Thirza Sawtell is the Director of Strategy and Transformation working across the eight CCGs of north-west London. Prior to coming into this post she was Director of Commissioning in Brent and Harrow and then Director of the Delivery Support Unit. In this role she had responsibility for co-ordinating the development of the out-of-hospital strategies for the eight primary care trusts of north-west London.
This interview is taken from our report on the practice of system leadership.
Do you see yourself as a system leader?
Do I regard myself as a system leader? It is an interesting question. My immediate response would be to say no – because I have none of the traditional authority or legitimacy or all of the things a leader would need in terms of moving things forward. But if by system leader you mean someone who sees their role as being… to ‘nudge’ is the wrong word… to help people coalesce around a vision and ensure that there is forward movement, then I would say yes.
It is almost as if we are using old terminology to describe a new way of working. The people who are leading the system are doing it in an entirely different way, and would not automatically see it as leadership, because it hasn’t been mandated in the way leadership has in the past. So am I one of the people who has a responsibility to ensure that the North West London health and care system moves in a direction in which the leaders of the system have decided they want to move? I would say absolutely yes. Could I say that I am the only one that has that vision, or that it was my vision that’s then gone to them, and I am now leading it? Absolutely no. That would not be my role.
My background is that I have never worked in hospitals apart from my training. I was a midwife and a health visitor and moved from a provider where I was working on integrated care into commissioning, then strategic commissioning, and for the last few years I’ve worked across London with the PCTs moving into clinical commissioning groups. So I am a community person.
The logic for me of integration is overwhelming, because it delivers so many benefits.
I suppose you do take a career path where some people are interested in providing, some people want to commission; but if you are interested in the whole system changing, you have the challenge of helping people understand how all the different bits, including social care, fit together – and you have to think differently. It is intellectually very interesting.
So what’s being proposed in terms of integration can work absolutely beautifully when you have a beautifully contained health and care economy and no one strays outside their boundaries because actually there is a great big bit of countryside or something on the edge. So you can do part of a Torbay in London, and that can get you so far. But in London it is incredibly hard to work in one borough with a provider that’s working across five or six boroughs. So you have to collaborate with lots of people and the question is, how do you get the whole system to change, and what are the rules of how the system changes?
What skills are needed, and what are some of the challenges?
There are eight CCGs and eight boroughs in the North West London Whole Systems Integrated Care programme, and I think the eight CCGs have been ahead in thinking about how, without giving up their sovereignty, they can see benefits from working together. The chairs had worked together as clinical leads in the PCTs for longer than in many other places. They were used to working together, on leading Shaping a Healthier Future [the major reconfiguration of acute services in North West London].
When the PCT clusters were undone and moved into CCGs, I watched across London and the people that had been forced to work together actually sprang back further than ever. But because, I think, our chairs believe strongly that they were doing it through their own choice, their own free will – and because it made sense for their own populations rather than because some organisation somewhere else had told them to do it – they kept going. So they had the relationships. They knew it was good to share knowledge and expertise. And they knew they worked in a provider landscape which meant that if they didn’t, they could get picked off, and they had a purpose through the reconfiguration. So I would say that they are the system leaders, and maybe I would describe myself as the system enabler.
Seven of the eight councils supported the integration project, and one didn’t. But it works very closely as part of the West London Alliance, which is where a number of the local authorities come together. So we work with ‘irregular geometry’ where you work together where it makes sense, and then you don’t where it doesn’t or it can’t for the time being.
And I think that’s part of the system enabler role. You have to be flexible and fleet of foot enough to recognise how to change something so that it is acceptable locally, and will resonate locally.
If you go in with too fixed a view you can get nowhere – and I would argue you can’t do that even if you have command and control. But certainly if you are working on a sort of distributed leadership, then you’ve got to be sure that you can listen to people and flex to their needs.
And I think there are still some councils where driving down price is the answer to everything because they probably haven’t had to do that before. So they have still got that opportunity, and they will at some stage go through that and recognise that it is not enough.
How we have coped is that we have just kept going. So I think one of the unique bits about our programme is that it has just kept going. It has kept a momentum, and people can decide to be a part of it or not. But they know if they are not, it’s not a case that we are all going to pause for them.
The question you didn’t ask, which would be a harder one to answer, is if no one wanted to take part or a bulk of people didn’t want to. But if it is just one, or where they don’t want to be in this bit of it, then you can be as flexible as you like. If the bulk of people don’t want to take part, then you should have noticed that before you start, and you should have rethought your strategy and your plans.
So at different times, with different people, we have had differences. And whole integration is about how you override organisational interest, or how you make sure that it is in their interest to be part of this.
So you have to be very sensitive to what people say, and to interpreting what people say. You have to be good at that to take on this role. ‘Emotional intelligence’ is your phrase, but you have to filter what people are saying in a way you may not have to when you are working in one organisation, or you are in charge.
So sometimes people will be saying things and if you don’t listen you will be entirely wrong. But sometimes they will be saying they can’t do this or that, but what they need is for you to keep going and they will get their courage back, or their determination or whatever.
And I have sounding boards, both internally and externally. People I can go to and say ‘why do you think this is happening, or why are they saying that?’’. You have to understand why people are saying what they are saying.
Can this be taught? I think it can be learnt, which is not quite the same thing as being taught. And are we doing enough to help people acquire these skills? I would say for North West London, which is the only area that I can really talk to, absolutely not.
Because what we are talking about in system leadership needs to happen at every level. So just to do it at one level will make no difference if you have not addressed it at every level. How do you recognise a barrier, recognise what’s been said, and work your way through it, rather than ignore it or try and fight your way through it?
Again, this is in North West London, but we don’t analyse enough how we can be in one room talking about how we are working collaboratively and then find no contradiction in going into another room and entering into a contract negotiation that almost tosses out what we’ve agreed in the other room. So I think there’s that sort of insight bit, which can be learnt, or reflected upon perhaps, more than we currently provide people with the opportunity to do.
We have some really good chief executives in the area who are good at calling out what has been dubbed ‘partnership shafting’… where you pretend it’s all wonderful and then you go outside and you do something that’s totally out with what you’ve just agreed as the principles of how you are going to work together. But we don’t allow people enough space to understand that.
And if we need more system leadership – and we do – it is probably the people who would benefit most from that who would least see the need for it. So how do you package it in a way that makes it relevant to people who have spent a long time climbing up a very different leadership ladder?
So you need constancy of purpose and resilience, and you need to recognise that it takes longer than people want it to take. We are much too keen to say something hasn’t worked when it never stood a chance of working within that timescale.
And you need stability in the core leadership of all this. The times when things wobble, completely, is when – and it always happens, so it is just going to happen – too many people go all at once, and they take too much with them, and then there isn’t the momentum to keep going.
So you have to think about what you do that keeps a core. The change we have made is for people to think that integration is the right way to think. That wasn’t there two years ago. It was this novel idea that some people had. So while you can’t guarantee stability, you can always be working on how to push it out further from just a core group of people that believe in it.
What have been some of your successes?
So, in terms of success, one in North West London has been genuine co-production with lay people… So that is a big success. And more people seeing that whole system integration as the way that we are going to solve the problems that we are in. So in terms of critical mindset changes, I think that those are successes. Failure would be if we don’t let go and allow our enabled local areas to move forward at a pace that is right for them – so the fastest move forward more quickly. Sometimes your planning can become so perfect that you never move onto that messy bit called implementation. And if we don’t do that in 2015/16 and 2016/17, that would be a catastrophic failure. So the big test is still to come.
And there is something about taking the credit. If you are someone who needs to take credit and needs recognition, you are probably not going to fulfil the role of working across systems and taking pride in other people’s credit and achievements.
I am not making the role sound very attractive, am I? ‘No one notices what you do. It’s hard work. It takes a long time.’ It’s not much of a sell, so far! But I would not see it a success of the programme if people were crediting me with it, because it is others who are making the real things happen. Which is why I say I think the skills needed for this can be learnt, but I am not sure they can be taught… Because if you have to be taught, you might actually prefer a different way of working.
Read the next interview: Jan Vaughan >