Change has become inescapable and all-consuming.  In the NHS, which actually has undergone wide reaching change, there is a constant exhortation of the need for change.  Not only change though, it’s transformation that is required – If only people were able or willing to do things completely differently….  Not surprisingly for some of the 1.5m NHS employees in UK, it comes more easily than for others. 

To be fair, with most changes there will be grounds for at least some questioning.  It is not always helpful that resistance tends to be characterised only in negative terms.

Transformation leads to talk of change of the paradigm – that overall set of concepts and thinking that influences the way we go about providing and developing health and social care.   The NHS Long Term Plan talks soothingly of the things we need to preserve but throws in challenges to the very way we have always gone about things.   I don’t know if you can have more than one paradigm. For me, there is a paradigm that dominates much thinking and that is the paradigm of the end state. We change from something to something else.  We do something and there is a clear cut end result.   Politicians love this – it legitimises the grand gesture, a whizzo scheme, seduced by some promise of salvation from the problem.  It’s logical, straightforward and make sense.  Down the line, this has given us the promised land of the internal market, the founts of initiative and efficiency that spouted from the private sector, the palaces of PFI and perhaps now the army of volunteers marching to save us.  Management consultants know that clients love the end-state too, responding with innovative seeming approaches to maintain “just-out-of-sight” mutual dependency.  Words like “solutions” are used.  Solutions litter the landscape including in those magical QIPP schemes that promised more and better quality at less cost with no collateral damage whatsoever.

But are there really solutions in the modern health care world?  Can there really be an end-state in an environment of constant flux with new pressures and challenges emerging all the time?  Our understanding of systems must surely lean us towards the notion that the best we can achieve will be some sort of dynamic equilibrium as we manipulate the system links and manage its feedbacks, forever on our toes  to maintain a highly vulnerable steady state?

And in this inherently unsteady world, what is the change that can be expected and what will work? 

I prefer the word shift to change.  For me, shift is a responding word – one shifts to accommodate, to readjust to, to test the water, or to go out tentatively on a limb.   It feels more within my control, less likely to be imposed as to be self-starting.  To shift, I need to understand why, and if I am not convinced of the consequences, by shifting a bit, I might find out more.

Of course, shifts can be at any scale – a seismic shift for instance, or that experienced in the scientific mindset in Thomas Kuhn’s original paradigm shift, will be pretty fundamental. But they are still arguably adjustments.   

Sounds a bit too reactionary for the changes we need to make? A world of reaction and no proactivity? A world of a constant shifting of bottoms simply to make ourselves comfortable?

But maybe this is the outlook that is more likely to result in the continuing change that is required. May be it’s more honest to think of the solution as an ongoing quest.  The art of leadership then is to be able to encourage the shifts, align them where possible and keep them going in the desired direction, maintaining momentum in the ever ongoing adjustment that is required.

So what on earth has this got to with sand?   Fairly recently, whilst working on the mental health performance improvement program in Saudi, I found myself taking shelter in a sand storm on a pedestrian bridge in Riyadh.  A fascinating, intriguing ten minutes was spent watching the sand inside the bridge – swirling, ebbing and flowing, settling, picking up, collecting and shifting.  Sticking my foot out upset the whole flow but the system adjusted rapidly. 

My first thought was of ancient school lessons about desert barchans forming around an obstacle (text books gave as an example, a dead camel).Then, more importantly, it all seemed to be a metaphor for the systems we were working with – ED flows, inpatient stays, unpredicted circumstances, interferences and random expectations – the things that most health systems have to contend with.

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