55 Suffolk and North East Essex ICS | ‘Our Journey Together’ 7.2 A system change perspective Our healthcare systems require transformation to enable the health of people and planet to flourish. A powerful way to support such transformations is to develop transitional systems that cohere innovation, help disrupt current patterns, and enable new futures and patterns to emerge. For example, a caterpillar transforming to a butterfly requires a transitional stage inside its chrysalis. This stage provides a supportive environment in which the old can be hospiced, resources can be reallocated, and visionary processes can create something newxlvi (Fazey & Leicester 2022). In our highly complex and integrated world (like health systems), transitional systems - like Suffolk and North East Essex ICS - are needed to cohere activities across silos at scale. To be effective, however, such bodies need themselves to be transformative. From a system change perspective, the development of Suffolk and North East Essex ICS demonstrates many hallmarks of what might be needed for other collective and integrative efforts supporting a transition to be effective: 1. Cohering action as if working within a ‘living system’. Effective systems working requires appreciation that systems are not just structural, mechanical entities, but are fluid, relational, emergent, responsive, and coevolving. This enables greater efficiency and adaptiveness, unlocks resources, and creates enabling conditions for innovation. Suffolk and North East Essex ICS powerfully illustrates this through its explicit application of complexity-informed decision-making, disruption of traditional top-down processes of organising and power hierarchies, and attending to the quality of relationships as much as it does to transactions or outcomes. The ICS’ attempts to give a stronger voice to those experiencing health inequalities is a laudable illustration of such power shifts. 2. Strong capabilities for reflexivity. Reflexivity involves deeper forms of learning that continually challenge assumptions underlying our activities and their outcomes, as opposed to more superficial learning about how to do existing activities better. To be effective, deep reflexivity is needed in transitional systems to maintain awareness of what is important, how to respond to dynamic conditions and challenges, and how to keep ambitions for change high. Suffolk and North East Essex ICS demonstrates self-awareness as a system, and a clear willingness to critically self-evaluate in a way that surfaces deeper reasons for success or limitations (illustrated by examples such as the Uncomfortable Truths system learning programme, or this Learning and Legacy project). 3. Effective transitional governance mechanisms for supporting transformation. A transitional system would not only need to create an enabling environment for innovation. For instance, it would also need to sensitively ‘retire’ the old system and reallocate the significant resources it holds, and protect existing pockets of action that already embody a radically different set of values. There is considerable evidence that Suffolk and North East Essex ICS has facilitated new forms of investment in the health system and sharing of information and resources, all of which can potentially drive transformative innovation. We have not yet seen evidence of large-scale reallocation of resources from the old system to something fundamentally new, but Suffolk and North East Essex ICS nonetheless shows promise in the way it has established an ecosystem in which innovation can flourish, providing a foundation for deeper transformational actions to occur. 4. Maintenance of transformational intent. Transformational intent is an ongoing motivation and commitment to support transformation – a major, fundamental change – and not simply more marginal forms of change. While many projects start with the best transformative intentions, we have seen many examples where this intent subsequently falls away. It is a major challenge to hold transformational intent across all dimensions of a transitional system. Yet we are encouraged by the framing of transformation and system change that Suffolk and North East Essex ICS has started to introduce, including Three Horizons and consideration of longer-term sustainability through the Centre of Excellence for Health Apprenticeships. Substantially more work would be needed for the ICS to fully embody transformational intent across its operations, but the foundations are there to do this. 5. Evidence of regenerative dynamics starting to emerge. Regenerative dynamics can be described as positive reinforcing cycles of health that a system maintains both within and beyond itself, such that ‘life creates conditions conducive to life’xlvii (Benyus 2002). A successful transitional system would include evidence of these dynamics emerging (e.g. within and between social, financial and natural systems). Suffolk and North East Essex ICS shows
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