Since the foundation of the NHS over 70 years ago and driven in large part by the advancement of science we have seen massive gains in overall levels of population health. The NHS continues to deliver improvements that lead to better health outcomes for many of those coming into contact with its services. It does this, of course, within broader health systems that include those working within the wider public, private and third sectors and that reflect the influence of a wider set of determinants. 

Yet we face unprecedented and catenated challenges. Incremental approaches to change, while necessary, are not sufficient. They exist within the current, limiting paradigm. Born as it was in a bygone era to address fundamentally different challenges following the second world war, this factory model of health treatment is poorly adjusted to deal with today’s complex health challenges, let alone the long-term trends and challenges looming over the horizon. 

We desperately need transformational change that creates the space for a new paradigm to emerge. As with so much change, this is unlikely to be through a ‘big bang’ catalyst or political mandate and much more likely to emerge from the committed and brave efforts of those working hard to challenge the status quo and design aspects of the new. This is a tough gig. 

The rise of the public entrepreneur 

But we can take heart. As American civil rights activist Marian Wright Edelman advocated “we must not, in trying to think about how we can make a big difference, ignore the small daily differences we can make, which, over time, add up to big differences that we often cannot foresee”. There are people within the health sector that are doing just this. Designing and testing processes and practices that are demonstrating a new kind of entrepreneurship – responding fast, taking judicious risks and experimenting to anticipate challenges. At the RSA we call them public entrepreneurs⁠^⁠1, people navigating the complexity of the public policy and financial arena and challenging convention. You might think of them as innovators and mavericks or, perhaps, disruptors and trouble-makers. 

We’ve seen incredible responses to the pandemic and while it’s hit society hard, particularly in marginalised communities and groups, it’s also accelerated changes that might have otherwise taken decades to advance. The systems and processes by which services are provided and received can be improved, collaboration fostered, new thinking incubated, the status quo challenged, partner agencies engaged and innovation liberated. 

When we have no choice, such as in a disaster, as Rebecca Solnit^⁠2⁠ points out, “people come together… many cherish it as an experience of civil society that is close enough to paradise… in the suspension of the usual order and the failure of most systems, we are free to live and act in another way”.

How can we liberate the collective potential of creative people more systematically, without waiting for disaster or acute service failure? Can we be pre-emptive, in other words, by working across systems to support efforts at transformational change without waiting for a burning platform or disaster to incite change? 

Together with NHS Lothian the RSA designed and ran a programme in a pre-emptive attempt to support some of its enterprising staff to do just that. 

Legitimising staff capacity for innovation

We piloted a Public Entrepreneur Programme with twelve members of staff who applied to be part of the cohort, each with an idea for change. Their challenges were a combination of strategic and service issues, new ideas, old problems and emerging opportunities. Working through the RSA’s innovation processes we have helped accelerate these ideas while at the same time fostering a collegiate sense of solidarity. We used different tools and techniques to understand the challenges, creating time and space to think and experiment, involving service users and citizens in these conversations and collectively offering encouragement and support for staff to do this work.  

Equipping people who work within local health systems with the skills, mindset and capacity to think and act differently will enable them to radically change services now and prepare them to respond to whatever challenges may arise in the future.  Yet it is not enough to equip staff with the skills and techniques to navigate change, bring ideas to life and create the transformations required of the vision. Such attempts at innovation often founder on contact with embedded systems and processes. It is vital that we invest in processes that wire innovation into the organisational infrastructure. 

Across time and space

Time is a precious commodity and devoting some of it to uninterrupted thinking is critical. It is well documented that the environment is a crucial determinant of our productivity and creativity, and a core way to maximise the impact of innovation work is to provide a protected time and space for NHS Lothian staff to do this work. 

Staff commitment and energy is fundamental to spotting the challenges and the opportunities for change, taking action to not only meet the needs of today, but those of tomorrow. But this is neither a solo endeavour nor is it one that can easily be layered on top of exhaustive workloads. To seed the cultural change that can help make flexibility and transformation a part of the organisational DNA, staff must navigate a range of tensions: between the old and the new, the immediate and the long-term, the Political and the political, the organisation and the system, prevention and cure…  

Navigating such an array of tensions to bring a new idea to life while continuing to perform in your substantive role is a heavy burden that practitioners carry.  One of the crucial insights – and perhaps the most valued gift the cohort gave each other – was that of the time and space to think and offer support. 

A rough guide

The projects that the individual cohort members were working on were vital as beacons of innovative activity; the legitimacy the organisation conferred on the cohort was equally as important. Indeed, we focused just as much on the collective impact of the group and their role at the vanguard of new ways of doing things. These strands – that of the individual projects, collective impact, and organisational influence – ran throughout the programme. 

So many insights arose thorough this work that we decided to share them as a map of the terrain we covered. We’ve called it a rough guide to being a public entrepreneur – or maverick, or intrapreneur, or anyone seeking change and challenging conventional wisdom. It is an open summary of the journey we’ve been on, the tools we used to understand and navigate the terrain, the insights and aha! moments that arose along the way, as well as the challenges to overcome. It allows us to showcase the work of the group, and hopefully inspire others to take this road less travelled. 

The Guide is available to download on the RSA website (pdf) and on this site here.

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¹ https://www.thersa.org/blog/2018/07/move-fast-and-fix-things

² Solnit, R (2010) “A Paradise Built in Hell” Penguin