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The unsung hero

The unsung hero

28 July 2015

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Changing a system involves the subtle art of persuasion and is not a task for glory seekers

Changing a system involves the subtle art of persuasion and is not a task for glory seekers

If anything involves system leadership, then clinical commissioning does. After all, it essentially involves deciding what the NHS wants to buy, and who to buy it from. And it is now universally acknowledged that for the growing numbers of patients with multiple chronic conditions simply acquiring siloed services, whether primary or hospital care, or social care and health care, or purely physical or purely mental health services is not going to provide the rounded service that these patients need. The days when it was sufficient to have great leaders of single great organisations have gone. For clinicians, managers, and commissioners it is all about working across the traditional divides.

Question time
But if system leadership is what the NHS needs, how do you go about it? What skills does it require? What challenges does it involve? What are the barriers that need to be overcome? And how do system leaders develop?
Those were the questions that The King’s Fund recently put to 10 people who might reasonably be called “system leaders” in order to produce, for its annual leadership summit, a paper entitled The Practice of System Leadership. It came with the slightly enigmatic sub-title of, Being comfortable with chaos.
The interviewees included the chief executive of a large county council; people who have led integrated care projects; those working with clinical networks, clinical senates and academic health science networks; a whistle-blower; the head of a large voluntary organisation; the chief executive of a large teaching hospital, and individuals who have led, or who still lead, the NHS at regional and national levels. System leadership was defined very simply as seeking to achieve change across organisations where people do not have direct line management responsibility.
The aim was not to produce a series of recommendations, but to reflect their experience of the task. How to get the changed services that commissioners want to buy with – by implication – lessons for commissioners on how to help others produce that.
Intriguingly, all the people interviewed recognised the need for system leadership, but a significant proportion had no wish to claim the title. To do so “is to put yourself 40-love down before you start,” Professor Sir David Fish, managing director of UCLPartners, says. “It can have really negative connotations. It sounds as though I am telling you what to do. And we don’t do that. We are, instead, a catalyst, an enabler. We are trying to help good things go faster.”

Putting patients first
A second, and related, theme was that you can achieve almost anything if you don’t wish to claim the credit for it. Or as one interviewee put it: “You have to give away ownership” – planting ideas that then come back to you as people’s own idea. So being a system leader was definitely not a heroic, Henry V, type role.
What it essentially involved was an act of persuasion across the primary, hospital and social care divides. Persuading individuals and organisations to act in the best interests of the patients even when that was not necessarily in the best interest of individual organisations or, indeed, of the individuals involved. It thus required different skills to line management, and additional skills to those needed only to lead a single organisation. It is not a task that will suit every personality.
As Thirza Sawtell, director of strategy and transformation at the North West London collaboration of clinical commissioning groups (CCGs) put it, with deliberate humour: “If you are someone who needs to take credit and needs recognition, you are probably not going to fulfil the role of working across systems and taking pride in other people’s credit and achievements. I am not making the role sound very attractive, am I? No one notices what you do, it’s hard work, it takes a long time. It’s not much of a sell, so far.”

It requires, perhaps obviously but also ideally, a strong evidence base – not least to help convert the unwilling. And it starts with a coalition of the willing, from which one can build outwards. “You need,” says Ruth Carnall, chief executive of the former Strategic Health Authority for London, “the best, most diverse group of clinical leaders that you can possibly muster. One of the biggest sources of influence was your ability to get powerful clinical leaders on side and then to take responsibility for leading it on your behalf”.
Time and again, these system leaders said it was crucial to involve patients, service users and carers. They, after all, often have strong views on what is wrong with the present arrangements and when they line up behind a system change “it is very hard to say to a patient you are not going to do something because your trust will lose out,” as Jan Vaughan, director of Clinical Networks for Cheshire and Merseyside, puts it.
Plenty of paradoxes emerged – for example, it requires both constancy of purpose, but also a degree of flexibility in precisely how the goal is to be achieved. It takes time, but time is at a premium. And just because everything doesn’t go perfectly at first, good ideas should not be dumped before they’ve actually been given time to prove themselves. All of which helped produce the sub title – That those doing this need to be comfortable with chaos, although that is chaos on the way through, not chaos as the outcome! And system leadership clearly works best when there is stability of leadership so that trust can be built and constancy of purpose can overcome the inevitable bumps in the road. There was an interesting divergence of views among the interviewees on the extent to which system leadership can be taught, or how far it has to be learnt in an almost apprentice-like fashion.

The barriers
It turns out, of course, that there are plenty of barriers to system leadership. The churn of chief executives – the lack of stability – is one. The sheer complexity of the current architecture is another. That leads to difficulty over co-ordination of goals, targets and requirements, while the consultation process for change, and the myriad impact assessments and business cases involved, came repeatedly under fire. Were the government to review the consultation and appraisal processes with a view to simplifying them, there would be cheers from some of the interviewees.
Nobody advocated another reorganisation. But it is clear that some miss the former Strategic Health Authorities, there now being no one single place where people can come together to resolve crucial issues. Work currently underway at the top of the NHS between NHS England, Monitor, the Trust Development Authority and the Care Quality Commission, is seeking to address that, but there is clearly a good way to go.
Despite the difficulties, the picture that emerged was far from gloomy. After all, those interviewed had all achieved at least a degree of system change, and the collected interviews amount almost to a handbook on how to think about, and go about, the task. But the clear message from the interviewees is that the job would be a lot easier if it was made easier to do. Clinical commissioning groups clearly have a part to play in that.
The Practice of System Leadership: Being Comfortable with Chaoscan be downloaded free from The King’s Fund at

Nicholas Timmins, senior fellow at the King’s Fund who carried out the interviews and a former public policy editor at the Financial Times.

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