Leadership is not merely about getting a move on, but being much clearer about where you are going. A clear destination is essential, writes Roger Steer
The HSJ devoted a whole supplement to “ending the crisis in NHS leadership”. Personally speaking, I doubt that the NHS lacks leaders, what would-be leaders lack is a clear destination.
One remembers “in search of excellence”, which became “in search of a chief executive”, which became “in search of a market”, which begat “in search of the balanced books”, which begat “in search of modernisation, quality and avoidable deaths”, which begat “in search of choice and competition”, and then “balance the books again”. So much searching and so little fixity on where we are all going.
In the meantime, it is not entirely surprising that if you give an opportunity to fill a supplement, managers will ask for more power and autonomy, more pay, bigger empires, more training and support, and presumably a get-out-of-jail card. I paraphrase slightly but that was my overall feeling on reading the report.
My objection was however to one very specific recommendation made, namely to fast track complex “change” proposals. This is necessary apparently on the grounds that those seeking change find it daunting and onerous, and it is acting to block necessary innovation.
It would be better, it is claimed, if the change processes were all much simpler, swifter and decision making less “political”. At this point I need to declare an interest.
Our team advises local authorities, scrutiny committees and others reviewing such proposals; we have been doing this for 10 years and most recently in South West and North West London, where examples of such proposals have been put forward.
This work has evolved over the years. At first it was easy to point out there was no business case, then that there was no stakeholder support or likelihood of funding being available to finance proposals, or that the clinical evidence for the claims made was disputed and unreliable as a guide to decision making.
Most recently it has been necessary to report that the costs of major reconfigurations have been wildly underestimated, with revenue costs of change exceeding the value of savings to be made; the claims that large reductions in admissions are possible from extensions of out of hospital care are not true; and that the best way of increasing quality is not to close hospitals in the teeth of rising populations, increasing needs and cutbacks in social care.
‘Leaders are being misled if they think they can fast track these changes’
If “leaders” think they can fast track these “changes”, it is they who are being misled. Such proposals can affect up to 2 million people, require investments of up to and over £1bn, involve up to eight different clinical commissioning groups, as well as many independent NHS, private and voluntary providers, up to eight different local authorities and hundreds of GPs; and all too often are presented without compelling evidence, complete and realistic business cases or any indication necessary funding approval can be obtained.
On top of this, proposals are put forward in such a way that the public, stakeholders and decision makers are given neither the time nor opportunity needed for proper appraisal or dialogue and negotiation. It is not surprising therefore, as anyone who has read the Independent Reconfiguration Panel reports over the years knows, that as a result objections are made, independent reports called for, delays occur and changes to changes first proposed made.
It’s not that there can never be a case for change but that the case should be a compelling one and not just based on wishful thinking, wilful blindness and “groupthink” (see The Blunders of our Governments by Anthony King and Ivor Crewe).
Seen to be doing something
Leaders who blithely insist that all this can be swept along in a brisk canter to a simple fence easily surmounted are not familiar with the territory, the animal or the consequences if things go wrong. Instead they seek to persuade by slick rhetoric, glossy presentations, dire threats and vain promises of a golden tomorrow.
Trust me, people have a sensitive nose for propaganda, sham consultation and do not like being asked to worship false gods, even if they are dressed up as improvements and as “sustainable”.
‘True leaders have respect for due process and evidence’
True leaders have respect for due process, evidence, winning hearts and minds and for the people who come after them who will have to live with their decisions.
The cynic in me suspects that many who call for less restraints on management are really seeking opportunities to make a name for themselves so they can secure better positions in the “transformation industry” or the unaccountable ”intermediate” tier. But more charitably, it is more likely to be because they are under pressure to be seen to be doing something and are inexperienced in large scale change processes.
So by all means discuss leadership but there should not be a supposition that it is merely about getting a move on, but being much clearer about where you are going.
Roger Steer is director of Healthcare Audit Consultants