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The Weed-killer Effects of System Autocracy on the Green Shoots of Clinically-led

If Clinically-led is the Answer, Kill It Swiftly & Remorselessly

When you examine the performance of Trusts in our current system, you can’t help but notice that the majority of financially stable acute providers are clinically- or service-led. Admittedly it’s a very small group, but then so is the number of Trusts that can claim to be truly-service led. Even more exciting is that the proportion increases when you combine financial stability with clinical quality & safety and successful transformation. Exciting? Yes. A surprise? No. However, despite a trend that should truly send positive palpations through our system leaders, we find instead that clinical services are being robbed of influence just as that influence is demonstrating itself to be a truly critical success factor. How? Do you mean you don’t know? Well, in fact that is part of the problem and one that has the most severe of consequences attached to it if it is not appreciated and rectified.

The Three-legged Stool

First, it is important to understand why we have seen such success from Trusts that have made a true move towards service-led. Not a token gesture hidden in the values section of a website that nobody reads but a proper realisation that by devolving accountability, responsibility and freedom to services you tap into an innate passion for solving complex problems in ways that actually work and that fully address the complexity we find ourselves facing. What resulted in an eye-watering speed of medical advance that has, ironically, contributed to the unsustainability of healthcare, also holds the key to changing the angle of the slippery slope we now find oursleves on. Take a group of highly intellectual professionals, with a strong sense of purpose and a tendency towards the greater good, trained rigorously in solving complex problems, and you’ll find they possess the capability to solve all manner of double and tripple loop, messy, wicked (pick your term) problems. That they can apparently do rocket science is not actually rocket science. However, what is important is that they are allowed to do rocket science.

Freedom to operate is at the heart of their success, as is perhaps freedom to experiment – the primary accepted methodology of solving wicked problems. But who grants that freedom? To understand this, we have to understand the three-legged stool, the point being, of course, that remove any single leg and it starts to fall over. We are witnessing, in most Trusts, all three legs failing and it is thus no surprise that those Trusts are crashing in spectacular form. What are these three legs?

Well, it’s all about leadership, and just who leads, and how they lead, together i.e. in conjunction with the other legs. It is the importance of the right leadership in all three legs AND its alignment in any one left with the other two that is so poorly understood, or poorly applied even when it is understood. Yes, the legs, you want to know what the legs are:

  • System Leaders (or Leadership)
  • Trust Leaders
  • Service Leaders

When these three legs have a common purpose, an agreed destination and an accepted (and acceptable) modus operandi for say transformation, then great things happen. More importantly, they manage to avoid really bad things happening, such as a collapse in quality & safety as a Trust wrestles with financial imbalance. But, if this is right, I hear you say, how have service-led Trusts been so successful, given that the first leg, system leaders, appears to be so dysfunctional and dysfunctioning and at the very least completely misaligned with the third leg – clinical services? The explanation is a simple example of how real life deals with or applies behavioural science.

The Temporary Alignment Trap

It is true that clinically-led Trusts appear to be successful despite the best efforts of the first leg – system leaders. Without wanting to be a harbinger of doom, I am going to suggest that this is both temporary and accidental. It is happening because there are so many Trusts in deep trouble. These many Trusts, attract the attentions of the regulators, NHS Improvement (formerly Monitor & The Trust Development Authority) and the CQC. Consequently, with their attention diverted to those really in trouble, they do not interfere with those that aren’t, or aren’t quite so, in trouble and if these happen to put the other two legs into alignment, they find themselves with the freedom to really start tackling problems. This in turn, moves them further away from destructive behaviours of the regulators and it becomes a virtuous circle, producing a collection of Trusts with really very impressive results. It’s not that the first leg is in alignment so much as it ‘allows’ them to behave as they wish because these Trusts give them no reason to look more closely.

You’d think, therefore, that the system leaders would be going “ahh, we have found the answer – become clinically-led” but instead they are inadvertently guaranteeing the temporary nature of this reprieve exactly because they are focused on the sheer number of ‘bad boys’ and thus behaving in response to dysfunction, rather than recognising what ‘high function’ is and looks like. The moves they are making are perfectly placed to rob services of their ability to be successful. The problem is in part the proportions – greater than 90% of Acute Trusts in trouble is a bit like saying ‘all of them’ even though it isn’t. However, it does justify, if you are a system regulator, a one-size-fits-all approach to bad behaviour, even if it destroys the green shoots of good behaviour.

The core issue is that as far as NHSI (and NHS England) are concerned, the fundamental problem is that Trusts, and their petulant services, just can’t seem to do what NHSI believes is the solution. I am not going to debate the sense or not of the current healthcare strategy (I just don’t have your attention for long enough or the will to live through the debate itself) but I do wish to point out that the regulators are completely focused on the ‘what’ and not the more important ‘how’ part of the success equation. What clinically-led Trusts benefit from is a ‘how’ that works – tapping into the capability and motivation of a highly motivated and capable group of complex problem solvers. Those same Trusts are less concerned with what the ‘what’ is as long as it works in producing concurrent clinical and financial stability. And so it does.

However, and worryingly (as in ‘we should all be petrified’), NHSI has embarked on a series of moves that seeks to destroy these green shoots of hope in much the same way as applying a weed-killer that does kill some of the weeds but in so doing, takes out the few bits of grass too. In our system though, my prediction is that they won’t grow back. It’s a very, very bad choice of weed-killer.

The Weed-killer of System Autocracy

System leaders set down a series of targets and control measures by which they judge the success of providers. You are very familiar with these, as you have been subject to the effects of most for a very long time. They are not in themselves part of the problem, although you will struggle to accept that given the regulator wrath that appears to appear each time someone doesn’t deliver against them. We are, of course, talking targets, including:

  • Elective waiting times
  • Cancer waiting times
  • A&E 4-hour target
  • Requirement for financial balance
  • etc

As more and more Trusts fail them, because fundamentally we have an unsustainable system that is not being addressed, NHSI responds by becoming ever more autocratic in specifying ‘what’ and in so doing, also narrows the terms of freedom to operate in some of the most damaging ways. Sadly, those ways create as many problems for those not in trouble as they do for those who are. Everybody is on the same slippery slope together. So what are these changes that all services leaders need to understand and yet most don’t?

It started on 22nd December 2015 when NHSE & NHSI issued a document entitled:

Delivering the Forward View: NHS planning guidance
2016/17 – 2020/21

This document introduced place-based planning, a requirement for a seamless patchwork of ‘regions’ (44 in total it turns out) to each produce what is called a Sustainability & Transformation Plan (STP), the contents and delivery of which, allows you to access some financial support that disappears if you don’t play ball. The document contained what are described as 9 ‘must do’ requirements which are best summarised as deliver all of our clinical and financial targets, along with transform in line with the Five Year Forward View or you’ll have no financial support.

It is also worth noting that the document laid out a set of timescales that literally dictated that no Trust could meaningfully engage with its clinical services AND comply with the timescales, which in themselves were part of the conditions laid down for continued support. Thinking back to our three-legged stool, the dysfunctional first leg had just forced the second leg in high functioning Trusts to act in a dysfunctioning way i.e. to break the bonds and freedoms built up in successful clinically-led organisations. In effect, its instructions were clear – engage and meet the timescales… or else.

Subsequent to that first bombshell, issued a few days before Christmas, whilst nobody was remotely looking, with a first major action point for the third week in January and a monumental milestone planned for June 2016 (a fully integrated place-based plan to meet the 9 must do criteria), we have seen more and more specific, not-optional instructions added in to the process, from regionalisation of pathology services to merger of back-office functions. More pertinently, we have seen the imposition of financial control targets that just about every Trust acknowledges are complete fantasy but to which they have been asked to commit or lose transformation funding and support – darned if you do, darned if you don’t (have I spelt ‘darned’ correctly?).

So, the outcome of this exercise, besides also devolving the responsibility for the collapse of our system away from Government and into local hands, is to effectively leave all of the bad boy Trusts with no option but to comply with a central, autocratic plan… and the good boys too. In so doing, those green shoots of creative problem solving will be crushed in favour of a plan that is fundamentally unlikely to resolve the issues, in part because the plan itself is questionable, but mostly because not only does it not deal with ‘how’ it imposes a top-down, autocratic ‘how’ that is the absolute opposite of what has so far produced the few rays of hope. In effect, it replaces clinically-led with ‘do as you are told’ and imposes the imposition of plans that have been devised with little or no clinical involvement. Moreover, and the real nail in the coffin, it pitches the three legs into complete misalignment and even conflict, meaning that it virtually guarantees the stool is going to fall over.

Some Advice

You are probably hoping for a happy ending to a story of haplessness? I can perhaps offer a modicum of hope that, although a happy ending is a stretch, we can perhaps prevent a truly catastrophic one. It involves two trains of thought:

  • Means and measures to lead and protect services to mitigate the effects
  • Preparation for a crisis and how to get out of it

There has never been a greater need than now for the clinically-led or service-led service, in the truest sense of the word. Rather than being made redundant by the narrative above, it becomes an essential vaccine to avoid the worst effects of the weed-killer, whilst knowing how to respond effectively in a crisis is very much the antidote when the weed-killer starts to bite. We have to be clear though that the vaccine is a bit like last year’s flu vaccine – only partially effective and unfortunately least effective in the most vulnerable. Equally, like most antidotes (no film heroics with a miracle cure here), ours will only be effective for some and the likelihood of success will be related to the degree of engagement in some very difficult issues.

True service leadership requires its leaders to thoroughly understand a complex set of issues so that service strategy, leadership and management can be approached in ways that work and deal with that complexity. It has as a prerequisite a deep understanding of behaviour because the toxic environment requires leaders to adopt very specific behavioural approaches or fall foul of the effects of this toxicity on rational thinking i.e. to replace it with emotional, automatic and unhelpful responses. These skills must be acquired by service leaders with urgency, or they will find themselves (are already in) in the midst of a behavioural maelstrom that they are wholly ill-equipped to lead through.

When the maelstrom hits, we must switch to crisis mode and that requires a mindset and approach which is different again. The mental shift from focusing on a good outcome to avoiding a disastrous one is crucial, requires a distinct type of preparation and a solid collaborative base. The more violent the maelstrom, the more important it is to have that base established ahead of time. Imagine the poor people of Haiti trying to lay better foundations whilst subject to the full force of Hurricane Matthew. One can only feel desperately sad for the plight of the people (please donate, by the way, as it’s a true catastrophe of which the 900 dead only serves to mask the underlying magnitude). What we face is an NHS catastrophe that, thanks to STP, comes with less of an early warning system as services are removed from the loop, and, thanks to the millions of NHS episodes, the likelihood of a much higher body count.

Helpful Links

Oxfam Hurricane Matthew Appeal – Click to Donate


Service Leadership Courses

A 3-part (but the bits can be taken independently or in isolation) course series that comprehensively address the context, leadership and management challenges of the clinically-led service. Click on the titles to visit the course pages:

Crisis Leadership

We have two offerings – an open programme and a more in-depth online learning package. Both are listed below:

If you wish to discuss options, you can email me at (copy it into your email, just helps keep SPAM down for me not to have it as a live link)

One response to “The Weed-killer Effects of System Autocracy on the Green Shoots of Clinically-led

  1. Excellent article. Gave me a good understanding of the future changes in NHS. I would request you to kindly write more about STPs and when and why they have been started and how they are going to impact the future NHS.

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