It is not unusual to find teams and their managers entangled in a cruel bind. Senior management conveys the absolute requirement to increase caseload sizes to meet an activity target.

Meanwhile, the team is equally clear that this will mean that they will fail to stay true to policy guidelines. As a result, people feel unheard by senior managers and angry that they cannot do what they signed up to do: the classic trade-off between quantity and quality.

Kenneth Cohn, author of Collaborate for Success! describes a "dance of the blind reflex" where people only focus on the part of the system directly in front of them. It has five parts:

  • people at the top feel burdened by unmanageable demands;

  • those at the bottom feel oppressed by the insensitivity of those higher up;

  • people in the middle feel torn and become weak, confused, and demoralised;

  • patients, families and also often clinicians feel short-changed by an unresponsive system of fragmented care and say so, which upsets those leaders who feel their efforts are underappreciated;

  • nobody sees their part in creating and sustaining the system they deplore, and instead trade in blame.

Cohn argues that to slow the dance we must first work to see the systems that we occupy, stating that "not only do we have systems but the systems also have us". Rather than relying solely on deficit-based approaches, we need to build a culture that seeks out and builds on success. We need to root out the solutions that already exist locally, and engage in more structured dialogue where practitioners are able to articulate clinical priorities.

This needs them to become more aware of some of the key features of complexity theory I discussed in previous columns. An example is the counter-intuitive notion that you can increase influence by admitting uncertainty and welcoming new insights and collaborations - acknowledging interdependence rather than constantly struggling to assert an autonomous sovereignty.

Simple ways for leaders to help reverse the dance include offering praise, celebrating success, and asking, "What is going well for you?" rather than making problems the focus of most interactions. Working to build relationships in this way also helps overcome defensiveness, cynicism, change fatigue and inertia.

Telling stories from the pointy end of provision is a powerful way of transcending the inhibiting effects of hierarchy, especially when people's hearts are touched.

Equally, I have witnessed the positive effects of senior managers sharing with practitioners the harsh realities of the environment they work in, including the personal risk to their own livelihood that failure to deliver can involve. Just another example of the benefit of sharing our lived realities more widely, wherever we sit within the systems that have us.