Prior to working on networks in health, I also did quite a lot of research in the 2000s around network organising in other contexts, the commercial sector, looking at partnerships and supply chains and the whole range of organising forms within those environments.

I was asked to do some framing. I don’t want it to be overly theoretical but to offer my interpretation of some of these things.

Please note that I’m talking about network organising – I’m not talking about networks. I’m not talking about networks as if they are objects but as a dynamic and a very highly relational concept which is a form of organising rather than an object that can be easily described. There is a lot of literature that describes the distinct character of networks, what makes them distinct from other forms of organising. We seem to keep wanting to move away from that fact but there is at least 30-40 years worth of literature that tells us what networks are, what they are effective at doing and what they’re not effective at doing, and ideas about how to measure their value and so on. But often, in healthcare, we begin the conversation back at the beginning, so first of all I just want to remind us there is a lot of evidence we should draw upon.

So, let’s think about theories of change. We have to think about what networks are for, as a form of organising, what function do they serve? What are they good for and what are other types of organising good for?

There are definitely certain things that we want to do in a very highly managed and controlled way. I don’t want everything to be framed in an emergent sense, some things I want done very reliably. There are some things I want to gradually improve and there are some things I want done completely differently.

I would say that networks are very good where you are interested in the latter, in transformational change, working with some of the systemic and relational aspects; essentially thinking of a different way of framing an issue and approaching it.

The other two approaches are equally valid and have purpose and meaning; but they do different things and tend to be framed by a different approach to change. For those familiar with the distinction between first and second order change. 1st order change tends to be about improving the reliability of something, doing things well, making sure of consistent standards or doing things better; so your looking for gradual incremental improvements. We’ve got lots of experience of doing both those things in a healthcare context. There’s a lot of work around reliable design and improvement methodologies, all of which have their place but they’re not the same thing as 2nd order, systemic or relational change, that I think networks are good for.

A network is a group of individuals, organisations or agencies organised on a non-hierarchical basis around common issues or concerns, which are pursued proactively and systematically based on commitment and trust. We are talking about groupings of individuals or organisations that are based on a non-hierarchical approach, they address common issues, purposes or concerns and are pursued proactively, so there’s an energy behind them and they work systemically, bringing difference together. A relationship of trust is fundamental. If you want to identify whether it is a network you should ask yourself: is it something organised on a non-hierarchical basis? Are there common issues of concern? Is the nature of the relationship based on the commitment people make and a sense of trust? My definition of trust is based on whether or not people are able to express their expectations of one another and whether or not they are met. ‘Expectation’ is a key element when thinking about how networks operate.

I’ve already said there is a wealth of research and knowledge about how networks operate. Some of the early work was done by Lave and Wenger 1991, where they looked particularly at the role of apprenticeship, how that worked. They uncovered the apparent master-novice relationship was not quite the way that it seemed when they looked in detail. One of the things that was particularly important was that the process of learning took place not just between the master and novice but also in a whole range of relationships within that work place. Though it appeared that the novice-master relationship was central, there were many other dynamics going on, which determined whether or not an apprentice became a successful master.

So let’s turn to some core principles.

Networks, as a form of organising, are particularly good when you’re trying to deal with an intractable issue. If you’re trying to solve a really difficult, ‘wicked’, problem it’s probably not going to be helped by trying to gradually improve things. You need to reframe the way you think about things, and one way to reframe is to get different people involved in the conversation, and if you achieve that then you’ll have access to different types of knowledge, expertise and perspectives. How tacit knowledge works and the importance of peer to peer relationships within a network is very important. It’s also a way of focusing on how power is being used and distributed in a network.

It’s important to recognise that networks are not a panacea. This is not without issues. When working with networks the chances are you’ll be faced with all kinds of paradoxes and disincentives, conflicts, diversity, and that is part of what being part of a network is about, and in terms of leading networks it’s something that leaders need to embrace and recognise they’ll be dealing with on a day to day basis and it is part of the work.

Networks are very important in terms of the interest and shared purposes of their members. I’ve yet to work in an organisation where everyone shares exactly the same purpose. We’re all motivated by our own purposes, both individually and collectively, and they can coexist but what that requires is a constant negotiation about how we understand our purpose. So it’s not about coming up with a common purpose and then sharing it with everyone, it’s about building a sense of meaning for the group, and how that changes in the context you are working in is really an important part of how you make sense of things. It’s a constant re-negotiation, it will be meeting your own purposes at times and not at other times and that is perfectly normal.

In terms of the kind of value that’s created we are looking at social capital, the investment you make that will generate in terms of value within a community. It may not be of immediate value, there may not be quick wins, you may have to give up things that are quite important to you, so there is a cost associated with doing it. It doesn’t come for free.
Networks should be designed with a light policy touch because they need to be able to evolve quickly, they are dynamic, emergent, they are things that will and definitely should change, so they should be designed with a very light touch to start with, and then how the rules evolve should be part of the conversation.

There are four things that are really important to give attention to.

1 Power – the need to keep a firm focus on how power is working in social relationships, how leadership is used, how authority is generated, and accountability handled. These have to be day to day conversations you are ready to have. It is not a one-off single design that means the power structure is organised. Hierarchies are pretty good for that sort of thing if that serves your purpose.

2 Purpose – consensus should not be a precondition for action. You don’t need to all agree all the time but you need enough to do the next thing and then the next thing. Don’t wait until everyone agrees with you because if you do that you will never do anything.

3 Knowledge I’ve already covered as a dynamic, shared and emergent element within networks.

4 Communication –within networks unlike in other organising forms, where communication can be understood as a transaction, encoded and transmitted. Within networks communication is a fundamental core organising process, it means you have to pay much more attention to it on an interactive basis, not as a transaction, but as something emergent.

Traps –
• Ignore power differentials
• Specify aims and objectives for other people
• Privilege plans over actions
• Know in advance everything that can be said and done
• Settle for ‘soggy’ consensus – go along with it but know people will do different things.

Tips –

Connect with what exists. Networks already exist out there. We are all part of multiple networks so they’re already out there.

Set simple rules. Recognising you need to design so you can evolve.

Keep animated – focus on action and energy. Recognising networks have times when they’re active, with a lot going on, and other times when they dissipate and over time things don’t happen. That’s normal, there isn’t a nice clear trajectory you’re aiming for. The ebb and flow of energy is perfectly normal in a network. The issue is knowing why you are at a certain point, which is often to do with context.

Learn from difference and conflict. It’s a normal part of bringing different communities and types of knowledge together that some of the energy you want will come from differences of view, that’s not something, in a network, that should be seen as necessarily a bad thing.

Questions.
Q: Firstly, what do you mean about NHS being good at planning because I think it’s absolutely shocking? Secondly, what is a ‘network’, what is a ‘networker’, and what is ‘networking’ and its importance in terms of creating networks? These are important things to think about. What brings people together, what skills, motivations? When we talk about networkers we’re talking about connectors (Gladwell’s tipping point) and their impact on a network. When we look at why some work there are other features of networkers and networking as well as purpose, passion.

A: what I meant was the NHS is very good at the thing it calls ‘planning’. It helps to think about those three things. ‘Network’ makes it sound like an object, ‘networker’ I like because it focuses on the skills and abilities. How could you define a networker, and what would that person do? There is plenty of good evidence in the literature. Network leadership is predominantly about brokerage, spanning boundaries, working with knowledge, it’s about those four areas, power, purpose, knowledge and risk. There’s not a single network leader it’s about distribution. It’s about brokering and understanding those four areas.

Q: there is a large literature, is there a large evidence base? I struggle when I look at the literature to get out of it effective guidance on how to make a network. There’s a whole series of problems, some of them are to do with definitions, we expect different types of networks to have the same characteristics and effectiveness. Some is around systematic reviews that say the literature isn’t strong enough. This is a big struggle, when it comes to taking something from the literature that really drives what we do, we find it very difficult.

A: what burden of evidence is required before you do something? Take a stab at it based on what other people have done. Some of it is emerging, so you have to live with the fact that there will not be a conclusive body of evidence. That tips the balance in terms of what might traditionally be done in healthcare where you might only do certain things if you’ve got enough evidence. But I question that as well. The way that evidence works is we demand evidence when we don’t really want to do something and do stuff without evidence when we do. We need to establish a different kind of argument.

Q: I’ve heard ‘relational’ used a couple of times. I’ve heard it in lots of contexts, but could you say more about what you precisely mean by that, because I use it in a very lazy way.

A: y definition would be that social realities are created in relationship with one another. The things we consider to be real and valuable, anything we give meaning to, occurs from within a social relationship. A fundamental principle of a relational approach would be that meaning and value occurs in a social relationship.

Q: then what’s the opposite of relational?

A: A very objective view. The world is a fixed place and we as human being exist separate from it and the natural world exists as an objective reality and we, as human beings, interact with it in a transactional way. Whereas I would say the relational approach places the emphasis on seeing the world (social realities) as created in relationship, so that means we give attention to the way the relationships work. I don’t mean that in terms of whether we have fun together or love each other but what is the nature of the social dynamic and how does it work? That involves everything from joy, to cruelty, to how social groups operate.

Q: I share how hard it is. It can be easy to get boxed into something you just do but leading networks is really hard. We’ve set up an Institute for Quality in Healthcare in Leeds. It’s a network built on a professional model, it’s about highly autonomous professional peers working together and co-leading across the city, across commissioning and provision, and the council and third sector and of course all the difficult stuff comes to the front really quickly. All the stuff that’s been sat on under the hierarchy for ages comes to the front; so you’ve got to have a level of skill (which is not endemic in NHS management) to handle stuff that you’ve run away from on a regular basis.
For instance, one of the doctors emailed me wanting to do a small thing but it had huge knock-on effects because it challenged some of the principles in the Institute. It was about one person coming to something for half the time they were supposed to come. But the conversation has and will continue to take a very long time because the knock-on consequences are extensive; it would be the soggy compromise. It would mean, for those who shout loudest and are difficult, we will organise around them. So it’s very symbolic but you’ve got to be really brave to take that on because, pay grade wise, they are way above my pay grade. In a partnership model that has to be handled in a different way to in an institution. So some of the stuff Murray talked about, how to get to simple rules and stick with or change them, is really difficult in networks. Network leaders need help in letting other people be brave. We know it’s hard to get it right, to craft it, to nurture it, it’s like having a teenage family. And that’s so different to running a bit of the NHS, if you live in both worlds it’s difficult. People need help to do some of this very difficult stuff and not pretend it’s easy. The number of leaders in the NHS who do not know how to give each other feedback is significant.