Malcolm Lowe-Lauri on his last column

Malcom Lowe-Lauri

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This will be my last column. While working in London I could sustain the roles of foundation trust chief executive, a member of various national boards, HSJ columnist and playing in my band.

Working in the East Midlands requires some adjustments and there is much to do in Leicester.

The commitment to the eventually unaffordable private finance initiative scheme consumed enormous energy. We will now turn that to a sort of organisational refurbishment. Clinical standards are high, so whatever I say should not worry the people of Leicester about the service they are getting. But we have big plans about the way we operate, from the boardroom to the shop floor. Our board has already agreed to deconstruct and reassemble itself to strengthen its focus on important corporate governance tasks.

We are asking a lot of ourselves, in terms of time and energy, to make this happen. The middle level of our trust - clinical director and general manager land - needs an imaginative development programme to convert enthusiasm and commitment into peak performance, in preparation for foundation trust status. We must support that by completing our work on financial and performance infrastructure. And we have a few irritants to remove. An example: it is difficult to persuade specialist registrars to fill gaps in the roster if the payroll system contrives not to pay them.

Keeping my musical commitment reminds me that an understated role for chief executives and other corporate leaders is that of entertainer (though it still puzzles me how tales of woe from the Mississippi Delta get people dancing as much as they do). Perhaps this is in the genes, given that my ancestry includes music hall performers. Many leaders find themselves in the position of telling their people they are not as good an organisation as they think they are. Some do it nicely but leave the dirty business to a rottweiler performance director. The better leaders take it on themselves but leave you feeling you want to bounce back. NHS chief executive David Nicholson definitely falls into that category.

The masters of metaphor

The best of my colleagues over the years have been masters of metaphor. Mr predecessor, Derek Smith, had a habit of effortlessly crafting phrases which left many of us in awe. Occasionally they required historical knowledge beyond reasonable expectation. Likening elements of health strategy to the Schlieffen plan was of great entertainment to those who had studied pre-First World War Germany. Others were bemused.

When I was at King's College Hospital foundation trust I tried a few contributions of my own. I used to refer to "the King's Paranoia" to describe our intuitive fear of our neighbours. Mostly, the paranoia was good. It kept us alert and inclined to innovation. Latterly we had to check it didn't get in the way of forming the right relationships with those neighbours.

At Leicester new phrases are springing to mind in the cause of "critical friendship". In a near-monopoly environment of secondary care services provision one can become isolated from leading edge organisational performance and risk slipping behind.

I have likened this to the 1960s, when it was assumed decline would not affect us because we were British. We must get out more, to find what the best are doing, and we must make sure we don't continue a localised version of the English Civil War by perpetuating unnecessary rivalry between Leicester and Nottingham.

Some of these are exaggerations to make the point, running the gauntlet between offence and insight. Of course, no sooner have you made the generalisation than you discover excellence - but if you don't get out you don't get that on the map.

Metaphor works and is fun and stories are powerful if not always amusing. They can mix the personal experience with the reported. One of my favourite illustrations of breakthrough change is from my Peterborough days, when primary and secondary care clinicians interested in a particular specialty moved from tense encounters almost devoid of eye contact to near helpless laughter. The service model moved a long way too.

Team work

One of my favourite sources of narratives is the accident literature, especially startling discoveries such as how the power of hierarchy can get in the way of disaster avoidance (Tenerife air crash) or the devastating effect of informal workarounds when the new employee doesn't know about them (Devonport sterile fluids failure). These bring home to specialist registrars and new consultants how careful they have to be with position power and why team working is so important.

Getting people to imagine the patient's predicament is surprisingly necessary. The system can trap patients, relatives and carers in the outpatient cycle for years until we remember how many bus journeys and how many periods of waiting they have undergone, perhaps to be told simply to come back in six months. Next time you are on a bus spot the frail elderly passengers and note how scary it is for them, especially if standing. My job is to describe that and encourage us to find other ways of providing a service.

Why are influential clinicians and managers so often oblivious to this? As I have said before in these columns, our knowledge and networks cut through much NHS process and render us somewhat ignorant of NHS experience.

Metaphor and stories keep us planted in reality. They can be an entertaining and acceptable way of imparting criticism. That may be why they pervade the change management literature just now. They are not a substitute for evidence, more a framework for it. And don't overdo it - that risks the story becoming unintelligible.