12. Altogether Better: Working in the liminal space between ‘professional’ and ‘life’ worlds

Working between the worlds of institutions and communities using Host Leadership is a brilliant innovation

The work of Altogether Better, an UK National Health Service network which helps doctors surgeries connect in different ways with their communities, shows an exciting innovation in Host Leadership. More about that later in the piece today – but first, some background.  

Host Leadership

Regular readers will know that I am recognised as an organisational innovator for my work on Host Leadership. The idea of leading as a host – rather than a hero or even a servant – came to me in a moment in 2003. It has been developing over the past two decades, first in a paper for the International Journal of Leadership in Public Service (2009) and then in two books: Host: Six new rules roles of engagement for teams, organisations, communities and movements (with Helen Bailey, Solutions Books, 2014) and The Host Leadership Field Book: Building engagement for performance and results (with Pierluigi Pugliese, Solutions Books, 2019).

Leading as a host is both a metaphor AND a model.  We all know something about how to host a gathering, whether it’s a formal do like a wedding or dinner, or something more informal like a bring-a-bottle-and-dance-till-dawn thrash. We’ve most of us been hosts and some kind of event. We’ve all certainly been guests. We know some aspect of the difference between a good host and a bad one. That’s the power of a metaphor; it connects something we know already to something we don’t yet know. We can recast the act of leading (a team, a group, an organisation) into hosting, and the focus changes from ‘directing’ (telling people what to do) to ‘inviting’ (engaging them in becoming active and involved).

The model of Host Leadership goes further. Helen Bailey and I spent years interviewing, observing and researching leaders who seems to act like hosts, and hosts who seemed to act like leaders. Many of them appear in our book Host; Everest mountaineer Sir Chris Bonington, TED curator Chris Anderson, networking guru Dr Ivan Misner, socialite Peggy Guggenheim, saxophonist and club founder Ronnie Scott and many more. We distilled a whole heap of great ideas, practice, ways of thinking, acting and relating into our model of six roles and four positions for a host leader. There is so much wisdom wound up in this framework that I still struggle to explain it briefly. And, of course, there are as many different styles of being a good host as there are people, so we are reluctant to get too prescriptive.

Triangle and circles: Institutions and communities

It was clear to me early on that leading as a host is a very different way of thinking to leading as a hero. The hero leader is on top of a pyramid. The servant leader (from the pioneering work of Robert Greenleaf from the 1970s onward where the leader supports and serves the organisation, is at the bottom. The host, however, is part of a circle. They invite people in, are one of the group as well as leading it, and seek to share power and build coherence.  

Around 2020 I started to become interested in communities and how they can flourish leading to my Village In The City project. It seemed to me instantly that host leading is a good fit for a community setting, where there is limited positional power and authority and people put in effort voluntarily. This was dramatically confirmed when I met asset based community development pioneer Cormac Russell.  He shared a model about the difference between ‘institutions’ and ‘communities’.

Briefly, institutions exist to deliver a product or service to consumers and users. They organise to support that activity and have responsibilities to various stakeholder groups including shareholders, funders, their staff and suppliers as well as their customers. Communities, by contrast, are self-supporting groups where the people act for themselves and others around them. The images are, again, the triangle for the institution and the circle for the community.

It’s worth pointing out a couple of key distinctions here. The people in the institution are replaceable; if the finance person leaves, they are replaced by another. All the little heads in the triangle are the same; it’s not supposed to matter much who they are (as people) but whether they can carry out their function. When the finance person leaves, they are replaced by the new finance person. In the community the heads are different; everyone is their own person and it matters very much who they are and what they bring in terms of experience, skills, passions and gifts. When Derek moves out of Number 24 and Angela moves in, she is not the ‘new Derek’; she is her own person with her own life and interests.

Another key distinction is that the institution functions by people acting by transaction. Folk are paid to do their jobs, which are mainly defined by the institution for its own functioning. There is nothing wrong with this at all, indeed it’s a vital part of making the world work. Communities don’t work like that at all. The people act (mostly) voluntarily to do things which benefit other community members. The activity is much more mutual, with the community gathering around their gifts and resources (as seen in the centre of the circle). One result of this is that communities act by the mutual commitment of their members, a ‘promise among peers’ that things will happen, rather than the threat of non-payment, disciplinary action or worse which hangs around institutions (again, nothing in principle wrong with this, it’s just a different way of working).

Leading institutions and communities

One corollary of this is that these two types of organisation require different kinds of leading. Institutions are mostly (even now) ‘directed’ as that’s quite a good fit with how they work. There are formal mechanisms of decision making, boards and committees are chaired (itself a key skill), votes are taken and decisions passed down to those who will implement them. It’s all about managing and controlling the institution to deliver its products/service/purpose in the interests of the stakeholders (who are a much wider group than the formerly pre-eminent shareholders who used to be the only source of authority).

Communities are fundamentally different. As there is little in the way of prescribed authority, community members are better ‘convened’ or brought together not because they have to, but because they want to.  Acting as a host is a superb way to do this.  Hosts invite people, prepare a space, welcome people in, connect them and also take part in whatever interactions go on (not just act as a ‘facilitator’).  Good hosts will attempt to work with broad consensus (or at least consent, with little objection to next steps) rather than voting – it’s important to keep as many people engaged as possible. The art can be seen as one of nurturing co-creation and choice among the community members, rather than controlling them.

Way to use Host Leadership

There are different ways to use Host Leadership ideas in real life. I’ve discovered a fascinating new one this week. And first, here are some of the existing ways.

1.       Make your institution a bit more like a community

When I first thought of Host Leadership my initial idea was that institutions like businesses, local government, hospitals etc would be better if they were a bit more like communities. If people were not altogether treated as interchangeable cogs in the machine, if they were engaged with choice more than coercion, if their individual talents and passions could be put to use for the organisation, if the leadership was more about engaging than directing (at least some of the time), then the world might be a better and more humane place.  I still think this! And… there are more ways to use the ideas of leading as a host.

2.       Think of yourself as a host

Hosting is a way of thinking about relationships. If you are the host, then the others are your guests. When you think like a host, you start treating others as your guests, which will inform your actions. Are they feeling welcome? Are you inviting them into a suitable space? Is the space prepared? Are they welcomed at the threshold? Do they understand the house rules or customs? Do they have what they need? Do they know how to use it and connect to others? Do they see you as someone to trust? Anyone can do this; a teacher in a classroom, a nurse on a ward, a shop assistant, or even a Chief Executive Officer. You don’t need permission to build better relations! Just put your (metaphorical) host’s hat on and do it.

3.       Hosting communities and community groups

If you ARE working in community space, then of course leading as a host is already a good fit. You can both build on the metaphor and learn the model to expand your horizons, increase your options, cover off any blind spots you didn’t know about, and enhance your overall skill and effectiveness. Hosting is more of an art than a science and, as with Solutions Focus, ‘every case is different’ so there is certainly no one way of doing it. And it can be very fulfilling and satisfying to work with others in this fashion. You can share hosting responsibilities around, you can take turns, you can always be on the lookout for ways to include the excluded, welcome the stranger and make more of what’s there in the people and place.

And now, here’s the latest way to use Host Leadership. It’s amazing, it’s exciting and it’s already here.

Working in the ‘liminal space’ between the ‘Life world’ and the ‘Professional world’

I was put in touch with Alyson McGregor MBE, national director of Altogether Better, who I was told was a great fan of Host Leadership. I finally got to talk with her last week, and she and her colleague Martin Fischer are doing some amazing work. Briefly, Altogether Better is a UK National Health Service (NHS) network organisation who are helping build models of Collaborative Practice around the country. These help health services and local people find new ways to work together in ways that improve peoples’ lives, release resources and improve services.

Collaborative Practice invites local people (known as ‘practice health champions’) to gift their time to a local GP practice or health service, working alongside people who deliver health services in a new, collaborative relationship. As a result, the practice and how it works changes. New services, activities, support and possibilities open up, based on what matters to the practice and what is important to local people. People’s needs are met differently, taking pressure off the service, reducing demand for clinical services, and making life better for everyone.

On one level this approach is simple, but it’s also hugely complex because it involves fundamental culture change. It changes the culture of the practice by changing who is part of the practice family, which in turn changes the business model of the practice.

The good folk at Altogether Better have looked at how this new role of practice health champions is about working in the ‘liminal space’ between the professionalised world of the medics and the life worlds of the patients. Liminal space means a space in between other spaces, where different rules apply and the normal ways of doing things don’t apply. It can be quite a profound concept; in many cultures rites of passage rituals (coming-of-age, marriage, death) are made using liminal spaces where the people involved enter the space, are transformed and then leave the space again. Here, the term liminal is used to stress that this is a different quality of space and activity, neither wholly part of the practice nor entirely of the community.

Altogether Better arrived at this idea of a liminal space via a linguistic analysis from Linguistic Landscapes. The work takes place in neither the life world or the formal world, but in the liminal space inbetween. This slide sums it up very well:

Note how well these two columns (though reversed in terms of left and right) match the community/institution distinctions I put forward earlier in this piece. People as roles and qualifications on the one hand, and people with many unique skills, interests and indeed needs on the other. Processes and protocols on the one hand, flexibily and improvisation on the other. Currency-based exchanges versus fluid non-monetary exchanges and rewards. And summing it all up, planned order opposite emergent order; strong ideas of how it should work opposite seeing how it might work. And they are using host leadership as a key part of equipping people to act in this new space. One of the findings seems to be that this relationship has to be negotiated afresh every time there are very few hard and fast rules.

Alyson McGregor sums it up as being ‘on the beach’ (metaphorically), in between the land and the sea.

We see Collaborative Practice as only happening in liminal space. We see each place as entirely separate and fit for purpose in its own right. But in this work people need to understand they are operating in a very different place – and we support both staff and champions to understand the rules and conditions.  We help them to understand what it means to be on the beach – it’s a different place and it sits between the land and the sea. Successful collaborative practices understand that the rules are different on the beach!

Alyson McGregor, Altogether Better

Sitting between the professional and life worlds - and benefitting everyone

It seems to me that one reason why this work can be so impactful is that the two worlds are both so clearly defined and held. We visit the doctor’s as ourselves in our own lives, not playing a role for someone else. Our health is existential to our lives and existence. And yet to the professionals in the practice, we will be one of hundreds they see, with budgets, contracts, bureaucracy, risk management and a million other things (like car park monitoring at my doctor’s) to consider. They have to be organised. And yet that organisation may not be set up to deliver what the people want or need.

They told me about one patient who showed up at their doctors 240 times in one year – that’s pretty much every day the practice was open. It’s very likely that this person is not seeking medical treatment per se but something else; maybe company.  If the practice health champions are organising walks, coffee mornings, peer support groups, craft activities (including with children), chances to connect and help each other, then there is something for this person to be pointed towards. The number of appointments goes down, the service is improved in both professional and community ways, and everyone benefits.

There is a large and growing body of evidence that this approach works for all involved – the patients, the champions and the practices. Their most recent in-depth evaluation (supported by evidence from the UK Government’s Foresight Project and the New Economics Foundation) showed 216 types of activity led by health champions in 30 GP practices. Involvement in the activities brought about improvements in patients’ wellbeing and resilience. It increased their ability to adapt, cope and live well with long term conditions. And it helped them better understand how to use the services available. More people are helped, and the burden on medical staff is reduced.

“We have increased our patient lists by 4,500 people and seen no increase in demand for either primary or secondary care consultations because we do things differently.”

Mev Forbes, Managing Partner, GP Surgery

Conclusions

This is a brilliant new way to think about both how to make these public-facing institutions work better, and also how to radically enhance the different ways they can offer support which benefits everyone – the community member, the practice champion AND the practice. And to work in this liminal space between, Host Leadership seems to be part of the answer.  I am very much hoping to continue conversations with Alyson, Martin and their colleages at Altogether Better and to investigate further into how they’re doing it and also maybe help them take the next steps. There is much more to be discovered, learned and shared about this humane and effective way of working.

And as always, please Like this piece and share it as widely as possible. Thank you!

---

Dates and mates

If you are at all involved in the world of making medical practice more effective, do check out Altogether Better’s website which includes resources, research and leadership development opportunities.

The Host Leadership Gathering 2023 will be held in Vienna, Austria on 12-13 June. Join me and others using and building ways to lead as a host in many settings including Agile. Two full days of inspiration! And of course there will be lots of chances for informal conversations, questions, connections and new possibilities.