Tuesday 13 November 2012 15:00 by Graham English (comments: 0)
When leadership isn’t enough – an open letter
Dear Sir David and Mr Francis
Executive Summary: Leadership has been applied as the solution to a long list of high profile service failures, from Ely to Mid-Staffs via Bristol and more, yet the problems recur. That approach can be a panacea, a trap of the slow-boiled frog variety, fraught with its own dangers. Just as the causes of such failures are multi-factorial so too must the solutions be. This is a dilemma. Our existing tools for getting out of a fix seem unlikely to work, just as they haven’t worked before. We need new tools to fix it. The solutions need to operate by a different paradigm. It is not enough to say ‘put the patient at the heart of our actions’, there has to be acknowledgement of the need for a new relationship with patients and the public we serve, based in different (specified) behaviours and a new power dynamic.
What are the limits to leadership? When is it meaningful, even necessary, to say that a problem isn’t amenable to leadership action alone? When might the pressures for leadership, often explicitly for ‘strong’ leadership especially in a time of crisis or turmoil, be too great? When might leadership have no impact or even a negative one (and I’m not simply referring to poor leadership)? Is it ever ‘OK’ to say that leadership isn’t enough?
Some of these questions may seem absurd or to imply an abdication of responsibility on the part of leaders. Even to ask them seems a little shocking (even to me, and I’m the one asking!). I believe that such questions, and our responses to them on the emotional level as well as the practical, are critical if we are not to be stuck in a hugely significant and self-perpetuating trap.
The questions came to mind recently thanks to a coalition of stimuli – presentations by various leaders associated with Mid-Staffordshire Hospitals, and the Public Inquiry into the awful events there led by Robert Francis QC, a discussion with an eminent coach and coaching researcher about the prevailing mindsets on leadership, and the nature of evidence to support or challenge such mindsets, the comments of some NHS leaders about the need for honesty with the public about the future of the NHS at a time of public sector financial retrenchment for example over the future of small hospitals and Trusts, and the work of the King’s Fund (whose goals are “to shape policy, transform services and bring about behaviour change”).
Partly in response to the events at Mid-Staffordshire Chris Ham and the King’s Fund have produced a set of responses focussed on leadership. They are good documents, have an ethically sound basis and reflect everything that is ‘on the money’ in current descriptions of the preferred effective management and leadership style, and I subscribe to such views too. These approaches underpin the thinking behind such initiatives as the new NHS Leadership Academy. So what’s the problem?
To see our response to this question, our proposed approaches and our solutions follow this link to the full text of the letter.
Sunday 3 July 2011 14:00 by Graham English (comments: 0)
Save the Heart Unit, Save Our Hospital, Save Our NHS!
Save Our Library, Save Our Fire Engine, Save Our School!
Notice, its rarely save (invisible and therefore vulnerable) community services, (unregarded) social care, or (unglamorous) planning officers.
But change in services has to happen, right, so this is just Nimbyism or narrow minded protection of the status quo (implicitly by people who just couldn’t get ‘it’)?
Chris Ham’s recent article in The Observer makes the point that there are up to 20 of our main hospitals which could reasonably be regarded as vulnerable to ‘reconfiguration’ - closure or merger by any other name. That’s circa 10% of the total, a very significant proportion, especially as the issue here is often not finances so much as the ability to provide either a ‘safe’ service (whatever that means) or a service which meets professional standards (for example about the number of consultant staff in key units, such as A&E or Intensive Care).
A crucial difficulty of course is in part that these are judgements made on the basis of professional recommendations, but they are only that, not more. They retain crucial value judgements which are subjective, unspoken or unspoken in public. Professional judgement is a fine thing - I want the doctor treating me or my family to exercise it. What I don’t want is not to know what is judgement and what is fact, or for it to be assumed that I wont understand if those judgements and distinctions are explained properly to me.
Chris Ham repeats the view that one of the Government’s aims in developing the Health and Social Care Bill was to de-politicise it, and he suggests a way in which, by a small tweek in procedure, that could be done with decisions about hospital and service reconfigurations. (Its about distancing the ‘Independent Review Panel’ from the Secretary of State’s powers and responsibility.) Which sounds straightforward, except he then goes on to make an apparently simple statement about needing a more honest dialogue with people about such decisions, in a single almost throw-away line.
This is at the nub of why this is such difficult territory. It is our contention too that such dialogue is needed. We are dealing here with perceived threat, not just to some remote, unimagined and rarely used service, but to something held dear if poorly understood. Something which touches virtually everybody at some time. Something which routinely figures in tv dramas and daily papers, local and national, which inspire intense and witnesses intense emotions. This is the very stuff of real politics. The NHS as a ‘state-controlled’ system is a political football, and the Government’s pause reflects just that, and singularly failed to change it, whatever they or Professor Ham (or we) would want.
More recently still, the NHS Chief Executive, David Nicholson has entered the nascent debate to ‘re-assure’ a largely uninterested public that ‘no hospitals will close’ or words to that effect, thereby leaving those who are paying attention wondering just what will close, or put another way just what the parameters are for decisions that trade off ‘public safety’ with ‘local and known’ with financial savings/prudence. Nicholson’s was as much a message to the NHS as it was to the public. And of course that too demonstrates the intensely political nature of such decisions.
There is another phenomenon just now. That there is a sudden outbreak of ‘hotspots’, where services or local people’s interests are perceived to be under threat, in health take Children’s surgery centres and outer London, take the High Speed Rail line ‘consultation‘, take X or Y items from ‘Cuts watch‘. And this too demonstrates one of the dilemmas and flaws of our current approach: there is only a very short period in our political cycle when our politicians can countenance ‘threats‘ to local services and interests. Never mind that Nicholson’s ‘need’ to save £20bn is about re-investment, not actual ‘cuts’, this stuff always gets caught up in a vicious and self-defeating argument about what the real reasons for a given change are.
We believe there is a different approach - one which works with the political nature of such decisions, one which moves people on from narrow concerns, which brings a reconciliation of professional expert and local and personal perspectives, which neutralises the key question of timing.
It’s the way which embraces relationships and emotion as key context for decisions, which values expert and local knowledge, which seeks collaboration and real ‘added value’. It engages local people and those affected in the design of new alternatives, in generative approaches and solutions which are only possible because there is a shared commitment to understanding the problems and creating the solutions. This approach involves people in the decision-making itself.
To those who still see the world as a linear place, or as a world in which experts are right and resistance to change is wrong, this is a more than a little scary. It needs careful management of process and an eye for the benefit of emergent approaches.
It is the way described in the Fontis Declaration. It is the work of Fontis.
Thursday 16 June 2011 09:00 by Graham English (comments: 0)
On Saturday, while the weather was good in these parts, I found myself watching a sort of birth, perhaps more accurately a re-birth or metamorphosis. A large, ugly and bizarre insect, having crawled from our garden pond, burst open and a beautiful bright green dragonfly slowly emerged and eventually spread its wings (a female Emperor I believe, pictures available here ). The spectacle was at once captivating, beautiful and horrific – a little like watching scenes from an Alien film. And once I’d seen one I saw two more transformations taking place elsewhere.
This week also saw the publication of the Future Forum’s recommendations and the very immediate Government response. What sort of metamorphosis was going on here?
First, some observations. Those involved seemed to feel they had been listened to (Is it just me or do I hear a weird echo of ‘I agree with Nick’?). Some but certainly not all of the critics of the original Bill, especially among the clinical groupings, said relatively kind words about both publications. And there is much that remains unclear – several of the Government responses are of the ‘we’ll tell you (the detail) later’ and ‘this is what we really meant’ variety.
It also seems that the announcements have, at least in the immediate interim, successfully balanced the competing political interests in the Coalition. (This has always been more about big P politics than about listening). True, there are right-wing Tory complaints of watering down of the competition elements of the original Bill, but interestingly that plays into Nick Clegg’s hand in the short-term (‘see, we’ve successfully toned down excessive competition in the NHS and annoyed some Tories too’). The commitment not to actively seek growth in either the private or public sector seems also to make possible exactly such a change, albeit ‘unintentionally’.
The document describing the changes sets out 19 areas of change in 64 paragraphs. My own view is that many of these changes are very minor indeed, having the effect of curtailing some of the ‘excesses’ potentially found in the original Bill, safeguarding intent while maintaining overall direction. I see very little in the way of U-Turns, and much now appears to depend on the wording of the mandate given to the NHS Commissioning Board.
Apart from fixing a political deal the Government felt it had to be seen to fix a deal with the clinicians too (to gain their ‘ownership’ of the planned changes in the jargon). Yet that is where the recommendations and responses are at their weakest and also least surprising – the latter perhaps because so much had been trailed beforehand. Why are these the area of weakness? – because here the greatest opportunity has been missed. While a cumbersome arrangement of lay inputs with forced chairing arrangements pays lip-service to a very real governance issue, the recommendations repeatedly fail to deal with the other more important deal that was there to be done – the deal with the public at large. Yes, there is reference to increased involvement of patients and public in planning services, and in a very limited way that is welcome to us. Yes there are limited potentials in different arrangements for Health and Well-Being Boards and for HealthWatch. However what is not clear is that any of those potentials will stand scrutiny against the criteria established by the Fontis Declaration. Will those new arrangements be other than marginal? Will they necessitate genuine involvement not post hoc consultation? Does the Emperor have new clothes or just a desire to be seen to have new clothes?
The best joke I heard in all this? ‘Andrew Lansley was first to agree when Dave intoned the phrase “nothing about me without me”’! Whatever individuals’ political futures hold, there too was the very nub of an opportunity missed.
And the dragonfly I watched? It clung to the side of the pond while it rained all day on Sunday and on Monday morning it was found floating face down in the pond. The others had gone, who knows where.