When we means us and us means them

31 01 2010

Managerially, things are a little “difficult” around here. Recently we were invited to our first ever “Strategy Meeting” to which I went, trying to be positive and viewing this as a sign of progress and engagement. Sadly itwas actually just an opportunity for senior management to tell us how bad things were and how “we have to make big changes that had already been decided otherwise we will not achieve Foundation Trust status and this will be a bad thing for us.”

I have commented previously on the nature of engagement between clinicians and management and particularly around the nature of organisational structures, as described by Mintzberg. The present feeling is that hospitals are managed professional bureaucracies (mpb) in which the “operating core” (clinicans) are the source of production and, because of the specialised nature of what is produced (clinical care), have a large degree of autonomy and control over performance. They are supported and to some extent directed in this by the “strategic apex” (management).

In light of our recent interactions I am beginning to question this classification. Previously I have suggested that rather than a mpb, hospitals are becoming more akin to a machine bureaucracy (mb) such as a factory characterised by highly specialized, routine tasks; formalized procedures in the core; a proliferation of rules, regulations, and formalized communication throughout the organization.

What struck me in our “meeting” was the frequent use of inclusive words such as “we” and “us”. Now, regarding this as more than simply management speak, of which I am heartily sick, and sadly also the insincerity with which we are frequently faced, it is clear that the management approach is based upon the concept of a team working in a united manner towards a common goal. This is to be praised and valued. Sadly this is patently wrong on many levels.

The operating core does not share the stated strategic goals of the bureaucratic apex. In the worsening financial climate with calls for “efficiency savings” in the face of four years already attempting such, the fact is that these new strategic aims are diametrically opposed to those of the core and possibly their fundamental belief systems. Even the most liberal minded strategist would see that rather than the example used previously of  an emergent strategy as being the joyful union of intended and deliberate strategies what is about to occur is discordant, divergent strategy.  This would be almost impossible in a managed professional bureaucracy and untenable in a machine bureaucracy.

Moreover, the operative core has recognised that “management failure,” in whatsoever guise this occurs, will not bring about apocalyptic destruction or failure of the bureaucracy (hospital),  merely a change albeit dramatic and possibly total, in and of the strategic apex. Complexity theorists should watch this space, we have serious disequilibrium.

Consequently, the nightmare scenario painted by the apex of “failure” for us is actually for them and holds few concerns for the core. It may even bring dramatic improvements. This failure is almost inevitable, not simply because of the financial crisis, but due to an instrinsic failure in the understanding of machine structure.


Clearly I’m missing something

27 11 2009

Following on from the last post, yesterday I was briefly interviewed by a junior doctor who is “on a leadership course”.

He was running a survey to find out “why theatres don’t run efficiently and who is to blame and whether this maters (sic) to anyone”. I tried to help by answering the questions but they were so vague as to be impossible to give a valuable response to. I asked what all this had to do with leadership and he responded, “To make people work better.”

I knew I was missing something.

Twitter fail whale

24 11 2009

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.

Being a leader is not simply about the magic 8-ball.

20 11 2009

There can be no doubt that the NHS without effective leadership will be (is) in trouble. There are many reports, projects, initiatives and clinicians addressing this problem whether it be by meausuring, documenting, planning or even studying the issue. What is interesting me of late is who should be undertaking leadership roles.

In the ideal world it is clear that a leader needs the appropriate

    • desire
    • skill
    • capacity
    • authority

to be an effective leader.

The characteristics that separate one clinician from others and designates them as a clinical leader are not however clear. The reasons why colleagues make the move into leadership will affect their ability to deliver in this role and simply being the only volunteer, selected by rota or even the best at interview does not necessarily embue the candidate with the characteristics that are required for success. Previous blog posts have atested to the value of developing effective, employed junior managers, thru’ schemes such as the MBA, into senior managers utilising their experiences gained in the realities of the task and blending and refining this with essential knowledge delivered by experts. 

Embryonic clinical leaders have no experience of the realities of management, self select for many reasons not all altruistic and commence work as a necessarily part-time role with no training whatsoever. The environment in which they work is firstly foreign, secondly hostile and thirdly there are few rewards with little support. Would you like that job?

For leadership to be effective the leader has to have the desire to lead the team. Whilst this may seem obvious it is very different from simply balancing budgets, developing the service or achieving targets as required by more senior levels and these priorities themselves may disengage rather than engages the team. The skills to achieve this balance with conflicting stresses are not acquired during clinical training, by osmosis or even simple good sense but take time, effort, mistakes and effective relationships to develop. Little of that is offered to the new clinical manager.

The actual capacity to lead must also be questioned. In a clinical directorate with a budget of millions of pounds do we really feel that the most senior figure, the lead and the encourager can do this job on an adhoc basis even without the time to address the challenge of developing their own role? What is certain is that no-one comes to the task fully fledged or full time. This wouldn’t happen in industry.

Lastly, the authority to lead is not implicit in such posts. It may be a position of managerial superiority but this only effective applies to those who consider that the management structure has this legitimacy. Unfortunately, due to the disconnect between the vast majority of clinicians and mangement, this relationship is seen (and perhaps expressed) as illegitamcy.

Whether all this is true or not it perhaps addresses the fundamental problem of current “Leadership” development programmes. The concept of the programme and the development of indivuals in roles of leaders is somewhat moot until the right leaders are in the job and not just “selected” when everyone else has taken one step backwards.

The artistry of leadership

28 10 2009

There is an artistry to effective leadership.

Expression changes everything.

This post by Garr Reynolds speaks more eloquently than I do.

tell me something positive please?

24 09 2009

I’ve had a bit of a rough week with our management team. I wrote a post and decided against publishing it as all it reflected was my negativity.

So I thought, why not seek out some positivity? Let us all (as there are regular visitors to the site) hear your encouraging stories of management, clinical leadership and how it works for you. Share how you can see how things are improving or where change has happened for the better.

Go on, let’s hear the up side?

Somewhere over the rainbow…

6 09 2009

Is it a fantasy? Is it a dream? Is it a story of a search for missing characteristics? Is it possible or is it even Kansas?

In preparation for my recent essay I came across the Really Learning Website and a “subjective think piece” written by Valerie Iles that explores the introduction of management into the NHS over the last twenty years, its relative successes and alternative approaches.

The piece is insightful, thought provoking and challenging. You should read it. It finishes with a paragraph that summarises much of what I have blogged about over the last few months.

“As we challenged our assumptions we might also recognise as fundamentally flawed the notion that any management consultant or policy advice team is better at devising structures and processes for the complex, dynamic interdependent set of systems, that together comprise our national health care, than are the people working within them. It is not Roy Griffiths’ fault that his prescription took the system as a whole in the wrong direction for 20 years, but we must make sure we never again allow one person’s view  to prevail. We must find ways of allowing locally relevant solutions to develop and flourish, devised, owned and implemented by local teams of clinicians and managers, held to account only for their outcomes and not for implementing a centrally prescribed set of processes. “

It wasn’t The Wizard that changed things.

%d bloggers like this: