Challenging traditional relationships and embracing shared decision-making

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Part of Working with patients, service users, carers and the public

The NHS Confederation conference last week was a busy affair; quieter, I’m told, than previous years but nonetheless a meeting place for reconnection, sharing and networking.

For me the most impact was made by the personal story told by a truly extraordinary lady: Kate Allatt. Her story touched me, stuck with me and points the way towards a new and powerful relationship between patients and the services they receive. It also points the way to a new and important leadership model for every aspect of health care and its delivery.

If you don’t know Kate’s story then I can recommend looking her up. Kate was diagnosed with locked-in syndrome, after a severe brainstem stroke left her unable to move or communicate. Her story is one of a determined individual who defied all odds and, against the predictions of the medical community, managed to make her dream of regaining control and reconnecting with her passions in life – her family, friends and her love of running – a reality.

Initially, the medical team gave Kate a poor prognosis and privately warned those around her not to raise their expectations too high. But this underestimated Kate’s indomitable spirit and self-belief; she and the people that loved her responded by advising the medical team, ‘Don’t lower Kate’s expectations, raise yours’. The human spirit finds its own way and when it’s unleashed the most amazing stories of regeneration and hope can emerge.

It so easy to say that health care professionals and organisations should find new and innovative ways of hearing the experiences of the people they serve. The NHS five year forward view talks about the need to 'engage with communities and citizens in new ways, involving them directly in decisions about the future of health and care services'. Of course this should be the case and I’m sure no one would really disagree.

However, for me, Kate’s story points to a fundamental challenge to the notion of ‘expertise’ and the need to co-create solutions that are truly relevant for the patient as an individual. If the health system is to change to become more patient-centred and relevant to their needs, relational leadership has to be at its centre.

Old leadership models point to a relationship where the power lies with the hierarchy: command and control. Those that lead expect to be followed by virtue of their position. However, in a complex world such a paradigm is no longer either true or helpful. In a digital world, where information and knowledge are freely accessible to everyone, we can challenge the traditional notion of leadership and power. Everyone can potentially become a leader and everyone becomes powerful. This is a challenge to the elite leadership model of the past but, if embraced, does offer the opportunity for shared decision-making with the hope of new and novel outcomes.

It also brings into sharp relief that in this new digital world people have a choice. A choice to follow or not. The followers are just as powerful as the leaders. You can’t lead unless those around you choose to follow. This is true for patients as well as people that work within health.

I firmly believe that those within health need to rethink the traditional relationship with patients. Patients’ voices, experiences and insights need to be listened to and be central to a new and exciting relationship.

Margaret Wheatley has written extensively about leaders and leadership in a complex world and I’ll leave you with her words:

Our great human capacities of generosity, caring and creativity are ignored or denied. And people themselves don’t remember their own capacities as they withdraw into fear, aggression and self-protection in response to this frightening time. Too many leaders grasp for control and self-interest, making short-term decisions that destroy both human potential and the future.
Margaret Wheatley


will sopwith

Comment date
04 July 2016
Great to see some blog attention to 'followership' from the Kings Fund. The ability to mutually and explicitly influence is a key facet of healthy relationship and especially pertinent for the 'patient' 'service' dynamic. Kate is certainly fortunate to have had friends that so boldly gave her voice when hers was limited. I'd suggest the majority are not so fortunate.

Too much of our health service is still designed on the assumption that the most important influencer of care is the professional, a situation that is ultimately disempowering for those being cared for. From minimal time for primary care appointments to consultant's hospital rounds with students in tow. Medical experience quite rightly trumps personal experience in many scenarios but should never be assumed. There is great relational value in being explicit about assumptions being made and this simple discipline helps patients engage rather than becoming passive in the face of expertise.

Clearly a huge tanker to turn around. Keep steering Marcus!

kevin riley

Retired Public Sector Solicitor and User and active Supporter of Doctors and Nurses working in the NHS,
Comment date
02 July 2016
No improvement in what is most important namely the proper care and treatment of patients will occur unless and until the Chief Executives of all NHS Foundation Trusts employ sufficient Doctors and Nurses to look after their patients to whom they owe a "duty of care".
Three years after Robert Francs identified that 1200 "preventable" deaths had occurred at two hospitals as a result of Managers putting cost cutting above patient safety the Pubic Accounts Committee identified that three year later the position regarding front line staffing has not improved and instructed NHs England and the DOH to report back to them by December with the action that they proopos to take and have taken to address this fundamental issue.

Robert Francis QC three years ago in his report as to the root cause of
the “preventable” deaths that he identified as having occurred at the Hospitals run by the Mid Staffs NHS

Foundation Trust was that they were the result of senior management putting costs cutting above patient saving money by reducing the number of nurses and doctors. .#

In his recommendations Robert Francis included a recommendation that the Government impose
a “safe” level of staffing for each front line “operational” area.

The Government refused to accept this recommendation and (contrary to all reason) stated that they were
content to leave these decisions to the Chief Executive of each of the 165 “independent” of any democratic
control, NHS Foundation Trust that now run the vast majority of NHS Hospitals.

The Secretary Of State for Health, Jeremy Hunt recently informed
the House of Commons that 200 such “preventable deaths” were occurring every day in the NHS.

Apart from the above being unacceptable to the patients concerned and their relatives such “preventable
deaths give rise to literally hundreds of millions of pounds each year in compensation being paid by the
tax payer out of the annual NHS Budget as a result of civil actions taken against the NHS Foundation
Trusts responsible for the Hospitals in which these preventable deaths have occurred –currently
NHS England are holding seven billion pounds “in reserve” to cover current and future compensation

However the Chief Executives who actually make the decisions on the number of staff employed do
not incur any penalty at all.

Therefore unless and until these Chef Executives are forced to accept personal responsibility for the
decisions they make on the number of staff they employ which results in the shortage of front line staff
which has now been conclusively proved to be directly responsible for preventable deaths and the
appalling scandals relating to “end of life” care no improvement is likely to incur despite what NHS
England and Jeremy Hunt may say

The above made even more certain given that neither the Government as a whole nor Jeremy Hunt and
not even NHS England itself can force any of the Chief Executives running these independent NHS Trusts
to behave in a particular way – they can only “recommend” and can do nothing if the Chief Executives of
these Trusts ignore that “recommendation”.

Kevin S. Riley Solicitor (Ret.)

Louise Hardy

Senior lecturer and OD consultant,
Plymouth University and Louise Hardy Consulting
Comment date
30 June 2016
Great blog - and generally your contribution to the leadership thinking in the NHS is refreshing and persuasive. I agree that with the advent of technology and free exchange of thoughts and information, leadership is everywhere and the human spirit does, and should drive endeavour. However, in the service itself it feels as though we lack direction and vision. Putting it another way, structures are unclear, regulation seems to take the place of encouragement and it is increasingly difficult for the worker at any level to know who's in charge. I like both approaches: the development of self and the confidence to lead change, but also clarity within structure and a stronger sense of a shared, sustained vision. My world straddles education and OD practice, and I'd say that both literature and experience tells me that this is where we are.

Marcus powell

Director of Leadership,
The Kings Fund
Comment date
28 June 2016
Mark - many thanks for your comment.

I'd be happy to meet up and have a conversation. Would you like to drop me an email and we can arrange something.

Best regards


Mark Duman

Comment date
26 June 2016
As an ex King's fund staffer who's attempted to engage with previous (more traditional ?) leadership colleagues I'd welcome an opportunity to explore 'patients as THE workforce' please?
Thank you
Mark Duman
07824 605 352

Leigh Powell

Retired......for now,
None at present....I'm typing for myself
Comment date
24 June 2016
I feel the idea is easier said than done, as in all life's aspects. To get current leaders to listen may distract from their current role, inefficiencyfying them resultantly. Voluntary groups may enable patients to achieve their 'leadership' potential. But this needs excellence in tuition, huge diversity of approach, and patient's own self insight.....which maybe hard to achieve in our aging, isolationist trending, pressurised, and multicultural society with its rapidly changing values and frustrations. A key aspect to me is "how to engender trust in single and group patients towards other folk", or 'how to get on with each other?'. And how can we slow down, reverse, the need for IT dominance in Britain? Maybe impossible to do, but o for simpler lifestyles, real understanding, friendliness and care of folk in different lifepaths. I just don't know, as I'm a complete amateur in health services, with health defined by me as 'holistic', from individual's healthy trust in others, with calmness, to really needed NHS services. We're all in this together, from the Monarch to the poorest, illest person in our island nation. I hope you receive far better suggestions than this.

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