Twitter fail whale

At a recent open discussion between the Trust and invited employees, we engaged in a discussion group where we were asked how we would express our support of the values the Trust wanted us to espouse.

Unfortunately I think this epitomises the failure of Clinical Leadership.

There is leadership, there is engagement, there is opinion seeking, there is discussion, there are shared values and there is a great big Twitter fail whale.

The engagement is almost totally one sided. The discussion revolves around decisions already made. The values are decided by one group and “shared” with the other group as de facto.

This is NOT clinical leadership. It disappoints me that others should think it so.

It’s not what you say, it’s how you said it!

A phrase guaranteed to strike a chill in the heart of anyone who has ever heard these words.

The recurring theme on this blog and the probable theme of my dissertation is the engagement of clinicians and management. I regularly bemoan the state of this interface and long for improvement. Some would suggest my view is biased and I have tried to reflect on this and question why it should be that some believe there is effective interaction and yet others disagree.

On the one hand Staff Surveys, Clinical Leadership Engagement programmes, such complex human resource terms as High Performance Work Systems (HPWS), Chief Executive Briefings and even open staff meetings such as “The Big Conversation” show a significant desire and investment from management in finding out what staff actually feel about the organisation within which they work. On the other hand is the negativity and lack of interest show by significant numbers and elements of staff towards such initiatives. When I personally consider the relational coordination as described by Hoffer Gittel it leaves me cold as our unit, department and organisation fail (from my perspective) across all seven criteria.  Clearly the signals that are being put out are not those that are being received.

The failure of each side to effectively engage with the other is not due simply to lack of available avenues of discussion. There are many contributing problems such as deeply held beliefs and suspicions; hurts and barriers from previous experiences; misunderstandings and mistrusts; all have so tainted the relationship that despite there being opportunities for rapprochement, neither side can really make any headway.

This is made worse by fundamental attributional error: “everything” is the fault of “management”. This might be lack of car parking spaces; the peeling paint in the theatre changing room; decisions regarding resource allocation in oncology; appointment of  junior service managers or even the corporate logo; everything bad appears to be blamed upon “management”. Consequently, whether such actions were valid or not, there is direct allocation of blame, with its implicit presumption that such actions and all future actions are examples just the “sort of thing that management does.”

And so we are doomed to follow this path towards permanent mutual resentment until each side effectively engages with the other. Is that a consumation devoutly to be wished?

The Real Inspector Hound.

A long, long time ago, just after 7.30pm on a Thursday we “did” a play at school called, “The Real Inspector Hound,” by Tom Stoppard. It was quite an undertaking for many reasons not the least that it was the first acting I had ever really done, it involved actual kissing on stage (I was 15 at the time!) AND me getting hit by an occupied, speeding wheelchair every night for four nights. Fiona Lindsay went on to great things after our on stage kiss, (“Don’t say anything for a moment; just hold me” gets me every time) and I was left with more than just significant bruises; but I blame Jonathon Smith who was piloting the wheelchair.

The play is actually a lot of fun and revolves, quite literally, around a murder mystery plot, the actors, Inspector Hound who is investigating the murder and the critics who are viewing the play. I won’t spoil the ending for you but you have to pay attention. The strangest part of this essentially strange little play is that for the whole of the first act there is a dead body lying right in the middle of the stage. The whole cast are completely oblivious to this and carry on with a cocktail party and bizarre game of cards right up to the point at which Inspector Hound, who has been sent to investigate the murder finds himself stood on top of the body.

My journey into Clinical Leadership continues and I can share with you now that it hasn’t been straightforward. Master Po of course would have explained this to me more prosaically suffice to say I am encountering various challenges that I am sure will make me wiser in the end. My enduring question has been regarding the nature of the interaction between clinicans and management. Various comments and colleagues have suggested that I have approached this problem from a negative and unnecessarily personal perspective and that the reality is far less disparate than I would portray.

As I prepare for an assignment for the course I have discovered an article that at last begins to mirror and more eloquently describe some of my poorly expressed thoughts on the matter; “Clinical Leadership: the elephant in the room” John Edmonstone.

I hope to discuss the whole paper in much more detail in later posts but in summary it describes the author’s contention that the concept of clinical leadership although frequently discussed and even formally studied (sic) it is not actually well defined. This is partly due to the divergent views of what clinical leadership represents: an essential and intrinsic part of clinical practice or a block to innovation and change. Edmonstone further contends, and here I would full support him, that this dissonance is principally due to diametrically opposite views on the nature of the organisation which then extends into totally contrasted views on the nature and delivery of health care.

Interestingly, in the play the exact identity of the body causes significant confusion and actually turns out not to be who we all believe it to would be. This adds to the overall farce as it is in fact two people and their roles are central to the play itself.  The point I am struggling towards here is that the body laid in the centre of the room and almost totally ignored by the cast on stage represents clinical leadership in the discussion around medical management.

Edmonstone suggests, “Clinical Leadership is large and significant- an obviously important entity that is often ignored or goes unaddressed for the convenience of other interested parties; principally general managers and politicians of all persuasions who (consciously or unconsciously) operate to a command and control model of leadership”

I believe the role of clinical leaders needs thorough investigation,  that their position and influence within the management of the NHS has to be re- addressed and embraced rather than simply ignored as “the elephant in the room” because what they bring to the discussion is not simply negativity and a block to innovation but an intrinsically different and important view on the value, purpose and practice of the organisation. The failure to even acknowledge the body is a principal cause of the disconnected hierarchy that now exists and the serious disquiet between clinicians and management.

If you’re such a good doctor, how come you want to be a manager?

I remember being in Mr Gordon’s class aged 12 and telling both him and my peers that I wanted to be a doctor. I don’t know if I actually knew what that meant more than “helping people” but over the next 24 years I have struggled through Med School and the rigours of surgical training to reach my current position as a Consultant Surgeon. Within that role I have been steadily progressing for eight years. In all humility, I am actually quite good at what I do.

Why would I want to stop doing that and take on a role in management?

The dichotomy of clinician management is significant. Many clinicians feel that “management” are completely out of touch with the reality of medical practice and that this role is best filled by someone with knowledge of the discipline. The discipline of management, whether an art, a science or even a black art, is clearly not covered in any detail in the training and practice of medicine. It is similarly clear that clinicians cannot simply step from, say, an operating theatre, into a committee room and hope to practice with the same élan. If we require our management colleagues to be trained, then shouldn’t we as clinician managers match similar criteria?

Assuming this is resolved, there are many other significant issues to be dealt with. If management is so important, then it is also important to devote  appropriate quantities of time to the role. Relinquishing hard earned and valuable clinical skills seems iniquitous on both a personal and organisation level and yet neither tasks will be effectively carried out on a part-time basis.  Is it possible to be both clinician and manager?

Authority of this management role is neither implicit nor uniform. Often clinicians of lesser experience take on positions that are imbued with an authority that itself may not be respected or accorded by more senior colleagues. The history of  the clinician/management interface is one of many pitched battles, multiple casualties and much propaganda often the fault of the system rather than the protagonists. Students of management are clear that futile application of inappropriate strategies over the past decades has resulted in a deep mistrust that underpins many subsequent interactions. It is often held that the two sides actually have completely divergent aims and thus achieving a common purpose takes even more skill than would be required in a profit seeking organisation. Is it possible to undertake a role where the ultimate goals of the protagonists are so disparate?

It is clear that clinicians are required to be involved in clinical management and that to do so requires a commitment of training, time and loss of clinical skills. The task is rife with historical prejudice and the rewards are not clear. Why exactly would someone take on such a role?

Further up the ladder of inference

I’m grateful for the interest in this blog. The hit count has now passed 2000 as I record my learning journey into Clinical Leadership through Action Research. One of the posts that has received the most hits has been on The Ladder of Inference and I intend to further explore that as a necessary part of my Thesis on the “Interaction between Clinicians and Medical Management.”

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What did you see?

Anything else other than a simple description?

The Ladder of Inference, originally described by Agyris and further developed by Senge in the book The Fifth Discipline Fieldbook looks into our perception of the world. From the information provided we select pieces of data. Upon this  assumptions are made and then conclusions are drawn. These are then filtered according to beliefs and understandings of our world and ultimately actions are then taken. Diagram here.

Going back to the photograph provided I would expect most people would recognise a sheep. Was it a happy sheep? Did the straw make you feel comfortable about the sheep’s well-being? How about the backdrop of bricks? Is that her pen or even the slaughterhouse? Did you perhaps recognise the image as one of photos that changed the world? If you now recognise “Dolly the Sheep,” does that change how you feel about the image and perhaps how Dolly was “conceived” and even your feelings about how long she survived and ultimately died?

Of course it does. That is the ladder of inference.  It affects every single piece of information and interaction we have and we must be aware how our perceptions change. Going back to the sheep, do you now feel positive or negative about her? Does the brick wall of the pen make you angry that she wasn’t allowed to roam a hillside or knowing that people vowed to kill her make it understandable she had to spend all her life in secure circumstances? This is how information changes our perceptions.

Clearly, in all our interactions, whether they are social or professional there is a ladder of inference.  The temptation of “jumping to conclusions” based on previous experiences and interpretations, each with their own inference, must be addressed. In order to overcome these, we first of all should critically accept the existence of such perceptions and then utilise both inquiry and advocacy seeking the true, rather than filtered or blinkered data from the source before make our actions explicit and understandable on the basis of the truth.

Leading by example may encourage others to do the same.

ladder-of-inference

The NHS is a communist society

I’m not the first and I won’t be the last to make that statement however shocking it might be to Daily Mail readers; the NHS is a communist society. Both in terms of the true Marxist concept and sadly too in the outworkings of post totalitarianism the NHS displays many characteristics of communism.

The first to make the comment was the man voted No.1 Welsh Hero, by Wales, in 2004;  Aneurin Bevan. One of the architects of the NHS, Bevan articulated this fact early on in his treatise, “In Place of Fear;”  when he says (p100), “a free health service is pure socialism and as such it is opposed to the hedonism of capitalist society.” I may return to that comparison later…

The ideals of the NHS, when conceived, were that

• services were provided free at the point of use;
• services were financed from central taxation;
• everyone was eligible for care (even people temporarily resident or visiting the country).

These tenets, buffeted by time, financial turmoil and even the Iron Lady herself have remained intact and a rally cry since the inception of the NHS in the late 1940s. We should be very proud of what we have achieved and work in, even despite our current concerns.

Regular readers should note that this is a fact, not metaphor or analogy. Those latter terms however might be easily applied to the politburo type structure of governance that is totally contrary to the original concept, to the inability of central government to fulfill major tasks such as Electronic Patient Record, to totalitarian approaches to infection control, to funding overall and to many other topics we return to like poor jazz musicians riffing forever on the same chord sequence. Please add your own metaphors in the comments section.

I wonder if this communist structure and ideal throws further confusion on the concepts of management and leadership when applied to health care? The initial market philosophy of Griffiths and his “new public management”  clearly did not work and was reviled by many within the organisation. Even despite the subsequent radical changes in approach and terminology incorporating and understanding of the concepts of a managed professional bureaucracy I wonder if the basic communism of the whole is actually part of the reason that management is so difficult and in particular the interface between clinicians and management so abrasive.

The NHS is a communist society. We have to accept that and incorporate that into our management strategies and understanding, Comrade.

The Four Arts of a Scholar – 四艺

As I mentioned in a previous post, my nom de plume comes partly as an expression of my learning status; insei, a student.

The ancient Chinese believed that a Scholar needed to learn and study to be proficient in the four arts; qin琴, qi棋, shu书, and hua画  and thus become accepted in discussions amongst other educated men.  Importantly these skills themselves of playing a musical instrument, playing a complex board game, calligraphic poetry and painting were not the end point for the scholar. Acquiring these skills was a demonstration of the individual’s strength in reason, creation, expression and dexterity.

We recently watched a video presentation from MIT involving a discussion between Ricardo Semler and Henry Mintzberg in which the latter bemoans the current state of management and leadership. I intend to discuss a few of the points made in later blogs but concentrate in this on this concept of training for management.

Mintzberg comments in the video that he believes candidates for MBA courses should not be sought directly from graduate schools but from industry itself. He believes the candidate should have learnt the arts and crafts of their business by experience, progressed upwards through the organisation so that then, when training in management they might apply their own experience to their learning of management principles rather than take the learnt experience of others and apply it to a job they don’t understand.

The ancients (and I don’t mean Prof Mintzberg) appreciated that to take on such responsibilities one must have experience and understanding of  life expressed in “the four arts” before taking on scholarly pursuits and similarly Mintzberg feels that experiential understanding of the organisation is central to the training of a manager why then do so many clinicians in the NHS move directly into management with no formal training in what is clearly a complex and difficult task?

I believe I have learnt my arts of the scholar (ars longa vita brevis) and now I am learning the skills required for management and clinical leadership. I am being encouraged to take on a managerial role in my organisation without having any experience or training in such a task.  Should I do so and learn by my mistakes or is it better to listen to those with wisdom and first gain insight to then apply that knowledgeably?

I would value, as always, comments on this.

A Good Leader

“Good leaders make people feel that they’re at the very heart of things, not at the periphery. Everyone feels that he or she makes a difference to the success of the organization. ”

Warren Bennis

sighs.

Hospital Consultants are like professional footballers…John.

I sometimes wonder if my use of analogy is counter-productive but as I was struggling to find comparisons and analogies to demonstrate the interaction and relation between Consultants and medical management I was drawn back to professional football and I think I’m onto a winner.

In hospital medicine doctors work in small teams under the supervision of a Consultant. Ultimately, most Consultants work as independent practitioners within the hospital. True they may be part of a Diabetic team or Upper GI surgery or the Acute Mental Health team but one of the goals and privileges of being a Consultant is that we work at the pinnacle of our profession attempting to deliver care to the best of our personal knowledge and ability.

Within hospitals these Consultants work as part of larger teams and that team delivers care for a particular problem; such as Diabetes or a geographical area such as central Nottingham or even for a specific age group such as newborn children. Ultimately there is a umbrella covering this whole varied group and this may be a Hospital or a Trust or a regional service ultimately managed by someone such as a Medical Director. The exact inticacies of this are not important but what you do have is highly specialised individuals working with others in a larger group directed towards one over-riding purpose for that uinified group. A Premiership football team.

Each “player” or Consultant is highly trained, highly specialised and often brought into the team at that level of maturity. They offer experience and knowledge that may be of international reknown in one specific area and whilst they can be developed that is only within this ability channel not generically. No more can you encourage the goalkeeper to take over as a winger than get a Vascular Surgeon to do some hip surgery even althoughugh in a previous junior “team” he may have taken on that role.

Clearly for the whole team to succeed there is a requirement for effective teamwork, communication and sharing of the ball. Some of the roles have glamour attached as media celebrities performing  Heart transplant surgeons up front receive the plaudits of the red-top press but there is no doubt that without the midfield solidity of General Medicine and the decisive tackling of the Casualty specialist at centre back that the team would fail overall.

Extending the metaphor towards breaking point it is clear that some teams play with no sense of common purpose. Glory seeking wingers rushing for the goal only leave gaps at the back that the goal hangers of negligence sweep past. Old fashioned tactics of brutal tackling and the high ball attract poor crowds and the finances dwindle away. Not every team performs on the day despite the ministrations of the manager as they just fail to gel and even an occasional sending off may actually bring out the best in a team as they draw together defensively.

Clearly, whilst the manager gives instructions and plans before the game, “when they cross the white line” every player is their own boss whether they hang back and make a mockery of the rush offside defence or leave the lone striker up front with no ball because of selfish showboating in the midfield it is all about effective leadership and communication.

I’m going to leave it there, John, give all credit to the boys, who held their hands up and played for the badge. It’s a marathon, not a sprint and if we keep our noses to the grindstone we can save ourselves from the drop. Myself and the lads’ll be back, you know, you know wif more analogies cos, you know, if we give 110% we can turn this around, regain the dressing room and, you know, do it for the supporters. all credit to them.

What do you think John? Did the lads done good? Is that an apt analogy or just another cliché?

I think the analogy is true.

Football managers as clinical leaders? surely not!

The Leadership hub has some more words of wisdom on leadership from the Govan shipyard worker who played a wee bit of football and ultimately rose through the ranks to be regarded as one of the best 5 football managers ever!

Now, Sir Alexander Chapman Ferguson CBE has many critics and I certainly wouldn’t claim to be a Man Utd fanboy. (You can find my team supporting most of the Scottish League above them.) There is a no denying that the man has had a magnificent effect on the team he took over  20 years ago. He cut his managerial teeth on such well known teams as East Stirlingshire and St Mirren before moving to Aberdeen and then eventually Manchester United.

His style is no nonsense and direct, he firmly believes that no individual is bigger than the club and he is renowned for being a strict disciplinarian. Very old fashioned. And yet, as blogged earlier, he has a style that engages players, even those who don’t make it in his team and he gets results seeking out talent and nurturing and keeping them. Ryan Giggs for instance joined the club aged 17 and eighteen years later is still making first team appearances. Something about the team and set-up at the place has retained him whilst others have moved on. Sir Alex’s style must be part of that.

The advice Ferguson gave at a recent visit to a school was

• Gain respect, not fear
• Delegate and observe
• Analyse defeat in order to improve
• Be decisive and stand your ground
• Remember small things, like names
• Take care of yourself
• Make all staff feel part of the team

It’s not rocket science really, is it?

Yet the more I consider it, the more I wonder if football managers have something to teach us as clinical leaders.

Although near the pinnacle of his organisation the manager will still be at the shop floor on a regular basis. He must know and interact closely with many people on many different levels. He must delegate and trust the delegated results. He must integrate reports and reviews from many sources. He must motivate and change plans and tactics at a moment’s notice and must motivate even when things don’t go well. He has to deal with defeat and disappointment and even unrealistic expectations and complaint. Few managers achieve the success that others crave for the club yet they must still carry on to the next match and the next season. Hopefully.

So whether it is at East Stirlingshire or Manchester United I think football managers have something to teach us on clinical leadership. What do you think?