“plus ça change, plus c’est la même chose”

6 07 2010

When I was a child our dentist was really, really poor. One day, during a general anaesthetic I woke up. He left broken teeth in my mouth that took months to fall out. I had baby teeth filled without any anaesthetic. He promised to stop if I felt pain; he never did. Even now I can still see the broken plate of glass in the bottom right hand corner of his lamp any time I visit my new dentist 300 miles and many years away. I struggle to forget.

When I was a surgical trainee I was abused so badly by one senior that in a moment of deep depression I’m ashamed to say I considered suicide. Any time I see a Volkswagen Scirocco like she owned I feel the shame.

Large numbers of clinicians have had and continue to have very negative interactions with managers. I suspect the converse is true too.

None of this means that all dentists are poor, all Scirocco drivers are abusive, all managers useless and all consultants bitter but you can understand why many hold negative opinions at least some of the time. This (sadly) is source of the permanent mutual resentment I mentioned earlier between managers and clinicians. It was even was twittered about!

18 months ago our Trust undertook to try and communicate with all employees by staging “The Big Conversation”. This was an event to which everyone was invited to come and share their thoughts on the organisation; a brave and very positive move. Virtually none of my consultant colleagues went. I asked many why they wouldn’t go the simple answer from virtually everyone was, “Why bother, nothing will change.”

The more I look into this, the more sad I feel; this situation isn’t going to change suddenly, it is crippling development and progress. I mentioned it at the meeting itself and was met with disbelief and even a degree of disdain from one of the Executive Board members. I mentioned it within our directorate to similar effect. To resolve such denial and bitterness and then develop engagement will take a lot of talking, understanding and forgiveness on both sides otherwise the permanent mutual resentment will remain (and grow) and no-one should be surprised.

The Trust encouraged us at the meeting to “write a postcard to your future self” saying one thing we’d like see happen. I wrote, “I will remain positive and look for the change.” I wrote this blog post immediately after “The Big Conversation” but, as a commitment to change I resolved not to publish it; one has to remain positive.  The postcard arrived 6 month ago and I have to confess I feel even less positive than I did way back when I originally wrote this piece. I still resolved to remain positive. Six more months have passed. Sadly, nothing has changed, both sides were right.

Clinicians do not trust or believe the signalling of management. Management do not trust the intentions of clinicians. There is a significant, almost total lack of effective engagement. Is it any wonder that little changes? I wonder what Sartre would have said?


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.

The fine ART of management

27 10 2009

I am blessed that currently I work in an institution that gives me many opportunities to reflect on different management styles. A further blessing is some insightful and gorgeous friends who stimulate and support my thinking and development.

Take a look at this piece of art. I love it.

sinister rainbow

Sinister Rainbow, Emma d'Souza (medium- acrylic, silk thread & felt)

Is it just paint splashed around? Is the artist authentic ? Does it encourage other people to come and look at other pieces of work? Will it influence others? Will you look at your own work and want to do better or differently next time? Could the artist explain why? Would you be proud to display or own this piece of art? Is it art?

I believe the same questions can be raised of management style.

I’m sure, with the right materials and time I could attempt to produce something like that. But is that art? Is it just the finished article we are looking for? Is a poor copy worth the same? Surely what is more important is the journey to that end point.

We all have to accept that targets are met, roles fulfilled, projects planned and appraisals achieved but surely (please?) what is actually more important is not the end point but the nature of the  journey in getting there. There has to be more art to management than simply administration.

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