Steve Onyett on loosening central control

They might come to work but their hearts and minds will be at home having a lie-in. The emotional labour that is involved in health and social care means we should look after their interests and aspirations.

Much central managerial control is unnecessary when leadership engages people in work meaningful to them, with the direct personal support of their line management.

As James Reinertsen highlighted with respect to the work of the US Institute for Healthcare Improvement, the challenge is not to involve clinicians in the improvement work of the organisation but rather to involve the organisation in the improvement work that clinicians know to be meaningful to their patients and service users. Control becomes less necessary where staff are treated as intelligent peers rather than commodities, and where there is willingness to give feedback through effective peer coaching, appraisal and management upwards, for example through the use of 360-degree feedback.

Consultant and academic Bob Hudson pointed out that long-term planning, rigid structures, precise task definitions, and elaborate rules for control can be detrimental, "fixing" an organisation in pursuit of a vision when an uncertain world requires flexibility. He advocates "holding frameworks" for relevant local subsystems to keep direction and coherence.

Loosening control is also not about laissez-faire management. It requires organisations to be strong on outcomes. But working well with complex systems requires only a minimal specification of outcomes to be delivered. This should establish the direction of the change, set boundaries for implementation that may not be crossed, and allocate resources for a period that is long enough for novel approaches to be explored.

Work on the "no needless" framework also highlighted the importance of board level leaders explicitly specifying the areas of discretion in which local stakeholders can innovate. Partnership working may also require the granting of "hunting licenses" to allow people to operate on the partner organisations' turf.

Attempting to achieve control over the uncontrollable is exhausting, particularly in organisations that undertake a complex range of tasks and where the span from the most senior to the most junior is so great. The time and energy could be better spent developing and communicating a values-based vision that engages people emotionally and intellectually.

Sharing accounts of the experience of end users of the service is a good way to achieve this, particularly when delivered by those end users. It also helps people to make the connection between their personal values and the aims and aspirations of the service. As the policy agenda increasingly requires a personalised approach to the well-being of patients we will need to work to ensure that staff bring as much of themselves to work as possible.