Drawing parallels between the US army’s fight against Al Qaeda with the tensions of providing healthcare, Nishma Manek discusses how the NHS can adopt the army’s tactics to improve its functioning
“We were failing and Al Qaeda was winning. We may have had the best equipment and the best special operations units in the world, but we were not—as an organisation—the best suited for that time and place”.
When General Stanley McChrystal took command of the Joint Special Operations Task Force in 2004, he soon realised that conventional military tactics were failing. Al Qaeda in Iraq was a decentralised network that could move quickly, strike ruthlessly – then seemingly vanish into the local population.
The allied forces were a highly disciplined machinery, with a huge advantage in numbers, equipment, and training. But none of that seemed to matter. They were losing.
In his compelling book, Team of Teams, McChrystal chronicles the enormous feat his team undertook in the middle of a gruelling war.
It’s often too easy to overlay learning from other industries onto the NHS, as tempting as the army speak might be. But there are some parallels here which are hard to ignore.
To the General, the culprit was clear:
“To each unit, the piece of the war that really mattered was the piece inside their box on the org chart; they were fighting their own fights…each team exhibited horizontal bonds of trust and a common sense of purpose, but the only external ties that mattered to each team ran vertically, connecting it to the command superstructure.”
Working in silos
As a GP trainee, this sounds familiar. I sometimes feel as though we have a system designed for specialist needs, treating patients as problems to be shifted from one side to another and back again.
As junior doctors, we rotate frequently through both sides of the fence. One day, you’re in the hospital, sending patients back into the ether with only discharge summaries to remember you by
We beaver away under mounting pressures each day, clear in our purpose of caring for the patients in front of us. But mostly leading a proximate but parallel existence to our colleagues from other sectors.
As junior doctors, we rotate frequently through both sides of the fence. One day, you’re in the hospital, sending patients back into the ether with only discharge summaries to remember you by.
Then, name badges are swapped, and you’re sitting in general practice – facing a different computer system, batting away “GP-to-chase” requests and firing referrals off to faceless consultants. Both sides are working as diligently as they know how, while connected only through a choke point.
Yet, our patients don’t think of their problems as primary or secondary or social care diseases. To them, there’s no distinction.
The corollaries of fighting Al Qaeda with the tensions of providing healthcare may not, at first, be obvious. But the lessons McChrystal learnt might be worth a second look.
Dissolving the gap
The allied forces in Iraq realised that their weaknesses lay on the fault lines – in the spaces between elite teams. Each unit was becoming tighter and more focused in an effort to speed up.
He discarded a century of conventional wisdom and remade the Task Force into something new, a network that combined seamless, shared communication with decentralised decision making authority. The walls between silos were dissolved.
But there was a sticking point: ‘our players could only see the ball once it entered their immediate territory, by which time it would likely be too late.’
They had to change. He discarded a century of conventional wisdom and remade the Task Force into something new, a network that combined seamless, shared communication with decentralised decision making authority. The walls between silos were dissolved.
Acquiring a whole system overview and building relationships between teams felt inefficient, but it had to be done. They needed to scale trust and purpose without creating chaos.
Leaders looked at the best practices of the smallest units and used technology to extend them to thousands of people on three continents. They created ”linchpin liaison officers”, the best performing members of a team.
These officers were posted with another team to see how the war looked from their partners’ perspectives and create the foundation for trusting relationships.
Slowly but surely, the Task Force became a “team of teams”– faster, flatter, more flexible – and began to win the war against Al Qaeda.
It’s happening in some parts of the NHS: from as simple as a GP and a named consultant having a dedicated phone line, to groups of practices working in partnership with community and social services, to whole new ways of working, where clinical commissioning groups, hospital trusts and local authorities sit around the same table. There are pockets moving towards creating a “team of teams”.
But it wasn’t an easy ride for the General.
There was an issue of trust (‘We were a real-life Prisoner’s Dilemma. Each agency feared that sharing intelligence would work against its own interests.’), cultural barriers between teams (‘they came with decades long histories and a particular telescope for viewing the problem—what happened outside that tube of vision was irrelevant’), and the need for a new leadership style (‘effective leadership in the new environment was more akin to gardening than chess…enabling rather than directing….“Thank you” became my most important phrase, interest and enthusiasm my most powerful behaviours’).
We don’t (and probably will never) have enough money. The most common chronic condition is multimorbidity.
The challenges we’re facing might not be so far removed after all.
For one thing, like the Task Force, our ‘enemy’ is changing. We don’t (and probably will never) have enough money. The most common chronic condition is multimorbidity. Technology is creating more health literate patients, and the role of the healthcare professional is being redefined.
But we have the right ingredients – highly skilled individuals, access to new innovations, and an explosion of knowledge. Yet with that has come increasing complexity, and increasing specialisation. And little sense that it’s consistently coming together in a meaningful way.
Perhaps, General McChrystal’s realisation wasn’t so different. And perhaps we too have no choice but to accept that, as much as we might like to hold on to our individualism, complexity needs group success.
That means moving away from an assembly line mentality, where patients are passed from one discrete four walled silo to another, to an ecosystem of shared information.
A team of teams, if you like.
That might just be one bit of army speak that’s worth adopting.
Nishma Manek is National Medical Director’s Clinical Fellow, NHS England