Better leadership for health and care (second meeting)
This was the second of two meetings on the topic ‘if we don’t like command-and-control leadership methods in our health and care systems, what are the alternatives?’ The note of the first meeting is here.
Tom Neumark, CEO of the 999 Club, a charity which works with homeless people in Lewisham, was our introductory speaker.
He described how he built relationships, over time, with key individuals at the South London and Maudsley NHS Foundation Trust (SLaM), and eventually this resulted in the charity bidding for and winning a contract to deliver a new mental health service. During this process the charity wanted to engage with the statutory health and care system in a spirit of partnership, but ‘on our own terms’, not allowing mission creep, and therefore not simply responding to a tender specification.
The 999 Club wanted to achieve the goal of creating a friendly, and safe well-being space with enough freedom to build a community where people with multiple and complex needs could be supported in their journey towards better health according to their individual circumstances.
So, the 999 Club set out an offer along these lines, and was eventually successful in the tendering process. The willingness of senior leadership in the statutory sector to consider different ways of doing things was vital to achieving this, and Tom praised the qualities of many of the leaders he worked with. Tom also noted that many NHS policy statements and principles are very supportive, placing emphasis on participation, inclusion, community, and relationships, for example.
But the system on the whole does not always match this – transactional service design still predominates, and the contracting process is very hard for a small charity to navigate. It is clearly designed for much larger organisations – even though it is so often the smaller charities and community-based organisations like the 999 Club which are best placed to ‘bring alive’ the abstract principles espoused by the NHS and Integrated Care Boards. Tom said he was very grateful to his charity Board which provided strong support during what was a very demanding process.
Here are some of the key points made by speakers and in discussion, following breakouts to consider what can be done to make better leadership more widespread in the systems of health and care:
It was emphasised that leadership which is committed and determined to follow through on the principles that the Better Way promote, is needed both in the health institutions, and also in the community and voluntary sector, to break through the old ways of doing things which remain so prevalent.
It is extremely difficult when leaders are in the thick of things, overwhelmed with constant pressures and urgent demands, to make a real change in how things are done. It is ‘hard to talk about the colour of the wallpaper in the living room where there is a fire in the kitchen,’ as one person said.
So, a fundamental mindset shift is required, an epiphany or moment of realisation – not least that the role of a leader is to create opportunities for others in the system to produce the solutions and design the services, not to take the responsibility for doing this all to oneself. Realising that a good leader listens, takes hands off, supports others – understanding that the task is to be in service of the front line. And appreciating the value of a permissive and supportive culture, e.g. ‘from now on, everyone’s going to be brave’.
And rather than only trying to fix the immediate problems, leadership should be seen as building a better understand of why the problems have arisen in the first place and what can be done to prevent them recurring. And leaders should be encouraged to do more to bring people together into a creative space to share experiences, and generate the ideas that can drive positive change, using different methods (arts for example) to make this possible.
The NHS has promoted a culture of leadership as ‘expertise’ – it now needs to move from this to a culture of ‘shared wisdom’. And we need to be talking about system leadership, not just individual leadership.
The NHS is massive, and needs to find ways to support its managers to be people, not machines, and ‘to experience the joy again’. Better leadership is more likely to flourish where organisations are willing to let go of monolithic control from the centre, and work in a more distributed way, with largely self-managing teams.
A lot of good practice can be found, but remains sporadic, marginal, or out of sight. We need to ‘elevate what exists’.
But it is a mistake to try to ‘cut and paste’ a successful model or method, and hope it will achieve the same results elsewhere. Generally, processes don’t travel, but principles do. Local leaders need the freedom to design what feels right in their locality, informed by the set of shared principles. And commissioning needs to get better at allowing and supporting things to evolve and adapt, and move away from fixed targets.
We should remember that a shift in the direction we have been discussing is certainly possible – community engagement and distributed leadership used to happen more naturally before the advent of new public management in the 1980’s. In the NHS and elsewhere it has been all about frameworks and targets and milestones. This hasn’t worked. We need to be able to get back to talking about relationships, care, even love, and bring our humanity to bear.
And the Better Way principles and behaviours are a very useful guide, it was felt, and within our network we should grow our own confidence that ‘we are the leaders that we are talking about’ – the starting point is to do it ourselves, and tell the story of the Better Way in action. The more we show the way, the more others will follow.