Combining three ways of thinking for whole system learning and change.

This blog was stimulated by three separate contributions at the August 2020 COIN meeting. The presenter (Margaret Hannah) described three different ‘horizons’ or ways of thinking about innovation and change in healthcare. In the ensuing discussion one participant commented that politicians often listen better than scientists. Another said: “it all comes down to education”. 

One way to bring these ideas together is to ask in what different ways do we validate truth and so learn and change. And particularly the different ways that scientists and politicians are expected to validate truth.  Most scientists use quantitative research methods from the positivist school that imagines that truth comes in discrete packages that can be examined one at a time. For something to be considered to be true it has to pass tests of objective validation. Something is true if it is statistically different from whatever it is being compared with and that observation can be repeated in separate experiments. So, scientists from this tradition are expected to listen to, and learn from, truth arising from experiments (more than listen to the experience of people).

Most politicians use sense-making to validate truth and so learn. Truth is imagined to come as interconnected networks of facts that make sense as a whole. They will have their own personal insights, from their personal experiences. They will listen to what their constituents and colleagues say. They will use scientific facts to add to the mix of inputs. From these diverse inputs they will form a view that something makes sense as a whole, and so is ‘true’. This is aligned to the critical theory school of thinking that says that many different truths coexist and are interconnected to build coherent stories. 

If we use the example of a garden we can imagine that the positivist school would examine in detail specific flowers and the critical theory school would describe the array of different components of that garden, including flowers, trees, animals and insects. A politician might be perceived to listen better than a scientist because it is their job to listen to others to arrive at their version of truth about the ‘garden’. 

In ‘The Paradigm Dialog’, Guba describes these two ways of thinking about truth – positivism and critical theory. He also describes a third – constructivism. This imagines truth to be co-constructed – we validate it by taking part in its co-creation. Shared action, reflective practice and discussion are main ways to learn in this paradigm of learning-from-experience.

Hannah’s three horizons resonate with these three paradigms. The First Horizon: ‘Sustaining Innovation’ is the managerial voice. It keeps existing innovations going by controlling individual actions, comparable to the way that positivism controls intrusive factors in an experiment. It is the ‘markets & targets’ ideology of New Public Management that has dominated the NHS since 1990.

Hannah’s Second Horizon: ‘Disruptive Innovation’ is the entrepreneurial voice, eager to try new things. Like the critical theory focus on a diversity of facts, this encourages individuals to try out new ways of doing things that might add colour to the ‘garden’. 

Hannah’s Third Horizon: ‘Transformative Innovation’ is the aspirational visionary voice that stimulates collaboration to co-create a better way of doing things, like constructivism. This could become what Ferlie calls a ‘new localism’, and could be promoted by Primary Care Networks.

These three paradigms/horizons are three different ways of imagining what is going on in the melting pot of life. Each has strengths and weaknesses. All are needed, thoughtfully combined to suit the needs of the moment. The combination of all three paradigms can help communities to learn and change – facts from (positivist) quantitative inquiry, qualitative inquiry that makes sense of complementary perspectives (critical theory), and (constructivist) participatory action research where a community explores a topic together. This combination has been described by Guba and Lincoln as ‘4th generation evaluation’. It is particularly appropriate in complex, real-life situations. It could be used in primary care networks to facilitate innovation in their geographic areas by, for example, driving the practical integration agenda within the Integrated Care Systems that are now emerging.  Paul Thomas

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