Are we up for it? Adaptive leadership in the NHS?

Jenni Russell in a recent article in the Guardian raised some critical issues about the NHS which require us to stop short and pause:

  • “The whole debate about the NHS is taking place at a level entirely detached from what people experience… the experience of the real person sitting in the clinic or hospital bed (or care home) is too often neglected. And yet that experience is at the heart of what the health service is for.
  • The problem is politician’s manic belief in the existence of perfect systems. (This lets us citizens off the hook too easily as many of us also hold a belief in the possibility of  perfectly engineered and designed systems  as if the NHS was a machine with levers and pulleys that could be designed like a Heath Robinson contraption).
  • What people want from the health service is indeed efficiency and reliability, but above all they want compassion and care… Politicians (and managers) shy away from this language because it sounds soft and is hard to measure.”

Russell’s article however creates a false dichotomy between a focus on systems or a focus on care. We need an integrated focus that looks carefully at system design and how it encourages or discourages certain behaviours.  The not uncommon incidents of discourtesy, lack of care, bureaucratic attitudes in the NHS are not just breakdowns of individual behaviour – a few bad apples – but also the impact of a culture and a certain kind of management system that has inadvertently created a climate where “an elderly patient can be told by the night staff that they were too busy to help her to the lavatory and she should just wet the bed” to give one example from Jenni Russel’s article.

Leaders at all levels in the health service need not to be afraid to talk about values and purpose. A critical aspect of leadership is to change the conversation and create with others a compelling and motivating narrative about who we are and what we are doing. Dee Hock, the founder of VISA, still one of the world’s most successful companies and at its inception one of the most innovative, said that “clear, meaningful purpose and compelling ethical principles evoked from and shared by all participants should be the essence of every institution.”

Barry Oshry asks what are we jointly committed to?  What’s the purpose that unifies the various players, institutions and tribes in the health service? Above and beyond our specialisation, competition and autonomy (all of which are helpful and necessary) what is the unifying overarching purpose that needs to be renewed? Leaders need to (re-)learn that leadership is both deeply systemic and personal.  System design matters but how we think about that process needs to shift radically.

This is the adaptive nature of the challenge – we need a retooling of how we think and act. But are we up for that level of not knowing, of holding open a space for experimentation and learning, of seeking to create new solutions with others, of sharing responsibility?

The reflex response which we may yet fall into again is to look to the Tops (Cameron, Lansley, Nicholson and the Department of Health) to sort it. That way is well tried and failed –  a few Top Leaders cannot effectively design a complex system from on high in isolation.

So the adaptive challenge is to face up to the stark fact that our thinking and core assumptions about change, leadership and organisation design need to move on.  There are pockets in the NHS who know how to do things differently – can we learn from those places of experimentation and next practice. There is much unlearning for the rest of us to do. Are we up for that? Who has the courage to name that agenda and to step into it for themselves and lead others on that journey.

Back to Visa, with a sixth of the world as its customers, Dee Hock reflected on governance that “agreement is always dynamic, imperfect and malleable. Reaching and sustaining agreement is a continual process, as alive as the people involved”. Public sector notions of governance are often too mechanistic and static, as if the system being governed was an inert object rather than a pulsating, complex web of people in multiple relationships. Hock’s conclusion is that we live in “a world of such complexity, diversity, and multiplicity of scales that there is little possibility of achieved constructive, sustained governance within existing concepts of organisation”.

Without this radical commitment to unlearning and experimentation, we can’t evolve our thinking and action into this new way of organising and leading. Without that step, we won’t be able to shift the dismally low success rate of organisational change projects. The latest book from McKinsey’s published this month, Beyond Performance, quotes a continuing failure rate of 70% of change projects.

Are we up for it? It requires all of us to enter this conversation and play our part.



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