What is the secret to ‘breathing life into our local systems of care’?

I first wrote a piece about system leadership two years ago. Since then, this language about systems appears to be engulfing us. Remembering the likes of ‘“world class commissioning”, is it just a passing fad?

I think not. It is widely recognised now that to achieve sustainable, high quality services, the best leaders in our health service need to create and enable operational “systems” and geographical ”systems of care” that work. The language of systems I think can remain useful and should not be relegated to the flotsam and jetsam of policy and evolving practice.

Under fire

In this year’s HSJ100, perhaps more than any before, we see a cross section of leaders having to work even harder in more aligned ways. What are the systemic issues they have been wrestling with? How are their styles of leadership evolving to meet this challenge? How are we enabling these capabilities to grow and mature across and through the system? How are we doing in enabling local areas to find their way to balancing competing leadership demands?

Pyschoanalyst and pioneer in the understanding of group dynamics Wilfred Bion started off as a tank commander in the First World War and in the second looked after soldiers with PTSD. He knew what it meant to be under fire and his work on what happens within relations in groups remains seminal.

Whilst we are not at war, all of our HSJ100 health leaders are certainly under tremendous pressure and, are more than familiar with the internecine challenges in and outside their organisations. We all have our own experience of what happens within and between groups; when things go well it is amazing; when they go badly, the experience can be quite terrifying.

Rationing decisions

Many of the leaders listed here today will know how it feels to be lightly roasted, or at worst scapegoated despite their best endeavours or have felt discomfort whilst seeking to hold on to the bigger picture when one sub-group has gamed its way to a better place at the expense of another. They are not inured to these pressures, nor to the fear of losing their own positions. And have we not all observed rivalrous behavioural patterns of relating, especially when traditional organisational boundaries and territories are threatened?

I suggest that the successful leaders going forward will need to be even more sophisticated in how they navigate the dynamics of human groups. Perhaps in the near future, the role of people and organisational development directors will become more central to strategic transformation and it is interesting that we are not seeing many members within our listing here.

All matters considered, it is therefore not surprising that our leaders’ list this year is dominated by those leading at a national level, with the exception of just a few operating at a local organisational level. We imagine those on much of this list are feeling the gaps in alignment more keenly than ever. How will they continue to take the troops along with them (including non-execs!) when the regulator still obliges competition, or indeed when the financial cupboard is so bare and so many are having to make really difficult rationing decisions?

The bigger challenge is making the scale and complexity of change happen at pace

Systemic changes are going on throughout and at every level, but perhaps are in most focus in Greater Manchester currently, with the gaze of many watching very closely how successful devolution and health and social care become one. There is much learning to be had here as they grapple with ensuring all parties have a fair voice: the organisations, the chiefs, the patients, the staff and indeed the politicians?

The bigger challenge though is making the scale and complexity of change happen at pace. Jon Rouse, chief officer for the Greater Manchester Health and Social Care Partnership, is charged with delivering success for the partnership and local people; his approach to systems leadership will determine his success and influence his position in our list next year no doubt.

How do we protect against low grade sabotage, where people misuse their power in pursuit of their own ends rather than the needs of the population

Through systemic change then, foresighted leaders will be seeking solutions to the dynamics of groups with questions such as:

• How do we sustain and build more intelligent and sophisticated inquiry about care across systems and protect people at all levels from getting hooked by issues of power and control?
• How do we keep the population in mind and help keep people true to this?
• How do we protect against low grade sabotage, where people misuse their power in pursuit of their own ends rather than the needs of the population.

In making our systems of care work as best they can, the art of holding and containing the group sits with each one of us. Whilst we might have a clear idea of what’s right from our particular position of insight in the system, the question always remains, how are we going to take people along with us – a key question that no doubt Simon Stevens and Jeremy Hunt are grappling with by the hour.

Holding and containing a diverse group coming from multiple domains of power is a profoundly human challenge. How do we invite people into facing those differences and building common ground in pursuit of a shared solution? Who do you know in those positions of power who is excellent at facilitating groups and addressing these issues and who do you know who perhaps struggles a little? Certainly some of those on the national stage, such as Stephen Dorrell or Chris Hopson, know how to build a concensus around a viewpoint.

Dead weight

A powerful lens to look at this is through the art of group process. I say this because there any many pockets of extremely sophisticated group relations throughout the system of care particularly in multidisciplinary teams. Mental health and social care providers have been working away at this for a good 20 years and so is it perhaps surprising not to see more leaders emerging from that arena? Each of us will be able to draw on groups that are functioning well and others that are struggling. Claire Murdoch has, of course, not only run a successful mental health trust in a challenging urban area but taken on a national role as well.

How do we all hold on to our own humanity with each other when facing into difficult issues?

Fewer will have a strong handle on the pedagogy of training peoples or using technology effectively in managing group processes. At a visceral level, we all know when that holding and containing is solid; when empowering and supportive is needed and, when the process feels like a dead weight.

This piece has purposefully focused on the humanity and frailty of groups of people who ultimately make up systems of care – the systems in which our top leaders operate and emerge from. And in that light, when breathing life into our future systems of local care, we suggest that successful leaders of tomorrow will have to consider the following questions:

• How do we all hold on to our own humanity with each other when facing into difficult issues?
• How do we honour the courage of those willing to risk speaking to the bigger picture and protect from more sectarian interests?
• How do we turn to wonder when the going gets tough and hold back from just blaming others? 

Good luck!

Simon Potts is head of practice and director of healthcare at Veredus.