How our ecosystems align with ‘old’ versus ‘new’ power

How our ecosystems align with ‘old’ versus ‘new’ power

My Learning goals for attending the conference:

I am curious about what works in creating impact and what gets in the way, particularly at a psychological level.  My hope for the conference was to develop a deeper understanding of how nano, micro, meso, and macro system levels can maximally support integrated care.

Sessions attended:

I attended a range of sessions looking at interventions exploring policy (macro); strategy, research, training (meso); services and communities (micro); and practice (nano).  In line with my role in neurorehabilitation and interest in community capacity building I prioritised sessions that focussed on these areas. These included co-designing care – adopting a user centred approach co-designing care services; engaging people with lived experience to design and deliver better care services; rehabilitation; building the capacity and capability of our community-based workforce; and caring communities as an indispensable element of a caring society.

Main take aways:

The various sessions I attended described a range of amazing developments.  My sense was that these could broadly be divided into two major groupings.

  • Top-down: these tended to arise from what I have described as the macro and meso levels focussing on strategy, policy, capability frameworks, and research.
  • Pavement-up: micro and nano interventions focussing on active engagement and integration at a community level.

The latter particularly resonated with me.  This may be because of my role as a practitioner but it also struck me that these presentations described integration in action not in principle.  I guess the proof of the pudding is in the eating, and this gets done at the tables in our communities not at those in board rooms and universities.  I write this as a somewhat tongue in cheek reflection, but an important principle of integrated care might be that proximity trumps strategy most of the time.  Those closest will be better sighted on, have stronger relationships, and have better understanding of what matters locally and what is likely to help.  This of course in no way undermines the critical roles played by other layers of the ecosystem in supporting and ensuring equity, efficiency, effectiveness, safety etc.  I found the conference an invaluable opportunity to think and talk with a range of colleagues and partners about how we can work most effectively together across the different aspects and layers of the ecosystem.

It was great having access to presentations that ranged across the span of the ecosystem.  However, I had something of a sense of a potential disconnect between what I have described as top-down and bottom-up presentations.  This sometimes created a sense for me of two parallel worlds.  However, in some conversations the gap was presented more in terms of a barrier.  For instance, a typical comment from what I have called ‘pavement-up’ presenters was that they felt that their initiatives were valued in principle but not in terms of investment.  There was a sense that they had to contend with excessively bureaucratic processes to access funds and onerous expectations in terms of evaluation.

In contrast, the former (top down) initiatives seemed to be more generously funded and higher status. For instance, in terms of the IFIC awards granted at the conference dinner.

I recognise that the above is somewhat subjective.  However, in my defence the challenges of integration seem to be as stubborn as those of person-centred care.  I drew huge energy, inspiration, and a renewed sense of urgency from the conference.  There is clearly no deficit in will and determination.  My question though is more whether there is an ironic need for greater integration in integration.

I think that achieving this integration may need a deeper dive than aligning initiatives at the surface level.  The conference reminded me of the idea of ‘old’ and ‘new’ power.  I think that the different layers of the eco-system noted above may align differently with the key characteristics of old and new power.  With the top-down presentations of meso and macro levels leaning more into old power values and structures.  In contrast the pavement-up presentations arising from the micro and nano levels leaning more into new power values.

If this is the case, it would create an understandable source of tension.  If these differences are largely held within different layers, this would then lead to tension at the boundaries between these levels.

As a random aside.  I have been trying to improve my freestyle swimming.  I am following an approach called total emersion swimming.  The idea is that one way to go faster and further is to increase your effort, move your arms and legs faster etc.  As an alternative, total emersion swimming focuses on cutting down resistance – being more streamlined, being longer and leaner, and moving forward with your whole body in alignment.

I wonder if we need total emersion integration.  What would this look like?  What might help all levels outlined above to move together with the minimum of friction.  For me there is something about bringing to the surface beliefs such as those outlined above.  My own sense is that we also need to fully acknowledge the valid human needs that underpin them.  Surfacing, discussing, and working through these beliefs, their impacts, and the needs they drive would help to align everyone with a deeper sense of purpose, recognising links with deeper values but perhaps most importantly also unearthing the fears and anxieties that potentially create friction and make us swim less efficiently.

The conference was a great place to start gently exploring this.  I found it incredibly helpful to meet and to be able to talk openly with people from different agencies, countries, roles, disciplines, but crucially from the different ‘levels’ of involvement outlined above.  It really helped me to start building a picture of what matters to them, not just in terms of services but also as people.  This feels like invaluable data in forming alliances that make the most of the available resources, including those held by our partners and communities both in Wales and beyond.

Daryl Harris
Aneurin Bevan University Health Board
Bevan Fellow