In my experience, many of the issues highlighted in Nicholas Timmins’ report are reflected in varying degrees and intensity across systems as they fly or hover nervously towards integration. Levels of belief in the need for change are variable, with some areas more enthusiastic than others. As highlighted in the report, the quality of relationships with other public and voluntary stakeholders also varies depending on personality, location and local politics. Clinical priorities more or less mirror priorities in the NHS long term plan – frailty, diabetes, personalised care, population health management to name a few – and governance is a conundrum because the legislation is not telling us what to do or how to do it. However, for me, putting the person at the heart of our thinking would drive the right system architecture and, with it, the right governance. Local NHS organisations now finally have the opportunity to co-create and design care that meets the needs of the populations they serve. It is an opportunity to step into the space and own it. It is exhilarating and not without its moments of intense nervousness.
While the public sees the NHS as the jewel in the crown, for politicians it has become a battleground for political advantage. For regulators, the ICS or STP will be the touchpoint for channelling accountability for performance – as highlighted by interviewees in Nicholas’s report. To date, the NHS has never really been held accountable for behaviours that undermine quality, and the relationship between behaviours and patient outcomes really only came to the fore after events at Mid Staffs. While the Francis Report rightly highlighted culture as an important element in shaping behaviours that had a direct impact on patient care, the ability to create the right culture has proved elusive. Key to this is recognising that values and their associated behaviours create the context that enables better health and care outcomes. The challenge is whether system leaders can effectively create a consistent culture across a system comprising many organisations.
The leadership challenges that come with building effective ICSs – focused around people’s needs – reside at many levels. Every organisation has its own culture and a myriad of micro-cultures within it. The people I work with – chief executives, frontline staff, clinicians, chairs in health, local authorities, and other stakeholders – have the potential to develop their leadership capabilities exponentially and developing the ‘right’ culture should be their focus. As we move from a paternalistic system of command and control, cultural development across ICSs offers the NHS a greater opportunity to deliver within constrained budgets and increasing need. However, while most people agree with this, they then lean back, sigh, and say: ‘It’s all so difficult and takes such a long time to change. What can I really do that’s going to have an impact?’. The answer is to do something, however small. I’m always reminded of the effect of that one single mosquito on the person trying to sleep. Annoyingly persistent and quite effective.
Individual leadership styles, including, at a very fundamental level, the tone in which we speak, how we engage and how we choose to seek accountability, have a direct impact on others’ behaviours and performance. As a system, the challenge and opportunity for leaders is how we improve culture and inspire others to want to do so across organisations and systems. A shared vision is not solely about stated values and shared priorities, but it is also about how we care for others and for each other. However, when an organisation is under pressure for its performance, it’s harder for leaders to adopt the kind of behaviours that reflect the right culture.
As mentioned by a number of interviewees in Nicholas’s report, this is where the leadership challenge must also be shared with regulators. Their leadership style in supporting and challenging system leaders is crucial in enabling systems to meet the performance challenge of today while also planning and delivering a sustainable long-term future. The real challenge, or opportunity as the optimist in me sees it, is how the assurers and regulators can also evolve to mirror the behaviours that systems need to aspire to and adopt. My recent interactions with these organisations give me hope that they are working to enable change. As structures, and possibly regulation, adapt to support system working, the question is ‘Can we all step into the space of holding each other to account for health and care outcomes in a supportive way that effects change?’ Leadership challenges become opportunities to cascade and share best practice to foster confident collaboration where there is genuine excitement about innovation and the impact that change can have on services and people – patients, carers, the public and professionals.
As leaders, we need to grasp these opportunities in whatever job we are undertaking and wherever we are in the system. In this regard, we are all being asked to reflect on the jobs we do, to ask if how we do it is still fit for purpose and whether what we are doing will result in the right outcomes. We are also being asked to explore new solutions, collaboratively, safely and in a supportive way. Change brings challenge, challenge brings opportunity. That looks like adaptive evolution to me. It’s a dynamic evolutionary process that will make us fitter and better able to deliver care in a changing landscape.