Leadership for Commissioning

There is no shortage of literature on leadership. The number of books and the styles of leadership are legion, the range goes from Kotter to Milan (Be The Pack Leader).
Attending a recent Clinical Commissioning Group meeting I was struck by the almost apologetic attitude of the board members, their reluctance to take their places on the table at the front for questions and answers and their non existent answers to the single question from the floor.
In terms of scoring against any indicator of leadership the performance was poor. Did they have a vision? Well, er, no not really. Did they inspire for the challenges ahead? Erm, ahh, no actually.
The big question is whether this "style" is actually appropriate at this time. Given that the changes in the NHS were not sought by many, except those driving PBC, it could be argued that they are reluctant leaders, thrust into the limelight. However the fact that they stood for appointment denies the excuse of reluctance. Perhaps they are awaiting a mandate and their constituents direction as to how they should work? If servant leader model is their modus operandi then they have failed to touch constituents directly, instead relying on practice contacts.

Perhaps we have not appointed leaders at all, perhaps we have appointed managers?

What would the ideal package or style be for a commissioning leader? Of course there is no answer to this question, they should be a balance of credibility, authenticity and vision. Whilst my colleagues are authentic, the lack of vision hampers credibility. There is certainly a long way to go to develop the leaders for commissioning in my locality.

Competition Time?

This weeks BMJ has an expoloration of competition as a means to drive up quality. It turns out that the jury is still out as to the effectiveness.

I think it is pretty clear that competition does improve quality, take motor racing for example. If there was no Ferrari, would there be a Maclaren? Would Red Bull be quicker if there was no one to race? The answer is clearly no, the fact that there is someone to compete against means that the quality indicator of lap time is improved incrementaly year on year.

Stepping back from quality the piste appears less certain. Right now a formula one car costs $7 MILLION. Now I appreciate that this costs is exactly what is required to stay ahead of the competition and that the purpose of the car is to go faster than the competition, but ask yourself this one question- if Vettel and Hamilton were racing in Ford Mondeos then would we find out who was the faster? The answer is of course yes, we would know who was quickest, the competition could be won or lost and the purpose of F1 acheived.

You see competition comes in many dimensions, with many aspects and so when we argue that competition improves things we are correct, when we argue that competion makes some things worse we are also correct.

So is competition good or bad?- the answer is yes.

America is not the answer

"When you go to the doctor feeling sick you spend time cooling your heels, first in the waiting room and then again sitting in a flimsy gown, on an examining table. Finally the doctor rushes in , pausing only long enough to ask a series of questions on a checklist before dashing out again to see the next patent. if the doctor refers you to a specialist, getting an appointment takes weeks. if the doctor prescribes you a drug, your insurer refuses to pay for it."
So wrote Shannon Brownlee in her book "Overtreated" - I was Recommended the book by a colleague who had spent a fair chunk of his career living and working in the states, not as some prized international guest but as a jobbing Doc, who saw the system from the inside, the old, the bad, and the ugly.
So why the fascination with America?
Is it the prospect of visiting a system in which every latest test and treatment is possible? ( insurer permitting). Is it the possibility of seeing what happens when you are in track to spend 20% of your GDP, the equivalent of the total budget of Italy, on healthcare?

I suspect it is because we in the NHS are foolish enough to believe the hype, the media, the spin that says America has it right, is sorted, is the way forward.

Ok, I accept there may be pockets of answers in the states, perhaps accountable care organisations have something to offer, perhaps safety initiatives can be transferred across the big pond. However I would also suggest that we have much more to learn from Europe, where primary care is more like our own, where health issues, financial mechanism and political environment offer more transferable solutions.

If you must look across the pond, why not try the other great nation on the continent of North America? -Canada.

it's networks all the way down.

Network theory offers some insights and structure to the study of systems, whether random or complex. In particular scale free networks "webs without spiders" are particularly resonant when it comes to looking at the NHS.
Scale free networks consist of nodes and links, some links are unidirectional, others work both ways. Some nodes are massively well connected, others have few links.
So far so good, but when it comes to scale free networks there are some caveats, the networks are robust, non random creations, which obey some key principles including a power law for distribution of connections.
Look at the NHS, consider clinicians as the nodes of the network and patients as the links between clinicians, either as direct "please see this patient" or as patient related data, letters results, conversations.
Now sit and visualise your surgery, hospital, patients.
Imagine the lines flowing linking you with the services and clinicians that you refer to and share information with.
Think about how those who work in hospital interact over patients, the discussions, referrals and the vast web of links that is created.
So far so good.

Network theory suggests that the disappearance or failure of some of those nodes will mean that the links reform with other nodes and in many cases the network re-forms, however in some cases removal of a key node results in a cascade of failures, with each subsequent node being subjected to a load with which it cannot cope.

We know this intuitively, as we see this when the clinicians in the local AED are overloaded, the Trust goes "red" and sure enough, the nearest AED takes the load and sometimes fails.

So far the NHS has just about coped with "nodal failures " in general they have been escalating pressures, either seasonal or semi predictable.
Unfortunately there is a property of scale free networks which is unpredictable and undesirable, in that they are vulnerable to attack.

Deliberate removal of a key connector node causes isolation and fragmentation of the network with subsequent failure or isolation of the remaining network.

The NHS has not been subjected to a deliberate attack in terms of removal of nodes, but it is conceivable that change in the infrastructure of hospitals, their service delivery models, and key staff may function as an attack. The consequences cannot be foreseen but could be catastrophic. In some way this could be seen as justifying the maintenance of status quo, no changes to services etc, but in reality Network Theory provides us with a warning, the changes can be done, should be evolutionary and must be thought through.

Baa-ram-ewe! Baa-ram-ewe! To your breed, your fleece, your clan be true

Who earns your loyalty and why?

It's a tough question because we rarely think about who or what gains our loyalty. The sheep in Babe give their hierarchy in the title of this post, but for clinicians the distinctions are not always clear.

Is it your practice or department which comes first? Is it your speciality? Is it your health community?

It is too trite to say that you are loyal to your patients, especially since all too often it is they who remain loyal to the practitioner who has failed them in the past.

This loyalty issue has a nasty inverse consequence. I recently met someone who worked for a specialist trust. She described consultants from that speciality who worked in nearby DGHs as having failed to attain the standards required to work in her organisation, and in effect, not fit to treat her dog.

When loyalties are put in conflict, such as organisational mergers we are likely to see reactions which are unpredictable, possibly aligned to loyalties not apparent to those outside the group. These conflicts will be increasingly common as the commissioning agenda develops.