 I'm going to talk about the relationship between professionals and organisational change, about ways in which highly skilled people with a strong occupational identity and, I suppose, a sense of service to society, professionals are sometimes both part of the problem and part of the solution when organisations need to adapt to changing demands placed on them. So, professional work, I think, it's got an old established character, but it's also possible for it to be transformed into something innovative. And what I'm interested in is what sort of transformations are needed and how they come about. And I suppose the place to start is these two sectors I'm going to talk about, healthcare and construction. I mean, they're, on the face of it, rather different, but they have, the first thing they have in common is that they're shot through with professionals, they're full of professionals who define how work is done. But they've also had a terribly hard time in terms of what policy makers and government reviews have said about them. In different ways, the NHS has been always at the forefront of policy concern, but so has the construction industry. The first report, government report about it, was in 1947 and there's been one about every 10 or 15 years saying much the same thing, that there's real problems with that industry. And there's some interesting commonalities in terms of what's said in policy circles about both these sectors, that they're overly fragmented, that they're based on highly professionalised parts, that professionals focus on parts of the overall service and do it to a very high standard, but there's a problem about how it all fits together. So there's problems of integration, there's problems in both sectors and interestingly the NHS is probably getting more contract driven. I'll return to whether the construction industry is getting less contract driven or not, but both are driven very much by the terms of contracts which judge the performance of the parts rather than looking at the whole. And so for both there's a long history of concerns about whether they're delivering value for money for patients for the clients of construction and concern also that they're unresponsive to change, particularly when policy makers try and make them more integrated. Now the nature of the fragmentation and the focus on specialised parts is very different in the two but it's I think it's closely linked with the way professionals work. And I suppose the other take I'd like to put before you in terms of the problems of highly professionalised sectors is what general managers in those sectors tend to say about the high status professionals, the doctors, the surgeons, the architects, the engineers. And I've, as Mark indicated, I've worked in my research and my teaching is highly engaged in both those sectors so I've had many opportunities to hear what managers have to say about the organisations they work in and the role of professionals. And I've often heard managers referred to the professionals as tribal, as too wedded to their Rolls Royce solutions or at any rate their own solutions. And managers often present themselves as having to carry the concern about the performance of the overall, about value for money, about how to make the service more responsive to what patients or clients really need. I think as an example of this some years ago there was a wonderful OU BBC co-production, Can Gerry Robinson saved the NHS, where, well, Can Gerry saved the NHS and I think some of you who saw it may recall there was a running story over several episodes of where Jerry as the enlightened general manager said surely it's possible for surgeons to operate to do hip replacements on Fridays. I can sort this out. Several episodes later, several episodes later he hadn't and it wasn't just the values or the traditions of the surgeons that stopped him, it was the traditions, the ways of working, the requirements of all sorts of other occupations and systems in the hospital. And as Gerry perceived it, the sense that nobody was taking overall responsibility for how the system behaved. And I guess that's what's the big concern behind this fragmentation and this focus on specialised parts in highly professionalised work, who looks at the overall. So I'm going to put this all in a bit of context, a bit of academic context to begin with and I'm going to start right at the beginning of my, I suppose my academic journey looking at the sociology of the professions. So when I was a PhD student at the Imperial, as Mark said, I read this book and I think it's still probably the best book written about professional work. It's by Magali Safati-Las and that's a picture of her as she currently is, courtesy of LinkedIn. And there you have the original edition I think that I read and the current edition with her new introduction. It's well worth reading. But what she points out is that when, is that professions operate by establishing control over a body of expert knowledge and practice and they do that on the basis, on a moral basis, that they're making an important contribution to society. That's the deal. We as doctors, architects, engineers will control this area of work and we should do it because we're doing it in the interests of society. So the interesting thing is that they, professionals, establish control over a market, a market for a certain sort of service, but they do it by trumpeting their non-market, their anti-market principles. They produce, if you like, public goods. They produce health, good design, social welfare and good governance. Now in the introduction to the latest edition Magali Larson begins to, I suppose, theorise that what's becoming rather detached from many expert professions these days, or technical experts these days, is they've begun to focus more on the market, more on their contribution to markets, more on their control of the market than their moral purpose. What I'm going to suggest is that an important engine for progressive change in professional work is getting professionals back in touch with their moral purpose, with their overall social and economic contribution. And my research, which I'm about to explain to you a bit more, indicates this may happen most strongly when different specialisms or professions come together in networks to consider how best to address needs. So this is what I'm going to be talking about at the centre, the idea that change comes out of interprofessional networks, that it's single profession thinking that actually, in a sense, might block change, or at least interprofessional networks, interprofessional encounters spur it on. And those are capable of producing new concepts for services, new ways of doing things in construction and in healthcare, and I suppose coming up with a powerful living moral purpose for why they're important. And in both cases that I'm going to be talking about, I'm going to tell you about how those interprofessional networks came into being, how they themselves found new sources of funding to do it. If you like, they recruited their own resources, their own funding streams, their own forms of backing to put their ideas into action. They put them into action by creating, down at the bottom, specific interdisciplinary techniques that if you allow them to live into the new concept. And they then, they didn't abandon professional control or professionally defined roles, specific roles, but they reworked them. If you like, there was an opening up and then a closing down, a reworking. So there was still order in terms of the areas of work that they controlled. So I'm going to tell you about two cases. They both began to happen about 10 years ago, so they're not brand new, but I think they're both highly relevant. And they've certainly, they've influenced my thinking and the sorts of teaching I've put together for professionals since then. So I'm going to start in construction. And I'll begin with something about the policy context. So the construction industry, as I'm sure everyone knows, it's packed full of professionals. A typical construction project consists of a client, who could be anybody. Then a set of design professionals, typically the architect, the structural engineer, the building services engineer designs the heating, lighting and ventilation, obviously the building, the structural engineer designs the structure. Then there are, then there are a variety of contractors who build or install what the professionals have designed, usually as a result of a process of competitive tendering, which is dominated and this is a persistent problem. It's dominated by concerns to get the lowest price. So what developed through the later part of the 20th century was an industry that fragmented the responsibilities for design and construction and then further fragmented the responsibilities for delivering different parts of the design between different contractors and subcontractors, each with its own scope of work and tightly bid price. And so that's why we've got this succession of reports from 1947 onwards, there was Banwell, Latham and so on, arguing that this fragmented approach did not serve the clients of construction well. And there are figures to show that the various players in the industry actually have historically spent most of their time and energy or more of their time and energy in disputes with each other about who takes responsibility for the extra work when things don't fit together. They put more time and energy into that than they have into research and development or in terms of innovating to improve the underlying value delivered to the client. So I suppose the most recent of those reports, it's happened some time ago but it was doing my professional career and it's this one. Sir John Egan was asked to set up a construction task force in the sort of the full flush of new labour optimism in the late 90s and he announced with this report Rethinking Construction, a new era in construction which was going to draw on his experience of leading Jaguar in the 1980s and of running an enormous programme of construction at British airports authorities to design and build terminal five, which was late 90s, early 2000s. And what Egan proposed was that the industry, the construction industry, should greatly improve its productivity. He reckoned it was 10% a year, which is pretty daunting, through operating in so-called integrated teams. So with designers, constructors and product manufacturers collaborating to meet the needs of its clients from the beginning rather than designers meeting first and then putting things out to compartmentalised tendering packages. And all that was possible for Egan at Heathrow because it was a huge programme of construction and he could hire these teams and pay them to do the design work in detail for a number of years before construction started so that everything fitted together nicely on site. But the big question was how could this be translated into an average construction project of a few millions or even a few tens of millions because it would really break with all the established routines of the design professionals as well as the builders. So it was this topic that I got interested in partly because I was in discussions with various industry bodies at the time. But clearly this issue has persisted because here's a more recent report from the client body of the institution of civil engineer. This is a report commissioned by the big water companies, transport companies, those who are commissioning construction in civil engineering. And this is last year and I was actually a member of the task force that commissioned this report and looked at it. I didn't write it but here are some quotes. So they're saying, still saying sorry, construction has failed to improve its productivity over the last 20 years and that by breaking projects down into hundreds of these specialised subcontracts we impede the flow of knowledge from the people who are building it to the front end designers and that's where value is created or should be created and isn't currently. And I found this poem, Kipling I suppose, wrote for children and for white men. But I think this just puts it so nicely, I couldn't resist it. And I think many people in the industry that I still come across are saying the industry goes on much as it was. So what I'm going to tell you about is a case where some working professionals in an average size project, about £15 million, did something different. And we start with an innovating interprofessional network. There's the contractor, I've called Clive, I've aligned the names with the, these are obviously not their real names, the roles aligned with the name starts with the same letter. So Clive the contractor, Peter the client, the property developer and Andrea the architect. Now all of these were well regarded figures in the local regional office of large national firms. So they're sort of there, they're kind of mates in a region, but they have large national organisations sitting behind them. And they were each well regarded within their regional offices, but what they shared was dissatisfaction with established ways of running projects and a commitment to building a local reputation so that they could continue to work mostly on local projects, they wanted to stay local, but they wanted to be seen as I suppose doing a really good job as really highly trustworthy. And they'd worked together previously on a project, a letter development that had been financed by Peter, so one of Peter's projects. When Clive had been brought in to basically turn it around, it was going over budget and time because things weren't fitting together on site, there were all sorts of problems. And Clive turned it around by getting the design consultants, including Andrea, to sit down with the contractors and work out how to make the building easier to install. And he did this without going over the budget. So when Clive learned that Peter had secured some land for this residential development which was subsequently built, he made him a proposal. He'd worked from the outset with Andrea's architectural firm and a structural engineer and a few specialist contractors that he'd also worked with previously. And they'd design and deliver the building within an agreed target cost per square meter, so they had an idea of what it should cost, but they agreed that they'd worked together to get it to cost just that. So there wouldn't need to be any competitive tendering. They were going to put together the team on the basis of its competence to work together collaboratively for the end product rather than their ability to quote a low price for an isolated part of the building. So they offered predictability as well as good value to the client. So the first aspect of what this interprofessional network offered was that they formulated a new concept for a way of working. And there was a moral justification for it. It would provide better value for money. In their minds, it was also that there was a moral justification that it would provide better work for the people involved because there wouldn't be constant disputes, there wouldn't be antagonism, and there'd be a promise of establishing more work in the same area, so people wouldn't have to travel to take on projects elsewhere, which was damaging to family life. It's family life for people who work in construction is notoriously poor and disrupted. But there's a particular point about this innovating network. Andrea and Clive and Peter, they knew about Terminal 5 and they knew about Egan and the report, but the idea of getting designers and key contractors to work together, to work out the design and build it cooperatively and smoothly came from their experience of working together. So it came out of their own practice, and Clive, I suppose was a key figure in this, wasn't even influenced by the supply chain strategy of his own firm, which said that nationally there were a number of preferred suppliers and that local firms should work with them. He really didn't care about that. He made sure that he put together a team of organisations to deliver the project, which he knew who were local and he knew he could deliver it. In fact, I think only one of them, of seven or eight organisations, was actually a nationally approved, a nationally approved, preferred supplier. So this is where, I think the word Maverick is appropriate, that this innovating professional network had a sort of detached life of its own from the larger national corporations. It had its own mind. So, now the next point is about how the work on this new model was funded. Well, it came from this property development, this opportunity that Clive seized on. So in a way, this Maverick into professional innovating network, it produced, it got its own funding and it got, it made sure that Peter funded firstly that all the design happened involving the contractors before they went on site. So it was funding that was in the right form, if you like. So they weren't looking for it. They didn't bid for opportunities and they certainly weren't looking for corporate backing. They didn't need anything from above. They just made it happen themselves. So what happened as a result? Well, they began to craft their own ways of working. The architect produced an overall design and then there was a series of design meetings where the contractors who would deliver the main components, the groundwork foundation, the steel frame, so on, the mechanical electrical systems, sat down and improved the design and made sure that it could be constructed without problems at the interfaces and in terms of removing unnecessary materials, which contractors will tell you, design professionals often specify to make sure that they're not going to be sued but which really aren't needed. And I'll just let you read that. That's the steel work that the contractor who was going to put up the steel work. That's what they said about these meetings. So they sat down and this is something that hadn't done before. They sat down with the design professionals and together they interrogated the design and they said, well, how else could we do it and what would be the order in which we'd do it in these various ways. And what they came up with was less pre-cambring, which is the pre-stressing or shaping of bits of steel, which is expensive to manufacture. They took cost out of manufacturing and they realised they could use smaller spans and less steel, all of which saved money but without compromising the structure at all. So it's just to give you a flavour of what that collaborative design looked like. So they had these very specific techniques for making collaboration happen. And then the final point about this model is the implications of all of this for professional roles. So what Clive and Andrew and their team did was provide a framework where specialist contractors could go off and do their own detailed design really. And that's something that they've always wanted to do, they'll often tell you. So the steel worker actually did most of their own drawings and that they could make the building better and easier to build. And they weren't working any more any further from the architect's detailed designs. So this is quite a big impact on the role of the architect and the structural engineer. So, and one way of thinking about it that comes to mind is that the architect was now in effect the enabling conductor, not a dominating conductor but an enabling conductor of an orchestra of players who were artists in their own right. The architect was no longer the prime design performer. And Andrew told us that she was very happy about this because she recognised that the subcontractors knew far more about the materials and products that they worked with and the methods of construction too. So alongside that logic of delivering values through collaboration was there was an idea of sort of re-centring the professional role of the architect. And Andrea told us that she spent much of her time clarifying detailed drawings that were coming in from the subcontractors and making sure that there was consistency between them. So there was still a responsibility for coherence but one that was actually much more easy to deliver and enact because all the designs were coming in before there was any building rather than trying to establish coherence once things were going wrong on site. So that's the construction case and I should emphasise that it was highly successful in terms of being delivered on time and budget delivering value and I gather that the resulting dwellings which were there was a small amount of social housing in it but the resulting dwelling seemed to be serving residents well. And it also paved the way for that same combination of players to get further work of building an even larger residential development in the same region. So that's the construction case. I'm going to move straight on, I hope you're not too overwhelmed with the detail, I hope not, to the sexual health services case. Obviously a very different area but there is commonality in terms of a background of policy attempts to change practice which are not getting too far on the basis of direction from above. I think that's that and obviously professionals involved who are sometimes seen as very tribal in character, doctors and nurses. So just a bit on the background, this is the sexual health strategy of 2001 but the background to this is that NHS services providing contraceptions and those for treating sexually transmitted infections developed during the second half of the 20th century along separate lines. So contraception services mostly known as family planning dealt mainly with women and girls and was staffed mainly by female doctors and nurses typically on part-time contracts and running clinics in community health centres. Over time, a specialism of reproductive and sexual health became established although it tended to be seen as rather low in the pecking order of medical surgical specialisms because after all they didn't work in hospitals, they worked in the community. So in contrast sexually transmitted infection which we use the jargon STI clinics were usually outpatient hospital based services. They were staffed by specialist genital urinary doctors, GU doctors, I'll use that acronym from now on, doctors and nurses who were mostly employed on full-time contracts and keen to see themselves as equivalent in status to hospital colleagues in other specialisms. Another absolutely crucial difference was that STI clinics were for both men and women whether they had sex with the opposite sex or with the same sex so a different sort of cleontail. But by the late 90s and this is the background of this report it was clear that there were significant problems for both of these kinds of services and that there was a link between them as well particularly in large cities with large populations of young people there were very high rates of unwanted pregnancies including teenage pregnancies and high incidences of STIs and in fact in both teenage pregnancies and STIs a number of English cities had the highest incidence had worked at the highest level of incidences in Europe. So it was clear that part of the reason for this was that there were long waiting times throughout the country in big cities for STI appointments and contraception clinics tended to have very short opening times it was just difficult to get there. So this report was put together a working group of clinicians, service managers and voluntary sector representatives called together by the Department of Health and they produced this new national health national sexual health strategy and it recommended trials of visibly and easily accessible one-stop shops this is the when the term was coined which would make contraception and STI services readily available within the same visit because the argument was that the same people often needed both. But implementation was very slow and throughout the early 2000s you'd find that some clinics began to offer some locations offered separate clinics for contraception and STIs under the same roof but there was little integration between the two and people had to queue for one and go to appointment at the other or queue for both there was just no integration in terms of the how people experienced them and the key issue recognised in this report was to improve population the sexual health of the population was to get people into the clinics often impatient demanding people and treat them quickly and simply before they lost patience and ran out literally. So and that's just to give you a flavour this this is one of the early one-stop shops and it has that sort of morning after the night before flavour about it that's to give you the sense of what what these high street clinics are like. So this case again we've got an innovating interprofessional network of three professionals so I've got Rachel who was a senior contraception doctor reproductive health doctor we've got Gwen who came from genital urinary medicine and Mandy who was a commissioning manager so responsible for for commissioning these services. Now Rachel had a long history of working in contraception services this is all this is all in in London and she'd often come across people who she felt needed STI services but then she'd have to refer them elsewhere which slowed them down and she wasn't convinced that they actually ever went. So she'd campaigned for a long time for her clinics to to offer STI testing as well but when she raised these possibilities she found that it was actually blocked by her colleagues by the existing colleagues in the local hospital in genital urinary medicine. As far as they were concerned they made it very clear STI tests were their business and needed to be carried out within a hospital clinic. The things changed when Gwen arrived on the scene as the new clinical lead for GU and Gwen was very interested in in a public health perspective on STIs and she was concerned at the local prevalence amongst men and women and felt it was vital to improve access to services and they both found a kindred spirit in Mandy who knew the national health the national sexual health strategy and wanted to make it happen. So all three wanted to break with the established separate clinic model so just like the professionals in the construction case they formulated a new moral concept if you like a new concept the their version of a a one-stop shop and the moral justification that came out of their own experience was to address the needs in the in the local population that weren't being addressed by the existing models. Maybe even more powerfully than the professionals in the construction case this innovating network found their own way of getting financial resources and management backing for what they wanted to happen. They were aware of a charity asking for bids to fund and asking for significantly sized bids to fund health service innovation and they made a case to this strategy for a significant initiative in sexual health services on the basis of the public health challenge that they they identified and they won funding for a pilot of a one-stop shop including funding for nurses to take on full-time roles to be trained in both contraception and STI diagnosis as well as for health care assistant grade staff who would administer simple tests. So they very obviously they they recruited their own funding for this they didn't go up through their they didn't go to their own their own commissioning bodies they didn't go to their own employing organisations they went and got significant funding for a charity and that unsurprisingly brought management backing management were delighted that these people had brought the money in and became very enabling of this public health oriented initiative and it's probably just as well because the next thing that happened was this first of all letters went to the senior executive from some of the the GU doctors saying stop this we never agreed to this and then this is a story told by another senior doctor of what happened to Gwen they said are you crazy what are you doing saying we don't need my you know we don't we don't need hospital we don't need a hospital lab for an STI clinic who do you think you are and Gwen was dispatched from from her management roles and she stayed on as a esteemed well respected consultant but she couldn't lead the initiative from that point even though she she'd been instrumental in getting the funding so but others others came forward and and the senior management in the in the hospital where Gwen worked made sure that another champion another senior GU doctor came in and found ways of bringing the colleagues along in fact we gathered that after this a number of the the consultants left they went they went elsewhere so the innovating network i suppose it survived an attack on it but it kept going so from then on again just as in the construction case they this innovating network had the resources to craft specific techniques that enacted the new way of working they had funding for workshops where they could invite colleagues doctors nurses service managers to to look at how one-stop shops could actually function and what they did what they started from was the experience of users doctors nurses clinic managers went to the workshops and they discovered that services what users service users found most off-putting were what they called hand-offs for example hearing to see a nurse for one test or procedure them being told that they had to see a doctor to get the result of the treatment or having to make an appointment or join another queue when it wasn't and it wasn't very clear where where they were in the position what position they were in the queues there's a lot of friction in the clinic and people getting up and going before they'd been fully treated so the key organising idea that held it all together that came out of this was was simply the notion that there should be no hand-offs whatsoever service users would be directed straightaway to a dual trained clinician who could who could do contraception who could offer contraception and diagnose and treat STIs and that everyone should have this whether they realise that they needed both things or not and all this was achieved using a screen break a screen based triage system which was based on what happens when you arrived at an airport it was a sort of an adaptation of that technology and these these these touch screens rather than going to reception and having embarrassing interchange with receptionist people tap in screens and ask them why they've come discreetly but very very carefully asked questions about symptoms and their behaviour over the last few few days or weeks and the answers led them to be directed to to see to one of three queues a healthcare assistant for simple tests in either in either area a nurse or a doctor depending just depending on the complexity of what emerged from the touchscreen triage um so what emerged again just as in the in the construction case was was a reworking of of professional roles um so nurses with enhanced skills in both contraception and STIs took on a central role in seeing the majority of patients in clinics and in fact in running the clinics so it um the best way of describing it is that the nurses were now in effect referring the more complex cases to doctors rather than doctors running the clinic and expecting nurses to do the simple clinical tasks and another perhaps surprising development was that healthcare assistants emerged as taking responsibility for some areas of testing including using microscopes to examine the slides of bacterial cultures you know something that right at the beginning that the consultants have said that only they could do it emerged that it was perfectly possible to to sort of protocolise if you like what you were looking for and you could test healthcare assistants so they got 10 slides out of slides 10 slides out of 10 correct and there they were um presiding over the test test for some for some STIs um but again i want to emphasise it was never a sort of free for all with the professional boundaries you know there weren't simply dissolved there were detailed negotiations within a clinic at each stage about who was doing what and even between the different bands of grades of nurse and and it certainly wasn't the case of the doctors reluctantly going on with what managers or policymakers wanted them to do to to give up some areas of work there were some senior doctors who were along from the beginning pushing it pushing it forward and many others who joined willingly because they shared the overall goal of of getting people into the clinic faster and getting more people into the clinics and treating them faster so i'll now pull together what comes out of these cases so in both cases we have this local maverick into professional network um a bit maverick with respect to their own professional communities in different ways but very much following their own mind and based on what they've discovered from from their own practice together and what's emerged of discussion across professional boundaries together and their dissatisfaction with existing system so um a first implication i think is i'm going to draw try and draw out an implication from each of these these five bubbles so the first one is if you're interested in bringing about change in professional work for example in the au or anywhere else um i think it's important to assume that informal innovating interdisciplinary oriented professional networks already exist you might doubt that they exist but go looking for them um and you might be pleasantly surprised or surprised anyway um so in my experience they're indeed you know there are insular professionals who want to keep to their their own colleagues and methods um and and there are you know people who who simply aren't interested in working across professional boundaries but i think they're as least as many who are um and there are likely to be maverick groups who come together in all sorts of ways and i think one of the characters to these groups is they have a great deal of respect for each other but maybe less for their own professional communities and their hierarchies um and you know i've come across a number of these and and i i think i've been in one or two as well and it's kind of fun um so the second implication um is along with from the in in the top top of the diagram along with a new concept for how to work that can come out of these interdisciplinary networks um there's likely to be a combined moral and economic justification for it um a sense coming out of the professionals as what they should be doing as responsible professionals able to contribute value and and secure further funding for their work um you know i suppose communicating a different kind of professional future um and and the implication here for bringing about change is about finding ways of grounding new principles of organising in the experience of people working with it in existing systems because that's where you get this moral commitment i think if it comes out of people's experience and dissatisfactions with existing ways of working um and i suppose the thing is to ask questions about like you know what kind of moral as well as economic or efficiency rationale is is there for a new way of working um and in what sense can it be seen as representing a better contribution to society uh and i'm thinking of how i've seen that kind of moral commitment emerge is in the setting up of mental health alliances that's a more recent research i've been doing in a different London borough um where a GP in charge of mental health services really challenged the range of providers to say that well there are too many referrals bouncing back to GPs because the patient isn't is too disturbed or not disturbed enough or two substance addicted as well as disturbed you know all all the services had their own professional remit and what they were doing was bouncing patients back to GPs because they would they felt that they weren't the sort of patient who would be good for their recovery statistics so what the challenge there was for for the um the providers to get together and organise their own referral into referrals and and they came up with some simple ways of doing that at a common referral form but it was that but the challenge was about how to improve the overall contribution the moral justification make it a more integrated experience for for the service users who were being let down uh some of them horrendously on these repeated referrals um next uh sources of funding um so in both cases it was the innovating network that sort of found their own ways of funding the innovation well that isn't necessarily always possible but if you have interdisciplinary interdisciplinary collaboration almost by definition there are more funding options um and I think that's a question worth asking you know what what other matching funding might be possible from elsewhere um so in that mental health case where they brought together public health budgets and um treatment budgets um so down the bottom the the interdisciplinary techniques very important to have interdisciplinary techniques that enact the way enact the identity of working together in a different way um so the implication is if if you want to sort of recreate a different kind of interdisciplinary professional work you need to you need to have the detailed tools and techniques to to bring people into it um and in that mental mental health case that I illustrated it it was quite simply the referral form that's what the alliance did um and they also set up um a um a complex cases discussion forum and believed or not case discussion forums had disappeared from the individual providers particularly the NHS ones because they didn't have time it was all about numbers so the meetings they had was about numbers and recovery it was about statistics but that people rediscovered their interest in particular kinds of clients uh in gay teenagers um all the clinicians who went to these complex cases referral meetings they were just talking about examples but they they said how they'd rediscovered their passion for mental health work and finally um reworking professional control okay um I've given examples of how architects work differently of how um of how senior doctors work differently because nurses were doing so much more but there was still um a negotiation of precisely what people did that was fairly continuous um and I suppose in in this mental health case well that was going on as well with NHS clinical psychologists who were now supervising voluntary therapists who were officially less high status less trained than them but who worked in voluntary sector organisations who had credibility with ethnic minorities because the NHS providers didn't so that's how the professional rule was changing but there's still had to be protocols for agreeing what they were responsible for so a bit overtime but um that's that that's just summarising the five points I've left I've left you with and I just want to leave you with this as you know the kind of direction that might be possible to establish with that approach to working with inter-professionally prompted um innovation in professional work that sectors like construction and and healthcare could become more integrated greater focus on whole services that there could be more collaboration driven than terms of contract driven more aware of the value they're delivering um rather than um the cost of particular contracts and more responsive thank you all for listening