I don't envy the leaders of PCTs. Following the recent rationalisation programme, they are under more pressure than ever to deliver improvements in healthcare within tight budgets and aggressive timescales. This against a backdrop of continuous political, policy, regulatory and clinical change.
I wonder what Sir Gerry Robinson would make of it. Perhaps he would suggest that many of the primary care problems can be resolved by charismatic, 'business-like' leadership, more common sense and a bigger can-do attitude. No doubt he would note that the various cultural differences between the clinical disciplines and particularly between clinicians and managers make it difficult to drive through change. Personally, I'm not sure that the NHS is the place that attracts the captain-of-industry style leader with a big personality and a bigger pay packetand I'm not convinced that they can wield the influence they have in the business world.
Let's assume that we do have competent leaders who are trying to do a difficult job in difficult circumstances. What could be lacking are some of the systematic methods and tools that are essential to run a large organisation effectively. One particular area that lacks maturity, good practice and an organised approach is the ability to understand and manage change.
You can think of a PCT as a system - it is complex and can only be effective when its constituent parts are working in harmony with each other. In order for any system to be viable, there has to be a fundamental ability to learn and then adapt behaviour in order to do better in the future.
Many of those who work within and around primary care would agree that change has never been so big or so fast. The PCT is like an aircraft trying to stay on course whilst having engine failure, flying into a hurricane and being hijacked over the Bermuda triangle, all at the same time. What makes things worse is that in some cases someone forgot to fit the navigation system and autopilot.
So how can PCTs help themselves and improve their change 'navigation' without budget increases, major staff changes or new generation IT? The six point plan below sets out the main aspects of a framework whose fundamentals can be put in place right now.
1. Grow a culture based on process understanding.
Process methods are central to any organisation's ability to navigate through change. They enable clarity, measurement and feedback. The foundation of being viable is knowing how the work is done today and what needs to be changed to ensure effectiveness tomorrow. If your PCT isn't really clear about how its processes are designed and managed (many develop ad-hoc over time) and if there's a lack of documentation to describe them, how can anything systematic be done to ensure they are 'fit for the future'?
Immediate action: Put in place a method of mapping key processes. Make it accessible to the entire organisation and use the staff doing the work to develop and maintain it - this is crucial to its success. Use the maps as a tool for training, risk analysis, communication and process improvement.
2. Develop 'organisational intelligence'.
Think of how military intelligence is gathered and analysed. PCTs need to have staff - aside from the leadership - whose responsibilities include evaluating new initiatives, building learning relationships inside and outside the industry, performing scenario analysis and generally 'scanning the horizon' to provide feedback to planning. Looking back, how early could PCT rationalisation have been predicted? How many PCTs spent serious time understanding the opportunities and threats of the new world? Organisational intelligence provides an early warning system and helps to prevent learning everything as a result of hindsight.
Immediate action: Create a function for organisational intelligence. Understand how to put a system in place and use present staff to resource it initially. If this is done well it actually frees resources up downstream because people need to chase their tails less and decision making is based on proper analysis of data related to change. Your PCT becomes much more proactive. Instead of everyone sawing the tree furiously with a blunt saw, some people are dedicated to sharpening it first.
3. Make your teams powerhouses for delivery.
The main aspect that comes to mind when putting a team together is ensuring that staff have the right technical competencies. This is important but what about the things that make teams really fire? How much thought is put into team design? How do you develop teams with the ability to really pull together to solve difficult problems in difficult circumstances? At the moment there's too much average performance, and there's a leadership culture that settles for average. Getting high team performance depends on many things - one of the really vital abilities is to have a team process not just for doing the work but for looking at how the staff interact and work together to achieve their purpose. There needs to be a more systematic approach than a bit of feedback in team meetings. What helps or hinders performance? How does the team learn? Who are the ideas people? Who are the communicators? Are they used to best effect? I recently sat down with an established team and asked the team members to each write down what they felt was the main purpose of their team. There were so many differences, the leader had his head in his hands in despair by the end of the session.
Immediate action: Set a high bar for achievement and demand performance excellence. Review team make-up and make sure they contain the right non-technical skills. Develop a means to chart the development of your teams that is directly related to performance. Understand how really good teams operate and develop the know-how to be able to move your organisation towards this goal. All teams in your PCT need to be able to do this for themselves.
4. Create a network of change agents.
At the moment, most of the responsibility for managing, coordinating and communicating change is assumed to be the responsibility of senior management. Why not develop your staff as 'change agents'? These are people who have an understanding of change management as a discipline. They know how to lead change rather than react to it; they understand how to set up feedback systems; they know how to find out what gets in the way of being adaptable and how to fix it. Change agents need to exist as a network at all levels of the hierarchy. They need to be where the work gets done - at the point of service delivery, in the mail room and on the Board.
Immediate action: Understand what is required of a change agent and identify people within your PCT for the role. Initially this is likely to be a part-time responsibility. It doesn't necessarily mean more work but if that's the case, then there will need to be a reapportionment of workload. Provide clarity on what they need to achieve and support them continuously. Use them to drive your PCT forward.
5. Develop meaningful feedback.
Make the search for meaningful feedback central to everything that you do. There should be a clear, meaningful set of measures in place that are directly linked to the key things that need to be done. Indicators are sometimes chosen because they're easy to obtain, not because they're the best measures. Sometimes there's so much data, the wood is lost in the trees. Sometimes good measures are used incorrectly as a measure for something they don't have a direct impact upon - either because the impact is 'attenuated' by other factors or because they're working at the wrong level of detail. So often managers find it difficult to really have an impact on measures because they don't have control of enough of the factors that contribute to their variance. There is good practice out there that can be used right now.
Immediate action: Look at the measures you currently use and ensure that they clearly reflect the performance changes you are concerned with. Understand what contributes to the variance in your measures. Techniques such as source-cause analysis can be used to do this. Understand how your measures link to each other - what are your primary indicators? There will be a hierarchy and interconnections between them that need to be appreciated. Separate out strategic measures from more detailed process and risk measures and make sure the accountability for performance against these measures is clear. Halve the number of measures you use and double their quality.
6. Improve decision making and link it to action.
There's no rocket science to making good decisions when managing change. Firstly, they're based on getting good information (see organisational intelligence above). Secondly, they mean having a process in place that organises and uses that information to best effect within the right timescale. Being in a position to make good decisions will generally mean being able to separate out the change information from the rest of the day-to-day work.
To know how good the decision was there has to be an ability to understand what the effect of that decision has been on performance - back to feedback and measurement. One way to achieve all this is to develop a method of project management that includes a means of clear prioritisation and governance. Projects can be seen as the actions that directly result from decision making - they are the performance related activities that are getting done by the PCT as a response to the change that is happening.
Immediate action: Look at the main activities that you are doing now. What is change related and what is concerned with the day-to-day operation? Budget and resource the change stuff separately. Call the change activities projects (if you don't already). Understand how they link together and what they are trying to achieve. Employ a pragmatic means of prioritising all projects. Know what your 'golden' projects are - those few that just can't fail - and resource them accordingly. Make sure your staff have the right competencies to manage projects. Develop a means of governance that includes clear accountability. If possible, create a separate 'change' function. I appreciate this may require some reorganisation, and possibly a different type of resource. But if linked with the idea of change agents, it needn't require additional finance.
Roger Noon is director of Kredo Limited ( roger.noon@kredo.co.uk)
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