and openness of the sharing was stimulating.  At the beginning of the day, Becky spoke of dialogue, she said, "It's only when we really know each that we can really have dialogue." This was one of those statements that illuminated my thought. In trying to unpack it the following things seem to come to view as learning points.

Perhaps to define dialogue we can look to a place where it holds a central place in everyday practice. This common place the word is used is in the religious world where different faiths will meet to work together and have dialogue. This is interesting as the world faiths have different views of the world and each other. Dialogue is the language or road they use to meet, listen and engage respectively with each other. The World Council of Churches has some wonderful words on the definition of dialogue. It states, "All dialogue involves an exchange, an interplay between speaking and suggesting on the one hand and listening and receiving on the other. Dialogue is, therefore, the opposite of monologue. It requires reciprocity and a certain equality...Dialogue is not merely 'discourse'". It is primarily a way of being together in charity, which gradually changes and renews the atmosphere.....where profound exchanges of thought and expression can achieve something which goes beyond clarity of conversation or individual conviction. ' ( WCC, Joint Working Group, 1967, 1). This definition embodies a rich message and offers a powerful praxis. It says to me that dialogue is about

          * being with the other

          * listening to the other

          * trying to understand the other's place - this doesn't mean necessarily agreeing with it

          * allowing the possibility of changing by exchange with the other.

Dialogue can only be deep when we know the other. Yet to know the other we have to dialogue with him or her. So there is a circle of connectivity and conversation which leads from dialogue to knowing and then to further and deeper dialogue. This circle of dialogue can keep going on and on. To be committed to deep dialogue means to be committed to deep listening, deep respect and deep sharing. It points to what the famous novelist Charles Williams called 'co-inherence.' This word gives us a clue to deep dialogue. It suggests connecting and in a sense dwelling in the other. To share in the hopes, struggles and life of another. This mutual indwelling while remaining ourselves would be the deepest dialogue. I have no doubt such dialogue has a power and connection that can cause real change and newness of vision.

Yet this deep dialogue seems to demands something else. A deeper dialogue seems to assume  a deeper commitment and conversation than we often have. I would suggest it demands an inner freedom in ourselves. The late British theologian Charles Davis spoke of "the openness and love that derive from inner freedom." This is a powerful insight. It's when we have authentic inner freedom that we can really love and be open. Our closed minds, fear and lack of real freedom within all make the most important things we both need and can offer very difficult. Charles Davis spoke of the need to find 'self-appropriation.'  He explained this by writing the following, "Happiness isn't not a quiescence gained by a narrowing of consciousness; it demands that a man accept the autonomy proper to him as a free person. A man has to take in hand his own becoming, decide what he is to make of himself, and then carry out his decision. Just to follow what others do or say and wait passively upon events is to live a diminished personal existence......to be fully a person does mean freely to take the decisions that determine the direction and growth of one's existence."

Deep dialogue flows from deep freedom and deep living. Perhaps this brings us to the fundamental lesson of leadership. Leadership is not something primarily we do - it's something we are. And that something we have to seek as we seek the freedom of self appropriation. I enjoyed the first Indaba meeting and look forward to the next. It was great to meet such good colleagues from different sectors and sit with them trying to listen and engage. It struck me that the Leeds Indaba was not just a space to learn but a school for deep dialogue. In that deep dialogue lies the possibility of some really invigorating and stimulating offerings. It's good to be on board the Indaba.

John Walsh. York Street Health Practice

A movement for a city

On Friday 5 September, York Street Health Practice had a very special visit. Two members of the Australian Parliament visited the practice. Our visitors were Steven Marshall, State Liberal Leader and Leader of the Opposition in the House of Assembly in the Parliament of South Australia and Stephen Wade, Shadow Minister for Health, Mental health and Substance Abuse, for Ageing, Suicide Prevention and the Arts. Sandy Biar the advisor to Mr Wade was also part of the visit.

The event was part of the work organised by Leeds and Partners. Leeds and Partners were represented by Tim Straughan, the L&P Director of Health and Innovation. Tim is a good friend of York Street. He supported the practice obtain funding for digital technology to support vulnerable people access healthcare in a faster more effective way. Leeds and Partners is based on the delivery of three strategic objectives. These are - promoting and raising awareness of the city of Leeds locally, nationally and internationally, work with partners to promote the city as a great visitor destination and work with partners to drive up the volume and value of inward investment in the city. 

Facilitating the visit were John Farenden and Tim Keenan from the health team of professional services firm Ernst & Young here in Leeds. John worked on the original development of the Leeds Innovation Health Hub and it was through him telling his international colleagues what wonderful work is going on across the city that the Australian politicians heard about it and specifically asked to come and learn more as part of their fact-finding mission. The meeting was joined by the Councillor Bill Urry, the Lead for Homeless issues on Leeds City Council, Helen Kemp, the new Chief Executive of Leeds MIND and our own, Neil Franklin, Chair of LCH. Anna Green, one of the new innovation leads at LCH, and Lynne Jones, our senior admin / medical secretary at York Street, hosted the visit.

The visit started with a short tour around the practice. We then met to discuss our work and the work of the city. We shared what we try to do. We spoke of the five areas of work we do. These are what we do as a health team, the services that come into York Street to make a difference such as benefit and legal support, where we go out to reach out to homeless people via outreach clinics and street work, our work strategically across the city and lastly our digital work using modern informatics as a tool to help people access good care. 

We also spoke about the model of care we use. This is not so much what we do as how we do it. It embodies three elements - the creation of positive space, therapeutic relationships and supporting people make the inner change to a more empowering vision. This was followed by a good and helpful discussion of health and social care, reaching the vulnerable and how to be build best possible care. Councillor Urry spoke of his work as an elected representative of Leeds going out into the streets with homeless workers and being deeply impressed by the passion he sees in those agencies working to engage with the homeless. Neil Franklin shared on how integration, inclusion and innovation were at the heart of what Leeds services do and how it was making a real difference as well as offering much opportunity for the future. The visit was  a special event and this blog expresses our thanks to Stephen, Steven and Sandy for visiting us. We would also like to express our thanks to Tim, John and Tim for including us on their visit.

The visit pointed to something bigger and much more important than York Street. What the visit expressed is something that is taking place across this city. Leeds like all cities has its strengths and challenges. There is in Leeds a consciousness emerging and moving in many places. It covers academia, health, the council, business, the third sector, the faith sector and a 101 other places. This consciousness is based on people seeing something bigger than themselves and their sector. This consciousness is with the city and for it. There are several aspects to this vision and movement across the city. It is an alliance of talents. It brings together people from all walks of life who bring their gifts to create something new and fresh. An analogy would be people all bringing different skills and ingredients and meeting to create a meal. Daily across Leeds services and people are meeting and working in innovative ways to make a difference for the better. We see it everywhere across the city. This coalition of care and development is real and meaningful. It is a learning community where no one claims to have all the answers. There is a humility and openness about it that is both inspiring and attractive. Although none of us claims to have all the knowledge we know that together we can create solutions and support each other to make Leeds the best city we can imagine. There is a vision and focus in this movement which is for the greater and common good. People come together to construct answers and projects to tap into the gifts and energies Leeds has.

What lies at the heart of this movement and consciousness are people who care and seek the good of others. There is also, in the most difficult of times, a sense of hope. What is amazing about this movement is that no one controls or even co-ordinates it. That is why we use the term 'consciousness' as this is an invisible network which visibly expresses itself and engages in the life of the city. Many of the people do not know each other and may never even meet. What is certain is that when they do there is a common vision, commitment and connection. This offers a potency, promise and possibility that means a great future for Leeds. We are proud, humbled and honoured to be able to play a part in this vital work. In this citywide movement which has no name is a model of what a city can do and be. It tells of what each and every person and each and every business and service can offer. In this energy and work together we co-create the future.

Anna Green, Innovation Lead, Specialist Services, Leeds Community Healthcare NHS Trust 

John Walsh, York Street Health Practice, Leeds Community Healthcare NHS Trust  

A timely call

The Centre for Innovation in Healthcare Management has this year produced a manifesto with the wonderful title 'Giving Inspiration a Chance to Flourish' . The manifesto is a bright and colourful production. I don't think the brightness and clarity of the publication is accidental. It reflects the method and spirit of the manifesto's message.

The CIHM is a health innovation centre based at the University of Leeds. Its website describes its dynamic work well  as a 'network of doctors, public sector managers, organisational change consultants and academics, who are passionate about improving public services. We believe that CIHM is unique in that it is a ‘think and do tank’: not only do we undertake major pieces of academic research but we also work with health and social care organisations to help create the conditions in which change occurs.' The Centre is  led by Becky Malby, a deeply respected and inspirational figure in the world of innovation and health. Becky recently visited York Street Health Practice.  Becky, Catherine Hall and myself spent nearly two hours in discussion and dialogue. It was one of the most enlightening and inspiring talks I have ever had in nearly 20 years of working in the NHS.

 The manifesto is a challenging and positive road map of where we can go and what we can be. The heart of the manifesto is 'finding solutions with people that deliver and use services.' The manifesto has eight key parts.

 (1) Develop local solutions with local people.

 (2) Provide conditions that allow staff, patients and communities to adapt, innovate and improve together

 (3) Create space for communities to provide health and social care,prevent ill health and be well

 (4) Support regulation to stop unacceptable behaviour; not to improve the behaviour of the majority.

 (5) Choose co-operation as the expected and default behaviour

 (6) Understand what’s going on around here now, how things work now.

 (7) Give people the chance to talk about what matters to them and how they will act towards each other.

 (8) Create opportunities for patients, their families and carers to have a voice in all aspects of their health and social care.

 Each of these elements has a 'Why?'and 'How This Works' explanation. The important thing about this manifesto is that it is underpinned by a clearly stated set of core beliefs about us all. The manifesto terms them as 'self evidently true' ( perhaps borrowing from the US Declaration of Independance's self evident truths ). These are located in a view that we are not just individuals but part of communities, that we have great potential, possibilty and can organise ourselves and that systems should learn from each other and understand each other. It is these clear and liberating beliefs that underpin the manifesto.  

This manifesto seeks to ground itself on what is best in us and others. It offers a picture of how the NHS could develop. In the section 'What We See What Inspires Us' we find people going the extra mile, kindness and the spirit to keep asking difficult questions. The manifesto is not a theoretical construct living in the clouds neither is it a collection of practical recommendations. It is rather a call for us to link mind and heart in positive action for the future. It marries the need for clear thinking with rooted actions. It is space that starts that discussion of what the inner being and external expression of the NHS can be. I would ask all colleagues to read this manifesto and let its aspirations and power challenge us. By all means debate and question what the manifesto says but let's have that dialogue. From this discourse, great things can emerge. Without it, I am not so sure. I hope we can all commit ourselves to grow opportunities and spaces for this Manifesto and it's challenge to become living practice. 

John Walsh, York Street Practice

Culture Change in the NHS

Leeds Community Healthcare is currently working in partnership with NHS Employers and Southampton University on a project to understand and support culture changes in the NHS. The project will run until November 2014 with specific outputs on tools for development of new cultural paradigms across the health economy.

The project team comprises of Catherine Hall (Service Manager for Specialist Services), Caroline McNamara (Senior Clinical Lead), Julie Mountain (Head of Adult Neighbourhood Services),  Julie Thornton (Development Lead) and myself.

Much emphasis has been placed on 'culture change' over the past couple of years in the NHS and we have seen forensic examination of system failures across the NHS. The outcome of this has immediate impact on patients and their families and the importance of putting these terrible events right is critical. One of the more astonishing and distressing facts to emerge from the Francis Report for example was the number of instances of not only poor care, but inhumane care. Patients were left lying in their own urine, or were left for hours without food or drink. Psychological studies have helped to shed light on the mechanisms underlying inhumane behaviour, such as ignoring distress and harm to an individual, although it is worth bearing in mind that none of them were caring for vulnerable patients.

Particularly pertinent is the ‘bystander effect’, in which individuals stand by and fail to help a victim in distress. Relevant variables (see Fischer et al, 2011) include the number of bystanders present (more means it is less likely that a victim will be helped); the ambiguity of the situation (more ambiguity leads to less help); and the similarity of the victim to the bystander (the greater the similarity, the more likely that help will be offered). Research has also shown that pressing situational factors may readily override explicitly enounced value systems and beliefs, such that a person in great distress is ignored (Darley & Batson, 1973), something that could find parallels in busy clinical settings.

Also relevant is Philip Zimbardo’s Stanford Prison Experiment (Haney & Zimbardo, 1998) where those who were put in charge of prisoners subjected them to inhumane treatment that seemed to transcend all moral boundaries. Relevant issues are discussed by Miller (2011) and by Haslam and Reicher (2012). The latter’s findings indicate that a positive hospital culture of strong leadership in human values and appropriate peer support should help to counteract any negative tendencies.

The vast majority of NHS organisations run perfectly smoothly and cope extremely well under the pressures that are currently being experienced by staff.  When we hear talk 'in the system' of culture change what do they or we precisely mean? It’s useful to nail down a definition here:

"Culture is a set of shared, taken-for-granted implicit assumptions that members of an organisation hold and that determines how they perceive, think about and react to things (Schein 1992)." In other words it’s 'The way we do things around here'. 

In a recent accompanied visit with a District Nurse to one of the poorer districts within Leeds we visited an elderly couple. The patient we had gone to visit had the start of small ulcer around his bottom and the Nurse had visited to offer treatment and reassurance. We had gone only to see the man for treatment but it quickly became apparent that both needed some form of care. Whilst Elaine was attending to the 'real' patient I chatted to his wife. A large portion of what we both did that morning was not only attending to the patient’s clinical needs but also a whole range of social and psychological support. Most of that was through being interested, curious and listening to stories about their journey through life; where they grew up, which school they went to, what their parents did and noticing the pictures on the wall.  Each photograph telling a story about their lives, the histories of their families and how they had grown up in Leeds. 

Often with huge pressure on their time, nurses (and other care professionals) do this day in day out with care, compassion and attention. This is clearly technical clinical competence done with kindness. We could say that kindness is something, which is generated by an intellectual and emotional understanding that self-interest and the interests of others are bound together, and by acting upon that understanding. Human beings have enormous capacity for kindness. It is this essence that is at the core of our change work in LCH.

If we are to support the changes that are necessary and needed within the NHS we also have to be mindful and supportive about the millions of positive interactions that take place every day across the country. The danger is that we become embroiled in negativity regarding the terrible events such as Mid Staffs without paying attention to the amazing work that takes place. There are things that we are doing and can do provided they make sense to staff and patients and also connect to our values and behaviours.

Culture change is happening all the time and as a reminder of this we only have to look back to how things used to be.  The essence of what we stand for in the NHS will never change, this is the greatest of all platforms with which we can truly 'stand on the shoulders of giants'.

‘We are living in a world of change - the tempo of life has quickened considerably. The wheels of “possibility” in our world of nursing would appear to be turning more swiftly. Many hospitals have been enlarged and new departments have sprung up within them. There is a new look in many of the Wards and Nurses' Homes. Revolution is in progress, and like every transitional condition, it has an upsetting and almost bewildering effect on the various members of our profession. Is it not all the more necessary, therefore, that everything possible should be done to ensure stability and continuity? But one of the main foundations is a sense of community, and all efforts should be made to foster and strengthen the feeling that we are all part of a whole, with a common centre and mutual purpose.’ (The British Nursing Journal September 1951)

Steve Keyes, Head of Organisational Development

 

References  

Darley, J. & Batson, C. (1973). ‘From Jerusalem to Jericho’: A study of situational and dispositional variables in helping behaviour. Journal of Personality and Social Psychology, 27, 100–108.

Fischer, P., Krueger, J., Greitemeyer, T. et al. (2011). The bystander-effect: A meta-analytic review on bystander intervention in dangerous and nondangerous emergencies. Psychological Bulletin, 137, 517–537.

Haney, C. & Zimbardo, P. (1998). The past and the future of U.S. prison policy. Twenty-five years after the Stanford Prison Experiment. American Psychologist, 53, 709–727.

Haslam, S.A. & Reicher, S. (2012). Contesting the ‘nature’ of conformity: what Milgram and Zimbardo’s studies really show. PLoS Biology, 10, e1001426.

Miller, G. (1969). Psychology as a means of promoting human welfare. American Psychologist, 24, 1063–1075.

Schein E (1992). Organizational culture and leadership. San Francisco: Jossey Bass

The British Nursing Journal, September, 1951.

Meet our staff...

Lisa, Rosie and Deanna are three Occupational Therapy students from Leeds Metropolitan University, working with Integrated Services. During their three month placement, they have been undertaking a project, which they explain below.

We are a group of three students studying Occupational Therapy at Leeds Metropolitan University, currently on a role emerging placement with Integrated Services until the 11th July. 

For role emerging placements, students enter into a non-traditional placement setting and introduce or expand the role of occupational therapy within the service and develop a project around this. Occupational therapists (OTs) enable people to overcome obstacles which prevent them from participating in the occupations that matter to them. This may be a result of the aging process, illness, disability or other circumstances.

Our project is to promote occupational therapy to the other professionals working within Integrated Services in Beeston (where we are mainly based) who are predominantly District Nurses and Community Matrons.

During the beginning stages of the placement we gathered information to help us devise our project by shadowing nurses and OTs on client visits, conducting a focus group with OTs and surveying the nurses based at Beeston. Our rationale for the project was that most OT referrals are for equipment or adaptation provision and the OTs in Integrated Services are aiming to work more holistically. This includes enabling clients to engage in occupations that are important to them, such as being able to socialise with friends at a weekly coffee morning, being able to take their dog for a walk, or knitting a scarf for a grandchild.

As part of the project, we have created several posters which will be displayed at Beeston Health Centre, as well as leaflets which will be distributed to staff and patients, explaining the role of Occupational Therapy. During the last week of our placement, we are holding an interactive session with the nurses based at Beeston to explore the meaning of occupation and how beneficial engaging in meaningful occupations is to a person’s health and wellbeing. We will then discuss potential interventions OTs can provide, using case studies to illustrate the role of OT with several different clients.  

Our placement mentors believe there is an unmet need where occupational therapy could improve clients overall health and wellbeing (e.g. clients experiencing social isolation, disruption in roles and routines) however due to the perception of OT within the service these clients are not getting referred. Integrated working requires professionals to understand one another’s roles so we believe promoting OT to other professionals will serve this purpose while also addressing the unmet need of clients. We hope that when the placement is finished our mentors will continue to use the resources we have produced to promote OT across Leeds. 

Lisa Downing,  Rosie Longshaw and Deanna Stephens

Informatics Revolution

Three weeks ago three interesting things happened to me over three days.

The first was that three civil servants from the newly established National Information Board visited York Street. Peter Hall, Jane Pawson and Tracey Dibdin came to visit the practice and see what we try to do to respond to the health and social needs of homeless people in Leeds. Over a cup of coffee we discussed the work we had accomplished with digital technology and inclusion. This work funded by the Tinder Foundation was to allow ourselves and five partner agencies (Genesis, Refugee Council / Health Befriending Network, Meeting Point, St Anne's Resource Centre, St George's Crypt) to host space where some of the most vulnerable people in Leeds could access appointments to York Street, book in advance and receive accurate information around health matters.

Dan Barnett, business manager for Specialist Services, led this work and it won the Excellence in Public Participation (Provider) Award at the NHS England Excellence in Participation awards. As I talked to these colleagues from Quarry House I began to see more and more how informatics (the use of the resources, technology and methods of modern technology to deliver and support best quality health and social care) potentially touched so much of what we did. For someone whose IT knowledge ends with YouTube and Amazon books this was a bit of revelation. I could see how informatics was a key to so much of the work we try to deliver and create. Informatics moved from a 'useful' category to a 'key' one in my work consciousness at that discussion. I'm grateful to these three good colleagues for this conversation and opening my mind up to these new roads to how we do health.

Following this meeting, Dan and myself presented at the launch of the National Information Board in London at St Thomas's Hospital. The NIB has the high level leadership role in setting the strategy and direction for the health and care system on technology and information. The event was attended by leading figures form the Health and Social Care world and was opened by the Secretary of State, Jeremy Hunt. Tim Kelsey, the first National Director for Patients and Information in the National Health Service, chaired the meeting. We presented about how Leeds has drawn a Health and Wellbeing Vision which challenges and calls the whole city to work for the most vulnerable. The great wording of the vision is about working for a healthy caring city and that 'people who are poorest will improve their health the fastest'( http://www.leeds.gov.uk/docs/JHWS_FINAL_webREV%20ZI.pdf ).

We spoke about York Street and how we seek to make this vision a reality on the streets and in the lives of the homeless. We talked about the model we use at York Street - a model about how we should work as well as what we do. This inner model offers identity to the work and team. It is focused on three fundamental human developmental needs - positive space, supportive relationships and hope. Dan spoke powerfully about how the use of digital technology following on the social value work pioneered by the Centre for Innovation in Healthcare Management (http://www.cihm.leeds.ac.uk/new/programmes-workshops/change-programmes/social-value/social-value-toolkit/) had benefited the poorest in our city. I felt proud that the CIHM, LCH and others in Leeds had worked together and from this these initiatives to use modern technology to support clients use IT to improve their health and the health of others had arisen. It showed what we can create when we work together and how we can support clients to access health more easily. The event was televised live over the internet and can be seen here - http://www.dh-national-information-board.public-i.tv/core/.

The third thing was that returning to work the next day, walking down the Headrow in Leeds, I thought further how the vision we wish to create is linked integrally to digital possibilities. I could see how integration, inclusion and informatics had to go together. If we really want the best, most effective and quickest routes and delivery of care these three must coalesce. At York Street and in Leeds they had created real gains and improvements for homeless people, those involved in prostitution and the asylum system. What we have seen in microcosm at York Street could be developed in many other places and arenas.
These three experiences haven't worn off. Today I met with Victoria Betton to talk about how York Street could develop it's digital work. Victoria is the Mental Health Programme Director at Leeds & York Partnership NHS Foundation Trust & Leeds Community Healthcare NHS Trust. To talk to Victoria is to walk into a vivid world of IT possibilities and opportunities. Her knowledge and ideas seemed limitless ( www.digitalmentalhealth.co.uk ) We talked about and generated some fascinating ideas to test and look at. While I am still linked solidly to YouTube and Amazon something else has started to happen to me around the use of digital technology. I hope it happens to you too

John Walsh, York Street Practice

What can we see?

I was invited to meet the members of the Executive Coaching Register at the NHS Leadership Academy. These are top coaches from around the UK who work with the academy to support and coach NHS colleagues. The executive coaches' are experienced in working with the most senior leaders in the public and private sector and will support healthcare staff in developing into the high quality leaders the NHS needs (http://www.leadershipacademy.nhs.uk/support/executive-coaching-register/) Over dinner, it was a real privilege to meet such inspirational people as Julie Hickton and Neslyn Watson-Druee. I was invited to this event by Yvonne Coghill who is the Senior Programme Lead for Inclusion and Coaching at the NHS Leadership Academy. As a grateful beneficiary of coaching (via LCH's Liz Whitworth), it was great to meet and talk with these good people.  

I was sat most of the evening next to Elaine Patterson. Elaine is an executive coach and has just finished her Masters on the theme of reflection and leadership. Her research question was 'What are leaders experiences of reflection?'. Elaine's website describes her practice as specialising 'in enabling leaders and practitioners to become all of 'who they are' because 'who you are' directly shapes 'how you work', your impact on others, your results and your reputation.' Speaking to Elaine was one of those conversations where new mental vistas open up and one saw the value and vitality of reflective practice much more clearly than ever before. We had a long conversation full of insights and ideas from Elaine. The following are some of the things that really struck me:

(1) Reflection is not an added extra. I don't think anyone thinks reflection is a bad thing. Many of us may regard it as a luxury - some of us maybe as not the best use of our time. Elaine's argument is that reflection should be and always is at the heart of good practice. Reflection is the act of creation. It is in reflection that we see ourselves and our work and the possibility of new options and practice arise. Habitual ways of thinking and acting get challenged and new insights emerge.  Through reflection we create the possibility of bringing something new into the world. Elaine quotes Einstein as saying, ''problems cannot be solved from the same level of thinking which created them; they cannot be changed without changing our thinking (http://www.elainepattersonexecutivecoaching.com/real-work-leaders/)

(2) Leadership is always connected to reflection. Who we are is how we lead. There is circular reality here. Good leaders are born from reflection. Great reflection is generated by good leaders. Not so much chicken and egg as how leadership and reflection both nurture and develop each other. I asked Elaine what the opposite of good reflective practice was? Her answer was 'that leaders stumble'. I thought this was a very interesting and important answer. Leaders, staff and mangers stumble because we don't reflect. Reflection gives us focus and vision. Without it we can only stumble. 

(3) Reflection is a constant practice and more. Reflection should be a daily practice. This leads to it being a being more and more a state of consciousness / a way of work life. My guess is some of the best reflectors do their reflection anywhere - on a bus, train or walking to the office. Of course, the need of conducive space and the use of exercises such as journaling can be of great assistance. I once heard the analogy of firing an arrow applied to meditation. The idea is that we withdraw, retreat in a sense. Yet it is precisely this withdrawal that gives the arrow it's power and energy. Similarly reflection is that retreat and withdrawal that gives our work practice energy and power. If we don't use these moments we either won't reflect at all or end up in negative reflection by just letting worries and problems dance around our minds.

(4) If we want good leadership, better staff morale and more innovative practice reflection will be a great key to this. I asked Elaine if the Mid Staffs tragedy would have happened if all the staff had been involved in reflective conversations and practice. Her answer was 'No, I believe not'. If we can create reflective culture and consciousness we can start to build the best services for all including staff. Elaine’s research also uncovered that costs of not reflecting. These were identified as poor decision-making and losses in understanding, creativity, relationship, energy and productivity.

Elaine's website is here - http://www.elainepattersonexecutivecoaching.com/ - and plans to publish her full research findings in the autumn. I hope colleagues will hear the message this all points to - we lead as we are. Reflection can be a great friend in the process of us being the best people we can be and creating the best cultures and outcomes for our services.

 

John Walsh, York Street Practice

 

A Timely Call

The Centre for Innovation in Healthcare Management (CIHM) has this year produced a manifesto with the wonderful title 'Giving Inspiration a Chance to Flourish'. The manifesto is a bright and colourful production. I don't think the brightness and clarity of the publication is accidental. It reflects the method and spirit of the manifesto's message.

The CIHM is a health innovation centre based at the University of Leeds. Its website describes its dynamic work well as a 'network of doctors, public sector managers, organisational change consultants and academics, who are passionate about improving public services. We believe that CIHM is unique in that it is a ‘think and do tank’: not only do we undertake major pieces of academic research but we also work with health and social care organisations to help create the conditions in which change occurs.' The centre is led by Becky Malby, a deeply respected and inspirational figure in the world of innovation and health. Becky recently visited York Street Health Practice. Becky, Catherine Hall and myself spent nearly two hours in discussion and dialogue. It was one of the most enlightening and inspiring talks I have ever had in nearly 20 years of working in the NHS.

 The manifesto ( http://www.cihm.leeds.ac.uk/new/wp-content/uploads/2014/06/CIHM-Manifesto-2014.pdf ) is a challenging and positive road map of where we can go and what we can be. The heart of the manifesto is 'finding solutions with people that deliver and use services.' The manifesto has eight key parts.  

 (1) Develop local solutions with local people

 (2) Provide conditions that allow staff, patients and communities to adapt, innovate and improve together

 (3) Create space for communities to provide health and social care, prevent ill health and be well

 (4) Support regulation to stop unacceptable behaviour; not to improve the behaviour of the majority.

 (5) Choose co-operation as the expected and default behaviour

 (6) Understand what’s going on around here now, how things work now

 (7) Give people the chance to talk about what matters to them and how they will act towards each other

 (8) Create opportunities for patients, their families and carers to have a voice in all aspects of their health and social care

Each of these elements has a 'Why?'and 'How This Works' explanation. The important thing about this manifesto is that it is underpinned by a clearly stated set of core beliefs about us all. The manifesto terms them as 'self evidently true' (perhaps borrowing from the US Declaration of Independance's self evident truths). These are located in a view that we are not just individuals but part of communities, that we have great potential, possibility and can organise ourselves and that systems should learn from each other and understand each other. It is these clear and liberating beliefs that underpin the manifesto.  

This manifesto seeks to ground itself on what is best in us and others. It offers a picture of how the NHS could develop. In the section, 'What We See What Inspires Us', we find people going the extra mile, kindness and the spirit to keep asking difficult questions. The manifesto is not a theoretical construct living in the clouds, neither is it a collection of practical recommendations. It is rather a call for us to link mind and heart in positive action for the future. It marries the need for clear thinking with rooted actions. It is space that starts that discussion of what the inner being and external expression of the NHS can be. I would ask all colleagues to read this manifesto and let its aspirations and power challenge us. By all means debate and question what the manifesto says but let's have that dialogue. From this discourse, great things can emerge. Without it, I am not so sure. I hope we can all commit ourselves to grow opportunities and spaces for this manifesto and its challenge to become living practice.

John Walsh, York Street Practice