Working beneath the surface: supporting leadership in complex times

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As a newly appointed co-director of The King’s Fund’s Top Manager Programme (TMP) – our leadership  programme for senior leaders in health and social care – I wanted to share my insights into why this type of programme is increasingly necessary and relevant in today’s leadership and system-change context. 

Programmes like TMP (and the Building Your Authority programme, which draws on a similar approach to support leaders) reflect on what’s possible when we scratch beneath the surface of what’s going on in human systems. This helps to make our interventions more effective as we’re more likely to work out what’s really going on – often unsaid – and therefore what’s really needed. 

In times of accelerating change and complexity, it’s becoming apparent that we need to develop new ways of doing things – to move away from relying on problem-solving techniques and towards approaches that support others to find their own solutions, while developing a willingness to recognise and work with what we don’t know. This willingness to balance the certainty and limitations of what we know with the curiosity and openness of humble inquiry requires a distinctive kind of leadership. As leaders in health and social care face growing challenges, this approach will help them to develop relational (the way in which people or things are connected) capability and to step fully into their authority, developing collaborative and compassionate leadership for their organisations and communities.

One of the things we do on the programme is to help senior leaders to view things through the lens of the system rather than to operate at an individual level. We help them to move away from personalising systemic issues and to develop alternative approaches. This way of thinking isn’t easy as it requires us to recognise the interconnectedness we have with things around us – and each other. Health and care systems tend to focus on making the system invisible, as if it didn’t exist. By paying attention to the system and understanding the systemic nature of events or our experiences, we let ourselves into the system and see our part in it. 

This way of thinking represents a counter-cultural perspective in the current health and social care system, where leaders are often held individually accountable for system failures (quality, finances, delayed discharges and A&E waiting times to name a few). This way of operating is predicated on the assumption that if only the individual was better, did more, worked harder, was more competent, then these kinds of failures would not happen. This, of course, is a fantasy. We have a long history for advocating against this heroic leadership model at The King’s Fund, calling on leaders, policy-makers and politicians to recognise that this leadership model is flawed. A radically different way of relating and being is required for the complexity of challenges leaders face in public services today. 

We know that thinking in this way can be challenging for leaders, as it requires relinquishing one’s need to be in control, a deeply held human desire, especially in times of uncertainty. We encourage leaders to pay close attention to their own experiences and feelings and to see them as important data. We invite them to explore these feelings (including those of shame, anxiety, envy and competition) and to spend time unpacking them with open curiosity, through joint exploration rather than individualised learning. 

The TMP programme also supports participants to work with unconscious processes (material that we may be unaware of – not hidden, just not known – and therefore material that is less readily available to us as a source of explanation for what is really going on). Working with this deeper, more nuanced data can help us to understand what may be driving behaviours and dynamics beneath the surface. We support participants to think about how these play out both during their time on the programme (in the ‘here and now’ of the temporary learning system that is TMP) and back in their workplaces and systems. 

Our intention is to encourage participants to think about how to work with, and respond to, the dynamics that help to unlock thinking and move people out of the entrenched positions that are often seen in how systems and organisations interact and organise themselves. Part of this involves exploring their experiences without being involved in the busyness and set agendas of the day to day, asking people to suspend assumptions and encouraging them to start from a place of curiosity. We know from years of experience running this programme that this approach helps leaders to relate to each other better and to build a more collaborative way of working. It also represents a move away from individualistic learning to acknowledging the collective wisdom of the whole group.  

Another component of our work on TMP is the ability to think about, and work with, difference – a key issue. Many organisations and systems grapple with this, and unsurprisingly it shows up regularly on our leadership development programmes. The consequence of not working with difference – where difference is denied or people end up being treated as ‘other’ – is hugely significant and can result in inequalities both in accessing care and in the quality of treatment for those from marginalised communities, discriminatory practices affecting people from BME communities when it comes to career progression, and substantial pay gaps for women in health care compared to male counterparts doing the same work. 

We’ve recently refreshed the programme team on TMP. And by ensuring diversity in the team, we’ve opened up what’s possible in terms of learning, particularly around difference and privilege. We’re trying to model openness and help participants to develop the courage to speak about what may go on above and below the surface. A diverse faculty team is a key enabler for this type of exploration, and as a more ethnically diverse faculty we are keen to explore how this supports whole-system learning and relationships. 

When thinking about things systematically I have found the following quote from Kabir, a 15th-century Indian philosopher useful; it speaks to the relatedness, interdependencies and interconnectedness of people, organisations and systems: 

‘All know that the drop merges into the ocean, but few know that the ocean merges into the drop.’


George Coxon

Various inc a humble leader in social care roles,
Comment date
18 January 2019

A really useful challenge to orthodox & conventional (same old narrative) ideas on leadership is so very much needed in our current state of H&SC system. Unquestionabley the essential ingredients must start with enthusiasm, belief in getting beyond self interest and a commitment to common interest with a generous helping of alliance forming likemindedness & collaboration Leaders without wisdom, credibility & good judgement will never inspire others. Instilling belief, positive loyalty and strong values to create pride in a workforce culture must also have a decent volume of a willingness to balance toughness, good humour, a flexible yet tactical capability for attention to ‘the little things’ as much as a horizon scanning strategic vision & plan

I’m part of an NHS Devon STP system wide leadership masterclass programme where we have a whole day simulation event next week (22nd January) in Plymouth. I’ve been asked to act in the role of Chair of our fictitious FT I will attempt to inject not only my humble ideas on leader role modelling in this experience but certainly will be using this article and the wider Kings Fund work as reference for value adding ideas on leadership in complex changing challenging systems. Thanks so much for this timely piece

Pearl Baker

Carer/Independent Mental Health Advocate and Adviser,
Comment date
12 December 2018

I have said this many times before. Leaders can only become LEADERS if they have the experience, knowledge, compassion to take on this important role: There is a complete ignorance and 'invisibility' 2 what 'person centred, personal choice, 'holistic' actually means, and rarely mentioned in anything I read on TWITTER or anywhere else. 'experts by experience' are ignored, yet we have so much knowledge 'willing to share' with so called Leaders.

Holistic: meaning 'relating to the whole of something or to the total system instead of just to its parts'. 'ICSs' is focused too narrowly for the following reasons: DWP Welfare Benefits, Housing Legislation, Education, Training, Independent Advocates, Carers appear to be left out of the ICS concept.

Government acknowledge CARERS are very important, save BILLIONS, yet we are not mentioned, or considered regarding our 'input' into the Health & Social Care of our Relative or friends. The DOH & Social Care 'Supporting Carers' updated 2018 has to be understood, and into account, and included into ICS conversation. Carers have LEGAL status, this is being forgotten, we can challenge the system at anytime. The LAW is on our side, we are entitled to Personal Budgets for what we do, this has a direct impact on the finances on the negotiations regarding ICS. Independent Advocates are not mentioned in any document I read re: ICS, and those subject to a COP 'Property and Finance Order' are most discriminated against. The Mental Capacity Act 2005 code of practice is clear they are entitled by LAW to a Personal Budget, helped by a Relative or Independent Advocate to manage.

'Person centred' 'Personal choice' 'Holistic' is not on the AGENDA, not spoken about anywhere, is not in any minutes I have read.

The lives of most suffering from a 'severe and enduring mental illness' have worsened, they are 'invisible' forgotten' 'abused financially by the system.

I will leave you with my thought for the day: if you don't know how the system operates, who your partners are within it, then this concept of ICS 'Integrated' system is 'dead in the water' forever. DATA cannot be right if they have become 'invisible' to the system.

I am an 'expert by experience' I have challenged the Courts on the DWP 'dreadful' system transferring from a Disability Allowance to PIP and WON. but we read how others are forced to live with nothing, destroyed by a system that 'thinks' it knows the way.

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