The Defence Medical Services (DMS) comprises personnel from the Royal Navy Medical Service, Army Medical Service, the Royal Air Force Medical Service and the Headquarters Defence Medical Services (HQ DMS).

DMS promotes, protects and restores the health of the UK armed forces to ensure that they are ready and medically fit to deploy globally. The DMS is staffed by circa 11,500 service personnel (8,000 regular and 3,500 reserves) and 2,600 civilian personnel and provides healthcare to circa 143,500 UK Regular Armed Forces personnel.

Service personnel and civilians work side by side as medical, dental and allied healthcare professionals with other personnel to plan and deliver excellent healthcare services wherever they are needed. The services offered by the DMS include primary healthcare, dental care, rehabilitation, occupational medicine, community mental healthcare and specialist medical care.

Website: https://www.gov.uk/government/groups/defence-medical-services

 

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CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:

1. Understanding the artefacts that characterise the group and its activity.
• The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.

2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests. 
• Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.

3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history. 

 

• ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.

4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning. 

This links to the fifth principle that:

5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”

Successful teams have the functional skills to lead a task, benefit from diversity, and are led in a way that creates time and space for reflection; the ability to take stock periodically, of the task and of the way in which the team is engaged in delivering it. Your stakeholder analysis [HYPERLINK] should help you assemble the most appropriate team and identify how the team interacts and relates to other stakeholders like sponsors, services users, etc.

The variation in the size, both in terms of population served and numbers of constituent organisations, and of complexity, between Integrated Care Systems, precludes the possibility of any prescriptive guidance on the way in which this team is assembled.

Engeström’s expansive learning cycle of learning actions explains how there are 7 stages of learning actions;

“If someone’s been working for a period of time, in a form of therapy, for instance, where there’s an agreed plan for the locality when they may present in an emergency situation … then it’s really important for us to be able to see that that information and be able to act appropriately according to that because, you know, there isn’t and there shouldn’t be a stock response to that. These plans are designed to be individualised and personalised.  All services should be giving that personalised approach to care wherever possible. And a standard such as [PCSP standard] definitely moves us closer towards being able to do that. [Not acting on agreed plans] is a key finding in terms of emergency responses over the years where responses have been inappropriate.” – Mental Health Nurse

“Following a particular plan that’s been put into place will result in much better outcomes and prevent the sort of poor outcome which would otherwise be leading to an unplanned hospital admission.” – General Practitioner