Complexity in public services - roadblock or hidden opportunity?

What can we learn together, from research and real-world experience about effective leadership and its role in public services? We’ve looked at some of the themes emerging from research and from our work supporting services in health, education, and for children and families. In each issue of the CES Leaders Digest we write about these themes and invite leaders to share their experience and perspectives. In this entry, we look at complexity in public services. Anne O’Connor, National Director of Mental Health, HSE, in Ireland shares her experience of leadership in the context of complex reforms to mental health services in Ireland.

Ces Crossing Graphic 21 Dec

In the first entry of this blog series, we looked at leadership in public services, and what makes it so different. It can be a virtual balancing act to manage the views of different stakeholders — from government ministers through to citizens, frontline workers and NGOs, particularly in ‘whole of government’ working. While they may be united in a vision of social good, their views can often be conflicting. As a result, leaders in the public service work in a context characterised by complexity.

Complexity is a messy business. Nicolas Timmins’ report for the Kings Fund helps to explain that complexity when he describes systems leadership in public services as ‘seeking to make change across organisations where people did not have a direct, line management responsibility.’ Trying to effect change in areas outside of a leader’s direct remit is a key feature of systems leadership. Through interviewing ten people involved in systems leadership he suggested that it is an act of persuasion requiring an evidence base — both to inform the course of action and to convince those that need convincing. Other recent work from the Kings Fund describe how systems leadership involves effecting change for social good across multiple interacting and intersecting systems. The assumption is that joining up across these systems will result in better, more efficient public services. Easier said than done!

We can recognise the presence of complexity through tensions that are apparent throughout the system. The good news is that these tensions are not necessarily a bad thing. The literature suggests that they can result in useful, system wide learning. They can spark innovation, allow for the development of new skills, and encourage adaptability. The challenge is in tapping into their potential, at the right time, in the right way to capture learning and apply it. This is where leadership comes in.

A feature of effective leadership in complex environments is the ability to facilitate and create conditions for change. Here, the ‘why’ or shared vision is much more important than the ‘how’. Take for example this OECD case study from Iceland, where a co-ordinated approach was piloted to tackle domestic violence and a small proportion of cases passing through the justice system. The pilot resulted in a greater level of police intervention, and court referrals. The approach has been adopted by other areas around the country since.

New legislation, a shared understanding of the broader impact of domestic violence, working with a range of contributors from across the system, the willingness to try new approaches and to learn from the experience were just some of the conditions that made the approach successful. Leadership was critical in developing these conditions and was encouraged across the system and the frontline.

What can we learn from Ireland about the experience of working and using complexity to drive change? Anne O’Connor, National Director of Mental Health, HSE shares her experience.

Ces Pyramid Graphic 21 Dec

Complexity is a reality experienced by any anyone involved in leading change in the Irish health services. This means that we need to orientate our leadership efforts towards a systems approach to enabling change. We need to acknowledge the actual complexity facing us when we embark on a significant change initiative and keep a clear focus on defining or describing the problem we are trying to solve.

Since 2015 I have worked on the implementation of a transformational change initiative in the HSE Mental Health Division, aimed at improving mental health services so that they can better meet the needs of service users and their families. It was clear that the mental health services needed to change to enable the development of improved responses to people experiencing mental health difficulties, as well as their families. Notwithstanding the excellent work carried out by many services, a growing demand for services, limited financial and human capacity to respond to this demand, and the changing expectations of service users and their families required a fundamental shift in the thinking and behaviour of many people working in the services. The views of service users and their participation in the design and delivery of mental health services are critical to the provision of person centred recovery orientated services, yet in Ireland there has been insufficient focus on the needs of services users and their families.

Building the scaffolding for change

Balancing the complexity of implementing change in a large professional bureaucracy such as the Mental Health Division with the need to maintain ‘business as usual’ in terms of service delivery required dedicated focus and a structured framework to support the organisational change process. A Programme Management Office was established within the Mental Health Division in partnership with CES, to support service improvement but also our capacity to support change. Given the demanding nature of the day-to-day business, a separate service improvement function was established and this, along with the PMO have operated in effect as a “parallel organisation” protected from the daily “urgent” demands arising from a service delivery perspective. This work is structured and is overseen by a Change Board, which provides the necessary governance to drive a system wide programme of change. We recruited a number of dedicated service improvement leads, to act as change agents and to integrate the work of the programme management office with operational services provided by the nine community health organisations.

Putting service users at the heart of systems change

Similar to the example of the case study on domestic violence in Iceland, the focus of this systems change has been on the needs of those who use our services. We wanted to embed a ‘Recovery’ approach into the work of the Division and mental health services across the country. That is not to take away from the need to support and develop our staff but rather to apply a “service user lens” to how we develop our services and prioritise our actions and critically, our investment. From the outset, and similar to the initiative in Iceland, it was clear that a shared understanding and “vision’ was required to ensure that the desired outcome could be achieved on a national basis. By framing our approach to service improvement within a Recovery context we were able to describe the desired change in the way that was meaningful for service users, families and staff. Significant work was undertaken at a national level to define recovery and then to look at how this approach would underpin all service improvement work undertaken.

The approach to service improvement undertaken helps us move from a position in which recovery related initiatives have been viewed as optional projects to one in which a recovery ethos underpins all mental health division activity at both local and national levels. Service improvement work undertaken has the potential to bring about significant change in the culture of our services with a much-needed rebalancing of “power” between staff and service users. There has been a shift in organisational culture and behaviour towards one of coproduction with service users and their family. A key turning point early on in this change journey was the appointment of a National Head of Engagement whose role is to ensure that the needs of service users are central to all work within the division. More recently, the appointment of peer support workers in the mental health services has signalled a commitment to co-production and a recovery ethos.

Facilitating leadership across the system

My role as the National Director has been (and continues to be) the enablement of the conditions to allow this transformational change to happen i.e. not by implementing change directly within services myself, but by supporting the national team and service providers to effect the change in an organised, programmatic way. The service improvement structure we put in place acknowledged the complexity of the challenge of improving mental health services on a national basis.

Systems change can happen in complex environments

Our experience of systems change within the Mental Health Division, whilst challenging, has been very positive. As leaders within the Mental Health Division, myself and the senior team have communicated a clear commitment to the change underway both internally and externally. This has been critical to what we have achieved. Our approach to collaboration, our interactions with colleagues in other sectors and service providers and our commitment to using research and evidence in implementing systems change in mental health are contributing to the enabling context we need for change to thrive.

Anne O’Connor started her career as an occupational therapist. She took up the role as National Director of Mental Health Services, HSE in Ireland in 2014. Along with responsibilities for the operational performance of the mental health division, as the leader of the division and a member of the leadership team of the HSE, she is charged with overseeing a programme of reform ultimately aimed at improving mental health services in Ireland.