Complex systems change

For over 10 years, Genio has successfully worked across some of the most significant and challenging social service fields in Ireland including disability, homelessness, mental health, dementia and addiction. Genio Executive Director Madeleine Clarke and Deputy Executive Director John Healy write.

Social services in Ireland are very complex and delivered by a large network of statutory and non-governmental organisations. The number of stakeholders and the complexity of the relationships is a key challenge in changing and modernising systems. Meanwhile, the population of the State is now at its highest level since 1861 and will likely increase beyond 5 million by 2026 and beyond 6 million by 2046 (CSO, 2013). Life expectancy has increased with an expected rise in chronic disease by 40 per cent by 2020 (IPH, 2010).

Genio’s experience tells us that the main obstacle to systems-level reform is not usually a lack of innovative ideas, but a lack of engagement with the real and complex challenges of bringing about systems change. This article outlines eight key lessons we have learned in working with colleagues in government agencies to introduce innovation and change in complex systems.

1. Recognise and learn about the challenges in the system you are seeking to reform

It is helpful to learn about previous attempts at change and the deeply ingrained assumptions that people implementing the current system hold. Innovations need to be shaped in ways that understand the system in parallel with any attempts at reform. In particular, those introducing new practices should be curious about what people for whom the service is being designed believe will work for them. Bringing people using services into the heart of reform efforts by listening and responding to their perspectives can provide an important counterbalance to the views of those invested in the status quo.

2. Find ways to encourage open thinking in rule-bound environments

This is a big challenge in systems that are characterised by compliance with regulations and guidance. While it is important to ensure adherence to good practice, some approaches to evidencing compliance can also undermine capacity to be resourceful, creative and innovative. People need support to develop a creative, innovative mind-set, to learn to think in an open way that takes account of the governance issues but also unlocks resourcefulness.

3. Seek out opportunities and get protected space for ideas to get traction

It is important to create protected space for a new practice to be tried and embedded. This often works better when resources can be dedicated to new ways of doing things, rather than adding new responsibilities to existing jobs. Usually, staff are struggling to achieve multiple objectives and management often have urgent, emerging crises that require a response. The Service Reform Fund (€45 million combining State/philanthropic funding) provided resources to help embed reform in mental health, disability and homelessness services. For example, within mental health services, the fund enabled the HSE to dedicate resources to introduce an evidence-based, mainstream employment programme called Individual Placement and Support (IPS). Dedicated staff were recruited and trained to develop and embed the programme within the mental health system nationally.

4. Start small and build out from a coalition of the willing

It is better to start small and to build from a coalition of the willing. Going straight for large-scale change without a scaling strategy is difficult (unless there is threat of a pandemic or other major consequence for behaviour change). For example, in Ireland a model known as Housing First aimed at long-term homeless populations, was introduced to Cork, Galway and Limerick after an initial pilot in Dublin. The target numbers were low in order to ensure that service integration could be agreed and embedded across regions. Housing First is now being rolled out to larger numbers based on learning and successes from the initial introduction.

5. Optimise peer-to-peer learning

Peer learning can help people develop deeper understanding, greater confidence and autonomy. For example, when supporting people with disabilities to move from institutional congregated settings, it is better for residents to learn from those who have moved already, where this is possible, and for their families to learn from other families. Similarly, it is better for staff to discuss concerns with those who are already working in a different way. In our experience, this is much more compelling than managers or others trying to persuade them of the benefits of change.

Genio’s experience tells us that the main obstacle to systems-level reform is not usually a lack of innovative ideas, but a lack of engagement with the real and complex challenges of bringing about systems change.

6. Prioritise the views of those who use services in the reform process

It is often argued that the most respectful way to introduce change is to get everyone who will be affected into the room to develop a shared vision. In our experience this can be the death knell of reform as it can immediately offer a platform to those who have vested interests in opposing change. There should be a rigorous process used to ensure that the voice of those using services are at the centre of discussions. This requires thought and preparation to ensure that views are gathered and represented is design processes.

7. Choose methods suited to complex challenges: Simplistic, prescriptive tools are not helpful

Simplistic models and tools that offer a sense of being at the cutting edge, but not based on any track record or evidence, are best avoided. In our experience, carefully sequenced strategies using action research methods during implementation are more helpful. Genio uses action research to encourage self-reflective enquiry by those involved in developing, managing and delivering services ‘in order to improve the rationality and justice of their own practices, their understanding of these practices, and the situations in which the practices are carried out’ (Carr and Kemmis 1986: 162).

8. Use innovation/transition funding to get from the old to the new

Relatively small amounts of funding, separate from the operating budget of the public service, can result in successful systems change. Transition funds can:

• incentivise the implementation of innovations;
• enable systems with ongoing responsibilities to transition to more innovative models where less cost-effective approaches are reduced, and resources are gradually transferred to newer models;
• support end-user engagement;
• resource capacity-building activities for key personnel; and
• provide for research and evaluation to capture and disseminate learning and measure outcomes.

2020 has seen dramatic and unprecedented change. The global Covid-19 pandemic affects everyone regardless of age, gender, race or wealth. However, vulnerable and disadvantaged citizens are most at risk and likely to be worst affected during and post-crisis due to significant strains on our economies, resources and services. It has never been more important to identify ways of supporting innovation that refocuses resources in a more cost-effective, evidence-based direction.