primary care trusts

Published: 19/09/2002, Volume II2, No. 5823 Page 26 27

Chief executives of primary care trusts need to influence many groups in order to be effective. Jane Beenstock explains

What makes an effective leader of a primary care trust? And how can they make sure they are sending out the right signals?

PCT chief executives need the ability to connect with a variety of constituencies, the capacity to set a direction and to ensure targets are met, plus willingness to act as a buffer between central demands and local aspirations.

There are many constituents who need to be engaged in the work of the PCT. Like all NHS trusts, we have a board.However, PCTs also have a professional executive committee, and tension between the two is to be expected as each works out its area of responsibility. PCTs are also involved with many separate organisations.

In Southport and Formby we have 20 GP practices, all independent businesses.We have 400 employed staff, 120 voluntary organisations, at least six other statutory organisations, 36 opticians, 53 dentists, 23 pharmacists and - finally and perhaps most important - the residents, who number 120,000.

So, who leads all these different stakeholders and ensures they are engaged in achieving the PCT's objectives?

The chair is the most visible leader of the board and probably the trust. But directly-employed staff often see the chief executive as their leader, or their line managers.

The PEC chair is the clear leader of the executive committee, and selfemployed GPs are likely to see that person as their leader. Some staff will see their elected representatives on the PEC as their leaders. The public, partner organisations and voluntary organisations probably see either the chair or the chief executive as the leader, depending on their contact with the trust.

So the phrase 'three at the top', which describes the relationship between the two chairs and chief executive, is critical to success.

We need to recognise that in a sense PCTs have three leaders, each one appealing to different constituent parts of the organisation.

Chief executives need to adapt their style according to the group in question.

The chief executive needs to connect people within the organisation with external constituents.

And, uniquely, chief executives, as full-time accountable officers, must have the responsibility for connecting all three leaders. This ensures that, between them, all stakeholders and constituents are engaged.

Devolution is a key policy theme, with PCTs set to hold 75 per cent of the NHS budget.

The government says: 'There will be maximum devolution of power to local doctors and other health professionals.'

1 The message is clear: we must move from a centralised service to a devolved model.

But how can chief executives be expected to lead an organisation when we are held to account for things which are actually delivered by other organisations? We need to live with a high degree of ambiguity.

Devolving power from the centre involves a tension. Our leadership style needs to cope with ambiguity and loss of control, while at the same time accepting stringent levels of accountability.

With performance management increasing, it will be a critical role for the chief executive to ensure that the organisation meets national targets.Meanwhile, frontline staff need to have the freedom to innovate and tailor national policy to local demands. So in some ways, chief executives must act as buffers.

Chief executives must give shape to PCTs and show a clear direction of travel, without getting bogged down. They must maintain a particular vantage point which allows them to be effective.

Ronald Heifitz suggests: 'Leaders have to be able to view patterns as if they were on a balcony. It does them no good to be swept up in the field of action.'

2He points out that 'without the capacity to move back and forth between the field of action and the balcony, to reflect day-to-day, moment to moment, on the many ways in which an organisation's habits can sabotage adaptive work, a leader easily and unwittingly becomes a prisoner of the system'.

The chief executive needs to ensure enough elasticity in the system to allow creativity and innovation, but also clear structures to meet statutory obligations and targets.

Chief executives also play a key role in team development.We have developed our teams at Southport and Formby through the use of the Myer-Briggs personality inventory, which categorises individuals into different personality types.

This has helped our team understand why I am stressed by one director's apparently last-minute approach to board papers. In turn, her view of me is as someone who can be rigid and overly structured.

The value of this approach is that it is a neutral way in which to understand personalities, enabling everyone to engage and learn together.

Chief executives are watched by everyone; their actions and their words are taken as cues for other people's behaviour. So we must decide on the tone and style we want in our organisations and attempt to make our own behaviour fit the model.

This requires chief executives to have a good understanding of themselves and their values, and an appreciation of how their own prejudices influence their reactions.

Recognising the influences on one's own life and analysing one's own motivations and reactions is vital if you want to lead others.

I heard on the grapevine that if I stayed at work after 6pm, staff found it hard to leave their own posts on time. So I stopped that, and it seems to have had an effect. I want staff to have a balanced life.

Chief executives must also empower their staff, but how?

Julian Richer, chief executive of hi-fi chain Richer Sounds, has banned the words 'staff ' and 'employees', so everyone in the organisation is an equal.

3The use of language and how we label organisational structures show how we value people and rate their contribution to the organisation. In Southport and Formby we call our senior management team the 'core team', middle managers are our 'co-ordination team' and everyone else is part of the 'wider team'.Why? Because of the impact of language. If one person is in the top team, where are the others? In the bottom team?

On a more fundamental level, We are trying to create community connection teams. Their job is to think about the needs of the population, with healthcare professionals, voluntary organisations and social services all being facilitated by the same person.

For example, the implementation of the winter flu initiative this year will be different in Formby to the rest of Southport, because local people and professionals will make their own decisions about how to increase immunisation uptake.National policy is likely to be implemented differently in the four community connection team areas.

guess that some of you may well be thinking that it is different in business, but human beings are essentially the same, whatever sector they work in.

believe there are many lessons we can learn from people like Ricardo Semler.

4It is only by having a truly empowered workforce that we will achieve the kinds of modernised services we currently aspire to.

Shifting the Balance of Power talks about the active involvement of staff.Although people often find it hard to define just what culture is, staff can usually tell us whether a culture is supportive and empowering or autocratic and demanding.We need to aim for organisations that will be exciting for staff and inspire confidence in those who use our services.

So chief executives need the ability to connect many different organisations and groups, a bold vision, a sense of direction and the ability to deliver.

Such a combination of vision and action could certainly change the NHS. l Key points lPrimary care trust chief executives need the ability to connect with a variety of organisations and groups.

They need to maintain a strategic vision.

They must be able to deliver on targets at the same time as delegating power and allowing local flexibility.

Their behaviour and values set the tone for the organisation.


1 Department of Health.Delivering the NHS plan: next steps on investment, next steps on reform.

HMSO, April 2002.

2 Heifetz R, Laurie D L. The Work of Leadership.

Harvard Business Review, 1997.

3 Richer J. The Richer Way.

Richer Publishing, 2001.

4 Semler R.Maverick!

Random House Business Books, 2001.

Jane Beenstock is chief executive, Southport and Formby primary care trust