Tough at the top: the challenges facing management teams in the new NHS

It is tough being on top teams at the best of times but now it has become even harder. There is nothing like a massive prospect of change to stretch to breaking point the capability and cohesion of the top team leading an organisation.

In a survey of public sector leaders about their concerns at dealing with the current deficit, 58 per cent said their top team was not fully aligned to deliver the savings and change agenda.

In times of intense change, the top team is required not only to deliver efficiencies and sustain and improve services, but also to inspire loyalty and give regular reassurance. It is essential that the chief executive and the executive team are clear about the rationale for change and are cohesive in their approach to delivering that change.

The NHS challenges of a new policy framework, new system architecture and the requirement of a £20bn efficiency gain follow a sustained period of significant investment and growth.

Among the present generation of senior leaders, many have never before faced cuts on this scale - or these combined pressures - from the perspective of an executive role. Their experience and often their working practices do not fit with this new world.

When times get tough, the cracks start to show and weaknesses previously unseen in top teams become apparent. What has been described as teamwork can show as mere collegiality without cooperation. What has been described as strategic thinking can be seen as maintaining the status quo. And what has been described as challenging debate can be seen as protecting self-interest.

Ultimate test

The challenges for top teams across the NHS sit within the same broad context but also vary in their specifics. Strategic health authorities and primary care trusts face the ultimate top team test of maintaining organisational performance while winding down - an unenviable challenge.

Non-foundation trusts face the challenge of raising the performance bar sufficiently to get to FT status. Existing FTs and others face the uncertainties caused by mergers with other providers and services.

Commissioning consortia on the other hand face the unique challenge of establishing new organisations, new structures and new operating models while also learning new skills and developing new capabilities - see box below.

The specific challenges may be different, but there are some core things that top teams need to do to be successful in this period of rapid change.

First, ensure that team members see corporate leadership as their number one priority above a function role. The key to this is a genuine collective understanding that their primary role is shared accountability for delivering the change agenda. Objectives, team focus and individual and group actions must focus on their interdependent responsibilities.

In other words they must focus on the fact that the change agenda is only deliverable if they all work together - no one team member can achieve their objectives without the others.

One of the most common mistakes of top teams under pressure - especially in a period of declining resources - is tribalism. Protecting their “own” function, department or team should be unacceptable within the top team itself. Decisions on efficiencies or cuts should be made in a peer-reviewed process with all areas examined equally without exception.

Second, the norms of behaviour for the team need to be restated explicitly. In times of stress previously implicit norms, such as not discussing top team disagreements in other forums, can break down.

Taking time to briefly restate and essentially re-contract the expected behaviours within the team helps to reaffirm the sense of team itself and smooth any feathers ruffled by the inevitable tensions and challenge in the room.

Third, focus top team time clearly on the change drive itself. Ask yourself: “Are the issues being debated, and the actions being agreed, all in line with the change we need to make?”

If not, they may reflect the old world and be at best distracting from the direction the organisation now needs to take.

Finally, the team needs to collectively and continuously work at communication and engagement of staff and stakeholders. Ninety per cent of public sector leaders believe this is the biggest challenge of addressing the public sector deficit. We also know from the recent private sector recession that one of the central differentiators in those that emerged with strong staff engagement, despite making cuts, was to increase the level and quality of communication from their top team.

Taking time - in truth probably more time than you would normally be comfortable with - to discuss challenges honestly and transparently and to engage people in the rationale for change will pay dividends later and maintain both trust and commitment.

All of the top team need to do this, across the whole organisation, for it to be clearly seen as a collective responsibility.

There is also an opportunity for top teams to look beyond the present challenges to reshape service models and approaches for a very different future - an opportunity that may not come again within a chief executive’s career.

In the private sector, 35 per cent of senior leaders thought that the actions they took during the recession damaged their organisation. And yet 87 per cent believed that ultimately the recession was a good thing for the opportunities it created for change.

That is the challenge for visionary NHS top teams leading their organisations and people through these stormy waters.