You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Language is a crucial marker of tribal identity. Both ethnic and professional tribes use language to recognise members of their own tribe and to exclude members of other tribes. Two ethnically related tribes may be distinguished by their use of different languages, but in other cases the linguistic differences may be subtle.

Small but significant linguistic markers of identity are known as shibboleths, after the Old Testament story in which the pronunciation of this word was used to identify members of an 'out-group.'

Where two tribes share a genuinely common language, tribal politics may encourage the creation of artificial shibboleths. Serbs and Croatians share what used to be a common language, but Serbs chose to write it using the Cyrillic (Russian) alphabet while Croatians adopted the Latin script. Over time, small differences in usage have evolved.

When two tribes live together harmoniously over a long period, a new ethnic and cultural identity often emerges, accompanied by a new language, formed from elements of the original language of both tribes. This kind of language is called a creole.

The tendency to create shibboleths and the so-called 'creolisation' process are both products of two cultures living and working alongside each other. Where community relations are good, creolisation is the stronger process. Where they are bad, shibboleths form and are used to mark the boundaries between the tribes.

"Hospice culture has evolved, like a creole culture, by taking elements from each profession, fusing the nursing, psychosocial, medical and pastoral models."

In my previous blogs in this series, I have been seeking to show the correlation between the maturity of a collaboration and the maturity of the common language used by its members to do their work. In this final blog, I want to describe how collaborations can intentionally create a creole which is both a marker of shared identity for the partnership, and an externally useful product of its collaboration.

Long-term collaborations will automatically create the conditions both for creolisation and for the formation of shibboleths. Creolisation is a helpful process for collaboration, providing a new language in which a partnership can further its goals using concepts and vocabulary in which all partners have an equal stake. Shibboleths, on the other hand, reinforce unhelpful barriers and slow the realisation of collaborative benefits by reducing trust and mutual comprehension.

A well-known example of such a creole term is the PEPSICOLA model of holistic assessment used in the gold standards framework for end of life care.

Palliative care has a distinct professional culture that reflects its roots in the hospice movement. Hospices are voluntary sector organisations staffed by lay volunteers, nurses, complementary therapists, counsellors, GPs, clergy and specialist doctors. Their culture has evolved, like a creole culture, by taking elements from each of these professions, fusing the nursing, psychosocial, medical and pastoral models. Since, in the face of approaching death, none of these models can have the final say, there is a remarkable equality of discourse; the implicit hierarchy, familiar in other healthcare contexts, in which the medical model trumps the others, is notably absent.

The PEPSICOLA tool is a striking example of this productive creole culture. Each element of the assessment aligns closely to one or other of the professional disciplines involved in end of life care, but the tool itself can be used by any professional with the support of colleagues. The tool empowers its users both with the knowledge they inherit from their own profession and with the frames of reference used by other professional 'tribes.'

The development of a shared problem-solving tool should be an early project for any collaboration that intends to survive in the long term.

Contributing to, using and refining the tool, whether it is for assessment, for performance evaluation, or for modelling, is itself a powerful context for accelerating benign creolisation. Further, the tool itself can become a visible statement of intent for the partnership, enshrining its creole values and blended capabilities in something that can be evaluated, shared and celebrated even as it contributes to the outcomes the collaboration has been designed to achieve.

Since you’re here…...we’ll let you in on a secret about Kaleidoscope’s funding. Spoiler alert: it’s not a secret. We’re a business. We design and support collaborations, run events, and help to develop strategy and policy. Our work is shaped by our clients’ challenges. We’d love to hear about yours: find out more.

Someone somewhere once said you can't teach an old dog new tricks. But who said anything about new tricks?

I recently had the immense pleasure of visiting my family in Australia. I'll admit, it's a familiar route for me, but this time was different; I was on a mission. I had arranged that while I was in Melbourne I would film my Grandpa for a TEDxNHS talk. He is quite something. Old Jewish Grandparents are supposed to bore their friends kvelling over their average to over-achieving grandchildren but the tables have most definitely turned in this case.

Grandpa D qualified as a doctor in 1942. Months later he was drafted into the RAF as a medical officer in World War 2. He served in the RAF for four years, in England and in the Middle East. When he returned to England in 1947 the war was over, the NHS was yet to form and, he tells me, there was a surplus of junior doctors!

Medical students, himself included, had had their training condensed so that they could join their comrades in the war effort. And when he returned, there were more doctors in need of work or 'something to make themselves useful' as he describes it, than there were jobs.

After some time he found ways to 'make himself useful' and in doing so went on to be part of the cohort of medics who established geriatric medicine as a distinct discipline, which was needed to cater for the unique needs of older people. His journey from Hartlepool Monkey Hanger to geriatric pioneer was what I was hoping be able to share at TEDxNHS. The conversations that followed were spectacular, meaningful and once in a lifetime. But it's the 'incidental' findings, as is so often the case, that was where the real magic happened.

Click on image to see all 20 rules.

Grandpa D

One such incidental was a document I found while snooping (with permission) through his study. 'Prinsley's Rules' is a list of 20 observations that Grandpa D had made and written down while he was in America in the 1980s. As I read these, I was astonished. Every single one applied to the health service I know today, including:No. 1 If you put up a bed, somebody will come lie in it.No. 16 It's not easy to transfer systems of care between areas.No. 20 No job is ever perfect.

I asked Grandpa D about these and some of the other truly profound nuggets he had given me: you need to care for the person first, and then the disease; it's important not just to ask about the person in hospital, but also the person who brought them there.

He simply couldn't fathom that anyone was going to be interested in his stories and thoughts. After some convincing, he asked me, "Well if it's still going on, what did I change?"

Shit. I'd unravelled a 97 year old man's life work.

Except that I hadn't. And the more that I thought about it, the more I realised life isn't a piece of string where we learn from the past, never to retrace the same ground and the future looks completely different. It's also not a continuous loop in which we are doomed to repeat all of our mistakes and successes. Maybe it's more like a spiral, or spaghetti. It's messy, unpredictable, and it doesn't repeat. We don't repeat. But it's really important to notice that among the human chaos there are some consistent truths. Some 500 years ago Shakespeare wrote tales of love, tragedy, comedy and that relative we'd rather forget, and we still relate to these. Grandpa D isn't Shakespeare but he has highlighted some of the consistent truths we see when delivering health services.

So, while we so often dwell upon the cyclical upheaval of centralisation / decentralisation, money / no money, managers / no managers that can make us feel quite powerless, it's worthwhile reflecting that underpinning that are some things that don't change. And that, irrespective of whether you are an old dog, a new dog or a middle manager, those tricks are here to stay. Our challenge is to notice them and to interpret them in the most meaningful way for the moment we are in.

TEDxNHS will take place on 21 August. 500 NHS staff will be with us on the day, and NHS organisations and staff across the UK can join via livestream. For more information about how to livestream TEDxNHS 2018, visit the TEDxNHS website.

Alex Prinsley is Business and Transformation Manager at Cental and North West London NHS Foundation Trust.

Since you’re here…...we’ll let you in on a secret about Kaleidoscope’s funding. Spoiler alert: it’s not a secret. We’re a business. We design and support collaborations, run events, and help to develop strategy and policy. Our work is shaped by our clients’ challenges. We’d love to hear about yours: find out more.

My grandfather was one of the first NHS surgeons, becoming a consultant ophthalmologist in North Wales in 1948; my father was a consultant physician in London and Bristol from the early 1970s; and I - well, I suppose you could say I am a consultant of sorts at Kaleidoscope, which is not part of the NHS but functions, we hope, as a benign disruptor in its ecosystem.

Seventy years after its birth, the NHS continues to exert a strong gravitational pull on my family, and on so many other families.

And my family is an early example of another NHS phenomenon that has grown in importance over the generations - and, like the NHS as a whole, is perhaps at a turning point. Since its inception, the NHS has been a generous employer of migrants.

My grandfather was already a qualified eye surgeon when he migrated, with his wife and baby son, from Budapest to Britain in 1936 - in search, so the story goes, of opportunities in the new technology of contact lenses - but surely also in search of a country that was not sleepwalking, like Hungary, into fascism.

But his qualifications were not recognised in the UK, so he began the task of revalidation, armed with a good medical education and a knowledge of English gleaned from reading Dickens. By the time he was ready for work, the war had begun and his hope of a normal medical career had to be deferred.

"The donors were Blitz victims, transported under secrecy to hospital where the blind airmen waited to receive their ration of one cornea each."

His ambiguous professional and national status made him a good fit for a role in one of those extraordinary, secret bits of the wartime state - a sort of ophthalmic Bletchley Park.

During the Blitz, he carried out corneal grafts on airmen who had been blinded by flashes from exploding anti-aircraft shells. Corneas could be successfully transplanted, but they remained viable only for minutes.

The donors were Blitz victims, transported under strict secrecy to hospital where the blind airmen, summoned by phone at the first blast of the air raid siren, waited to receive their ration of one cornea each - not enough to replace what they had lost, but enough to give a blind man his sight.

The procedure broke new ground not only surgically but also ethically. In the 1940s, there was essentially no ethical framework for organ donation. Donors were of course unconsented - there was no process for giving consent and the circumstances were maximally distressing - but the rigid-jawed utilitarianism of wartime culture prevailed. A cloak of secrecy spared the squeamish the necessity of confronting the ethical dilemmas.

As the war ended, my revalidated grandfather was able to resume a more conventional surgical career, and he completed his retraining in North Wales where, after some huffing and puffing, he was offered a full consultant post on an NHS contract. The story goes that a letter addressed to Mr Laszlo, North Wales, would reach him.

For him, the NHS provided a fast track to the kind of contented assimilation that he wanted. As migration seems to be getting harder, let’s hope that the NHS can continue to harness the talents and commitment of a diverse, humane, and global set of people who are drawn to its ideals and able to work around its foibles.

Since you’re here…...we’ll let you in on a secret about Kaleidoscope’s funding. Spoiler alert: it’s not a secret. We’re a business. We design and support collaborations, run events, and help to develop strategy and policy. Our work is shaped by our clients’ challenges. We’d love to hear about yours: find out more.

We recently spent two stimulating days at HSRUK 2018. Our colourful tablecloth, quirky leaflets and coffee maker attracted a lot of great people and we asked them all the same question: "What gets in the way of research, policy and practice working together?"

The good news: people not caring is not the issue.

Nonetheless, there is a range of factors that people in health services research seem to run into on a regular basis: misaligned agendas and languages, a perceived lack of time because everyone's always busy, not knowing how to engage properly, logistical problems such as different locations and timescales, and the absence of clear logic models ahead of implementation.

Many researchers we spoke to said that they did not really know how to bring their research into practice and policy. The latter emerged as particularly opaque: as most health researchers, including myself, have not received a formal 'policymaking 101' during their training, identifying access points to policy and using these in an effective way poses quite a challenge. Where do I start? Who do I approach? How do I reach important decision makers?

Although academics aren't generally known for needing an ego boost, when it comes to engaging with policy and practice, a lack of confidence seems to persist as a barrier – even a lot of incredibly experienced people we spoke to at HSRUK felt like they did not know enough to comment on the topic. Besides the notion of creating a whole new professional group that would be responsible for bridging this gap, possible solutions proposed by attendees centred around making more room for training and development, and incentivising dual careers – a path that currently still comes with a lot of hurdles.

"For research to answer the questions that need to be answered, it is crucial for policymakers to signal what is needed."

A lot of it came down to bringing people together: the need to break silos and bubbles, and reach out beyond healthcare, is evident. In order for research to answer the questions that need to be answered (which might not always be the most thrilling ones), it is crucial for policymakers to signal what is needed. There was a consensus that overcoming the much talked about differences in agendas, languages, timescales and knowledge requires collaboration and conversations. But how? Solutions given by attendees include seemingly straightforward things such as talking to practitioners and policymakers, networking, attending conferences like HSRUK and taking advantage of Twitter.

The need for a formal platform for researchers to engage with policymakers was mentioned repeatedly – some even went as far as pitching a dating app. We could draw on lessons from public engagement and, in line with increasing calls for a greater weighting of qualitative evidence in evaluation and impact, it was also suggested to use patient stories as a means to align disparate agendas and bridge gaps between research.

While we still have a long way to go, there is certainly no lack of willingness to engage. Researchers, clinicians and policymakers can only benefit from talking to each other, and it's in everyone's interest to work towards facilitating these conversations.

In the words of Professor Nick Black: "Problems cannot be solved by organisations on their own. We need to make space for the right conversations to occur".

Thanks to everyone who made HSRUK 2018 unforgettable, and see you next year!

...we’ll let you in on a secret about Kaleidoscope’s funding. Spoiler alert: it’s not a secret. We’re a business. We design and support collaborations, run events, and help to develop strategy and policy. Our work is shaped by our clients’ challenges. We’d love to hear about yours: find out more.

At the Health Services Research UK 2018 Conference, plagued with mid-conference excitement, I cannot help but ponder the curious way we talk about and go about disseminating research: as dedicated but inexpert gardeners, and as children holding dandelion blossoms, respectively.

Dandelions can do more than sully your pristine lawn; they can be used in both savoury and sweet recipes and are loaded with health benefits. But if you want to cultivate them for such purposes, you wouldn’t grab the stem, blow the seeds and wait for your salad and tea in the kitchen. Wishful thinking.

You’d control seed dissemination: you’d plant and water them with time and care. You’d tend to them daily; harvest the greens, the flowers and the roots when ready; and delight in cooking them for yourself and others.

This is how researchers cultivate their research: with time and care and ultimately to be used by themselves and others. The trouble with this model is that very few of these others are willing (or able) to search through the weeds or prepare palatable versions of relevant research findings.

Too often, research is disseminated like dandelion seeds - blown with the winds of chance to propagate serendipitously. Though health and care researchers bear the responsibility of tending their garden of research, it should ultimately be harvested and consumed not only by them, but also by clinicians, hospital managers, policy makers and patient groups, among many others.

The responsibility of circulating research findings is generally assumed to be that of the researcher. Although we may have our small plot of vegetables at home, on the whole we don’t expect farmers to grow our food, do our grocery shopping and prepare our meals for us. We, as consumers, feed ourselves.

Too often, policy makers and practitioners expect to be spoon-fed research findings - prepared in an easy-to-digest language with clarified results ready to be used in policy or practice.

Consumers of evidence-based research likewise bear the responsibility of extracting the nutritious evidence from scientific sources and using it to nourish the health and care system. Too often, policy makers and practitioners expect to be spoon-fed research findings - prepared in an easy-to-digest language with clarified results ready to be used in policy or practice.

The expectation of researchers to disseminate their own results is deep rooted. Even the word disseminate insinuates a one-way flow of research evidence: pushed out by the researcher rather than absorbed by the consumer. There is no shortage of resources available to researchers on exactly how to make research palatable to the masses, how to 'sell' one’s research pre- and post-publication.

But very few instructions are given to policymakers or healthcare managers on understanding scientific publications and statistics or how to take part in developing a research plan or interpreting the results. Terms like knowledge co-production or knowledge mobilisation better describe the dual responsibility of producing and using evidence-based research, but the change in semantics does not (yet) represent a change in culture. The change in vocabulary, ironically, is seen primarily in the scientific literature.

As researchers, we of course should strive to produce sound scientific evidence relevant to public and patient needs. We cannot close our eyes, make a wish and hope that our findings reach those we intend to help. I emphasise that word because in a workshop here at the HSRUK 2018, someone asked the question, “Who is it that we want to influence with our research?”

Surely, the question should rather be: who is it that we want to help with our research and how do we go about doing that? Research should not be sold or used to persuade, but rather presented and used to ameliorate.

However, neither should our carefully cultivated results be ignored as weeds or consumed only in painstakingly prepared bits for picky palates. Perhaps dandelion greens and dandelion tea would be more commonplace if the flowers were grown and cared for in community gardens and their health benefits discussed among these gardeners.

It’s no secret that the health and care sector would benefit from this kind of community involvement. This requires that researchers leave their 'academic bubbles' (as mentioned by Dr Louise Wood at the conference), but of equal importance is that the rest of the sector assume responsibility in absorbing and understanding scientific research.

...we’ll let you in on a secret about Kaleidoscope’s funding. Spoiler alert: it’s not a secret. We’re a business. We design and support collaborations, run events, and help to develop strategy and policy. Our work is shaped by our clients’ challenges. We’d love to hear about yours: find out more.

What drives successful (and sustainable) system change? This won't stop being a relevant and compelling question. We should perhaps acknowledge though that, at least in terms of healthcare, we have a prevailing orthodoxy - that top down, mandated and performance managed changed is the default method.

The healthcare system has been trained to receive and act upon the annual operating plan. That plan describes the what, the how, the 'by when', and the 'how much'.

There is some evidence that this is at least partially successful if we consider the changes arising from the 2000 NHS Plan, the national service frameworks, developments in PBR, and referral to treatment programmes that followed it.

However, the limits are obvious:

that method can only drive the change it can describe – what isn't included may not get done

it takes an immense network of assurers and regulators, almost feudal perhaps, to check and chase that the action is being taken

it can influence only the NHS – changing public behaviour, securing the contributions of other public service partners, academia, industry and the VCSE is beyond the scope of that instruction

most significantly perhaps, it may limit the system's sense of permission to drive its own improvements and act beyond the operating plan.

In weighing the question of top down or bottom up, we have had the benefit of participating in a significant comparative analysis of two successful system changes focused on the reconfiguration of stroke services in Greater Manchester and London ( see 'Explaining outcomes in major system change' and 'Lessons for major system change: centralisation of stroke services in two metropolitan areas of England' on the Learning from Stroke website).

Both systems sought to respond to key elements of the National Stroke Strategy by establishing a hyper acute stroke care model to increase the reliability of urgent, evidence-based treatment for people suffering a stroke.

In London, it was a declared priority of the strategic health authority and that body drove the participation of providers and the faithful implementation of the model. The model worked, it saved lives and has held. While on the face of it that may look like a top down method, the sustainability of the model suggests some real bottom up engagement that has held together beyond the life of the SHA.

"On the face of it, this looked like a negative effect of the absence of more top down control, but in reality something interesting and different had happened."

In Greater Manchester, the change was driven entirely from within the providers and commissioners in the system - a bottom up model, if you like. The first phase of implementation, on a pathway that ensured that only a proportion of victims of stroke were received in a hyper acute stroke unit (HASU), did not produce the impact Greater Manchester was looking for. It was clear that the pathway needed to be changed to ensure that all patients experiencing stroke were taken to a HASU.

This might have looked like a negative effect of the absence of more top down control, but in reality something interesting and different had happened. The stroke community in Greater Manchester, as an operational delivery network by then, had taken responsibility for the pathway and its development, had proposed the amendments and won the support of commissioners.

The bottom up model had effected a change, taken responsibility for the outcomes, learned and corrected. The result is that Greater Manchester now has the highest performing acute stroke services in the country, all 'A' rated on the national audit system.

More profoundly, Greater Manchester as a whole has recognised the stroke chapter as part of its own story. It confirmed our belief that we could take collective responsibility, commission together, organise delivery across hospital boundaries and, if needed, enhance and iterate the model too.

The inclusion of the stroke work as part of our transformation narrative did inform the eventual work on health and care devolution. It informed the development of our model for major trauma and for the reorganisation of acute care as part of Healthier Together. So the Greater Manchester health and care system has permanently set itself to take responsibility for its key challenges, coordinate itself across both civic and clinical leadership and drive improvements to health and care.

Greater Manchester's healthcare transformation since those days in 2010/11 has accelerated and deepened. The leadership from commissioners, clinicians, councillors, council leaders and council officers has kept looking forward. I have no sense that this progressive mentality has any appetite to lower its focus or wait for leadership to arrive from elsewhere.

Warren Heppolette is Executive Lead, Strategy and System Development, for Greater Manchester Health and Social Care Partnership.

I watch and read a lot of dystopian fiction and one of the grimmest things about the world to come is the extremes of 'identity': think red cloaks in The Handmaid's Tale, unseeing Ul Qoma in The City and the City, or a replicant in the persistent rain of 2019 Los Angeles. People do like to categorise.

I include myself in the catch-all; anyone who's ever seen me present on analytical matters will often hear me kick off by apologising for being a career analyst (it can be an awkward admission to make, especially in taxis) as a way of laying out my stall.

In the rhetorical sense, such 'identity-splaining' can be a useful device for drawing in an audience and playing on their preconceived assumptions (oooh, everyone look at the nerdy lady) but in the day to day reality of making health and care better it's a problem.

I've had the privilege twice now to spend time with the Sir Peter Carr award winners and nominees who are forming the beginnings of a network of passionate people with projects in hand to make care, and life generally, better in their organisations.

Ranging from a project for sparing 15 seconds to save 30 minutes (check out @15s30m on Twitter) to encouraging and supporting the grassroots use of data, the teams' ideas bring together the often tribal communities of clinicians and managers. At a workshop back in December, as we discussed challenges to the developing network, the issue that really stuck in my mind was hearing one of the award winners say, "I was told, you're a clinician, you shouldn't be doing this, it's a waste of your time."

"One of the many advantages of learning as part of a network is the opportunity to challenge yourself with views from outside of your tribal stomping ground in a safe space."

Quite apart from the lack of support and kindness that shows, it perpetuates the us and them mentality that prevents so many from venturing into new arenas of discovery and perhaps improvement.

One of the many advantages of learning as part of a network is the opportunity to challenge yourself with views from outside of your tribal stomping ground in a safe space; to truly get at the alternative view that could shed that crucial bit of light on the problem at hand. At Kaleidoscope we have enshrined that in one of the principles that underpin all our networks – 'beyond boundaries'. That doesn't necessarily mean being uncomfortable, but it does mean challenging yourself and others to look for the learning in what you might think are unlikely places.

I recently spent an afternoon with Ali and Anna, one of the Sir Peter Carr award teams, ostensibly supporting them with some of the technical stuff around using data for improvement. I nodded sagely and tried to impart a spot of wisdom, but in reality I learned as much in their company (if not more!) than they did in mine. I was able to challenge some of my assumptions about how data is actually used in Ali and Anna's context. And as someone who is interested in the interface between data and change, that is gold dust – and while Ali's office wasn't the least unlikely place to find it, it wasn't something I necessarily expected (thanks to them both!).

The nascent Sir Peter Carr award winners and nominees network promises so much more; by challenging themselves to break through so much of the 'identity' barriers, the network is a glimmer of a promise of a future far away from the dystopian bleakness predicted by my bookshelf.

Since you’re here…...we’ll let you in on a secret about Kaleidoscope’s funding. Spoiler alert: it’s not a secret. We’re a business. We design and support collaborations, run events, and help to develop strategy and policy. Our work is shaped by our clients’ challenges. We’d love to hear about yours: find out more.

There is a long running joke in my family that I don't like change. It's true, I don't (the irony of having to make four major geographical locations over 8 years working in the NHS hasn't been lost on me). Change is hard, especially when it isn't on your own terms.

In part of my role, I work with the HS. Accelerator and the Department for International Trade to help health technology startups grow abroad. This involves overcoming myriad barriers and obstacles that prevent change being effective, if happening at all. It's not for no reason that adoption of innovations at scale takes around 17 years.

Within each of these, effective leadership plays a key role. But we know that - it was the focus of the Griffiths Report 35 years ago. Since then, the theme of leadership has arisen again and again, most notably in the Francis Report on the failings at Mid Staffordshire hospitals and in Lord Rose's report 'Better leadership for tomorrow'.

A number of organisations exist to try and develop better leaders, such as the NHS Leadership Academy and Faculty of Medical Leadership and Management. In addition, there are many offerings in the form of fellowships, courses, degrees, conferences and programmes. However, these activities can be costly to both participants and their organisations and be difficult to fit into work schedules that are already full to bursting.

At Kaleidoscope we're interested in whether there might be another way to support leaders making change across the NHS. We are partnering with AbbVie to create an event series that will bring together emerging leaders from across the NHS and beyond to inspire and empower them to make change happen and debate how change can become the rule, not the exception.

On 27 June we’ll be piloting a new lunchtime event format – Disagree to Agree – and discussing whether the future of the NHS resides in doing what we already do but better, or coming up with new ideas. This takes place at the Handel and Hendrix Museum.

On 16 July a webinar will explore how 'positive deviance', an approach that is increasingly being used to support change, can support change in your context. The webinar will include UK and international experts - register for the webinar.

On 20 July a half-day learning event will focus on the nuts and bolts of starting change. Joined by a host of speakers from inside and outside health – including Paul Gaudin, founder of the New York Bagel Company and CareRooms – we’ll be exploring the small sparks, the ‘micro-actions’ if you will, where all significant improvement begins. This takes place at the Crypt on the Green.

We will look at case studies of positive change from across the NHS, internationally and from other sectors to understand how change was made, focusing on practical actions that will help participants both now and as they move into more senior leadership roles.

Do join us, and let's see if we can make change for the better, happen better.

...we’ll let you in on a secret about Kaleidoscope’s funding. Spoiler alert: it’s not a secret. We’re a business. We design and support collaborations, run events, and help to develop strategy and policy. Our work is shaped by our clients’ challenges. We’d love to hear about yours: find out more.

We at the Stroke Association are boldly pro-reconfiguration. As an organisation representing over a million stroke survivors and advocating for the best possible treatment and care, how could we be anything else?

We see it as our duty to ensure as many patients as possible get access to world-class treatments and round-the-clock care – both of which are more likely in reconfigured acute stroke services.

Evidence of the benefits of stroke service reconfiguration is overwhelming. Where it has already happened, for example in London and Greater Manchester, reconfiguration is saving hundreds of lives a year, and patients are reporting positive experiences of care in hyper-acute stroke units (HASUs).

But reconfiguring stroke services, as with making changes to any hospital services, is hard work. While the opportunities are great, the obstacles are also significant. That’s why a wide range of people from all parts of health and care came together recently to discuss the challenges, barriers, frustrations, as well as opportunities, we’re all facing in trying to make it happen.

After all, it’s a complicated message we need to communicate. Telling somebody they may need to travel further in an ambulance to receive better care in a HASU could sound contradictory, unless the enormous advantages are also explained. The public can be understandably concerned about their local services shutting down, services that are familiar, nearby, and may have served them for many years – the same services that may even have saved their lives.

Add to that a highly politicised debate around the future of the NHS, distrust in politics and the ever-present fears around increased levels of private sector involvement in health, and that message only gets harder to communicate. But it’s our job to tackle this head on: to bust the myths, to communicate the virtues of reconfiguration powerfully and accessibly, to push for reconfiguration wherever it is possible.

"Without proper, meaningful engagement with local people, major systems change will always be challenging, if not impossible."

It may seem obvious, but we believe that, without proper, meaningful engagement with local people, particularly those the proposals are most likely to affect, major systems change will always be challenging, if not impossible. But all of us – whether stroke professionals, health systems leaders, politicians, stroke survivors or the third sector – must play our part to break down the barriers to reconfiguration. Together, we must engage, listen, inform and persuade.

That’s why the Stroke Association is becoming increasingly involved in reconfigurations up and down the country. We’re working to ensure stroke survivors and their families and carers make the most of opportunities to respond to local consultations and help shape the reconfiguration process. We come together with trusts, boards, CCGs, STPs and others to improve the accessibility of consultations, and we help health systems leaders to communicate the evidence and benefits.

We run engagement events, consult our Stroke Association clubs and groups, and respond to local consultations, putting our own position clearly on the record. In partnership with Angus Ramsay and the team at University College London, we’re going to help mobilise their research, making it accessible and understandable to the public. We also work with local politicians where necessary, to share evidence and provide a strong, independent and expert voice amid an often fraught debate.

But conversations don’t just need to happen locally. We’re influencing at a national level too, explaining clearly to Ministers and senior decision makers that we urgently need more areas to reconfigure their stroke services if we’re going to ensure patients have access to the best possible treatment and care. Of course, evidence shows that reconfiguration saves the NHS money in the long-term too. At a time of unprecedented challenges for the health service, this shouldn’t be forgotten, and we shouldn’t underestimate this as a key message for those at the very top of the system.

The new national stroke plan for England – which we’re developing with NHS England – will embed action on reconfiguration across the whole system, and we’re working across all four UK nations to tackle the current postcode lottery of care facing stroke survivors.

Put simply, reconfiguration works. The evidence is clear; it just needs to be heard. Delay reconfiguration, and we risk stroke patients dying or living with severe disability unnecessarily. We cannot let that happen. Working together, we must make clear that reconfiguration is the key to world-class stroke treatment and care.

Mark MacDonald is Head of Policy and Public Affairs at the Stroke Association.

Stroke is not the same as cancer. Maternity services are not the same as psychological therapies. But is there learning to be gained from thinking about how system change happening in one clinical area could be transferred to others?

That was the premise behind our event series, in partnership with UCL, and funded by the National Institute for Health Research, which explored how the learning from stroke reconfiguration in London and Greater Manchester could support successful system change across the NHS.

It's not top-down versus bottom-upThe day began with a discussion about the sort of leadership needed to achieve successful system change, with the shared sentiment in the room being that a dichotomy between 'top-down' and 'bottom-up would not get us very far. Leadership needs to happen at all levels, from patients and clinicians to the government, with the key point being the alignment between them.

We also learned there's a real case for diversity in leadership types throughout the change process. Warren Heppolette from the Greater Manchester Health and Social Care Partnership pointed out that the leaders needed to start an organisation or movement may not necessarily be the right people to maintain it. And, as is so often in 2018, the notion of social movements emerged as a powerful tool. Support from patients and communities for system change will not be sufficient if it sounds and feels like an irrelevant (and boring) plan.

How to approach patient and public engagementThere was a clear feeling in the room that we often involve patients and the public in change because we 'have' to - a form of VAT that we have no choice but to add on top. Do this at your peril, was the message from Chris Naylor, chief executive of Barking and Dagenham Council.

"If you don't involve the public in your plans, just presume they will fail," said Chris. Involving patients and the public isn't something additional to a change process, it should be deeply ingrained in it.

We also spoke about instances where patient and public involvement might NOT be the right thing to do, and about the need for a more honest approach to what can and can't be gained from involving patients and the public. Thinking of the 'value' of engagement in change, rather than its 'impact', is the way forward here, says Professor Chris McKevitt.

Patients and communities won't support system change if it sounds and feels like an irrelevant and boring plan.

Judith Williamson, lay member for the Patient, Carer and Public Involvement Clinical Studies Group, emphasised that regarding lay members as 'just patients' reduces them to a very small part of what they are. No one had ever asked her what she did in her life outside the hospital, even though she felt that her experience - rather wonderfully - as a management consultant specialising in transformational change was more valuable in this setting than her patient experience.

Focus on the communityAs mentioned above, we established that there is a clear need to engage on many levels. We learned that in the stroke experience, while clinicians and academics tended to focus on getting acute care right, the people affected cared more about local and community services. We talked about the risk that, when designing and implementing system change, we are not paying enough attention to longer-term aspects such as quality of life and rehabilitation in the community. Reflecting on stroke reconfiguration, both Tony Rudd from London and Sarah Rickard from Greater Manchester saw not acting faster on community care as a significant regret.

Measurement needs purposeWe can all agree that a lot of thought needs to go into measuring large scale change, but there was a feeling that measurement is sometimes seen (a bit like public engagement) as an add-on rather than integral to change itself. We talked about the importance of selecting the right measures - useful, meaningful, and actually reflecting the change - but also about the limits of what data can tell us.

"Evidence tells one part of the story, but compelling narratives and communication are crucial to bring people on board and make change happen," said Jemma Gilbert, Director of Transformation at the Healthy London Partnership.

We also learned about the value of capturing 'organisational memory' to illustrate current experiences and form a baseline for change. There was a feeling that when designing measurement, we do sometimes forget that our ultimate aim is “to change lives rather than services”, as Warren Heppolette phrased it.

Still optimistic after a day of talking about system changeWhile we agreed that change is hard work, our amazing speakers and all the great conversations instilled a lot of positivity and zest for action. In a quick voting session at the end, 97% of attendees saw value for other areas in looking at stroke reconfiguration, and 90% believed that the NHS is capable of successful system change. The challenge now is for that optimism to be reflected back in the daily practice of those leading change across the NHS.

Since you’re here…...we’ll let you in on a secret about Kaleidoscope’s funding. Spoiler alert: it’s not a secret. We’re a business. We design and support collaborations, run events, and help to develop strategy and policy. Our work is shaped by our clients’ challenges. We’d love to hear about yours: find out more.