The leadership challenges of sustainability and transformation plans 

A group of friends and I are walking the full 102 miles of the Cotswold Way in 10 stages over the next four months, with the shared purpose of being able to spend some time together and hold those conversations we rarely get around to in daily life.

Unfortunately the heavy rain and strong winds a couple of weeks ago meant that there was actually very little opportunity to talk as we embarked on the first stage of our challenge, but we agreed to meet up again in a few weeks’ time to complete stage two.

What has this got to do with the leadership challenges associated with producing local sustainability and transformation plans (STPs) ?

Over the past few months I have been working with senior leaders from a range of different health and care organisations, facilitating some critical dialogue about how organisations can better collaborate to speed up the implementation of the NHS five year forward view. In the pace-setting and task-oriented culture of the NHS and local government, taking time out to reflect and plan for the future has not been easy for many leaders. But in most instances they recognise the importance of developing a shared purpose and vision for the population they serve and the need to build understanding and trust across the local health and care system. In my opinion senior system leadership groups play an important role in designing the structures and processes to support three critical behavioural shifts.

First is the need for staff to move away from explicitly pushing a growth and expansionist strategy, and instead accept the need to combine resources through networks, new alliances and partnerships. How these resources are allocated between different organisations and the way that risks and rewards are shared will require detailed technical knowledge, but it will also call for a less transactional and more relationship-centred approach.

Second, senior leaders in organisations play a critical role in modelling collaborative behaviours and removing the prevalent ‘silo’ thinking across the NHS and local government. In her book The Silo Effect Gillian Tett analyses the practices of financial firms, police forces and surgical teams, and reveals how the questioning by staff of assumptions and established practices led to a positive transformation in ways of working – across silos. The development and implementation of STPs will only be effective if local leaders use their authority to design structures and processes that support more collaborative working – both within and across organisations.

Third, we need to move – at both local and national level – away from a culture of blame to each organisation holding the system to account. So, for example, issues with poor quality in a local community service provider should be viewed as a system-wide problem, rather than necessarily the fault of the individual organisation. Changing established practices and behaviour will take focus and commitment from senior leaders and their staff. It is short-sighted for leaders to delegate the work of producing a good plan and ignore the ‘softer stuff’ that feeds into it, as it’s the process of developing plans that will lay the groundwork for adopting a more collaborative approach in the longer-term.

My goal has been to give health and care leaders an opportunity to explore – in a protected space – the realities of delivering a new care model. Just as the success of a long-distance walk depends on the preparation, it is the careful placing of some enquiring questions that allows leaders to hold some very different conversations. This in turn generates a better understanding of the varied individual and organisational interests and challenges, enabling leaders to identify common ground and go on to develop a shared purpose and better collaborate moving forward.

It has been challenging in some cases for leaders to agree how they will work together – often this is influenced by past events and, in some cases, by where an individual leader is on his or her own career trajectory. Rarely is this achieved in one meeting – just as the Cotswold Way cannot be walked in one day, it requires regular and ongoing commitment. Last but not least, the weather conditions will be critical – leaders at a local and national level have an important role in influencing these. Collaborative working does not come easy.

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#546071 Prof.Minesh Khashu
Consultant, Prof.



Names or titles of projects don't deliver by themselves ie by calling it a transformation fund we can't deliver transformation; by calling it a forward view we do not ensure we are actually moving forward.

From what I have seen so far, the Vanguard plans are not visionary enough. Even more important is the lack of appreciation that the most important requisite of leadership today is SYSTEMIC LEADERSHIP or TRANSBOUNDARY LEADERSHIP. Putting this into action is critical for transformation as well as sustainibililty. Last but not the least, the only fool proof way of generating HEALTH is through a SOCIAL MOVEMENT.

#546108 Mr Simon R Dodds
System Designer and Surgeon

Dear Nicola, an excellent blog. Thank you. Working as a surgeon in the NHS and as a complex adaptive system designer outside offers me an interesting dual-perspective. Surgery is about solving complex and often high risk problems with the clock ticking and that is impossible without co-labor-ation (working together) as a 'system'. Design starts with the future common purpose and the objective is a fit-for-purpose design. The word that means 'common purpose' is com-petition. Sadly that word has attracted negative associations so is perceived as 'bad'. The key to unlocking this paradox is to examine the unconscious mental model that drives our conscious thinking. The question to ask is "Do I see this challenge as a race or a battle?" The language used gives it away. In a race we improve faster and further the more we compete; in a battle we deteriorate faster and further the more we compete. So silos are defense designs and are tangible evidence that the 'battle meta-program' is the dominant one. The belief that underpins the battle meta-program is the zero-sum game: if you lose then I win - the sum is zero. In a complex adaptive system such as healthcare ... everything is interconnected and interdependent. The zero sum assumption is invalid. Everyone can lose, and everyone can win. What makes the difference is the collective mental model and the design of the system that emerges. So the choice is ours. Each of us can choose our mental model; and each of us can choose to learn how to collaborate and compete to create better system designs. Simon Dodds

#546383 Dr Will Sopwith

Great thoughts Nicola. Even the discussion about agreed ways of working together (let alone the practice) can be coloured by unspoken assumptions and perspectives. When poor history is thrown in then even desires or intentions that are explicitly voiced can be mistrusted. There's often a lot of stuff to get out on the table!

Our experience is that expanding positive relationship and agreement further 'down' through the system is the bigger challenge. There is much focus on senior leaders but (as Prof Khashu alludes to), the systematic trans-boundary elements of giving the right collaborators space to collaborate are vital. It is often the case that senior tiers do not have a clear and current understanding of how well the system relationships are working (how would they?) and that pockets of inter-organisational transformation are not sufficiently visible and linked up to the rest of the system.

Creating the right 'ecology' for the collaborative relationships to thrive and the right information to flow is an attractive outcome, but it may not be all about 'structures and processes'.

#547554 Gabriel Sayer
Sustainable NHS Zealot

Wouldn't it be great if we had to deliver sustainability and transformation programmes that had expectations of sustainable resource to meet the needs. System leadership is the toughest and even harder where resources are few and each agenda is as important. Collaboration is hard when the discretionary labour and discretionary funding are gone. Local conditions will always vary hugely.... but time together as you say can build trust and deliver.

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