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.

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.

When conversation is better than commissioning

A hero of mine, Enrico Coiera, once wrote a paper entitled "When conversation is better than computation" you might expect that kind of title from a luddite, with anti technology principles, but at the time Enrico was a Vice President at Hewlett Packard in their special research division.

Enrico argued that despite all the computational power available there were times when developing a relationship and establishing communication was the right thing to do.  I would like to suggest that the same principle might apply to commissioning. We have services that could be improved by stepping back, starting again with a clean sheet of paper and buidling the perfect pathway. Although this risks the God Complex, it will be appropriate at times.

What would happen with conversation?

If there was an outcome which was less than expected it could be talked through and the incremental changes required could be put in place without the need to start again, spend hours redefining and re-procuring the system.

Cynic will argue that talking will just support the status quo, but they miss the point, the incremental change means that the status quo moves whether it wants to or not.

Perhaps the next time you have a letter from a hospital which asks you to look up blood results on the same hospital system the consultant could use, and furthermore to send it to the consultant, rather than moaning about being made to act like  a house officer (F1) you could always initiate a conversation- try it, you'll be surprised.

Irreconcilable Differences?

Writing in his book Blink, Malcolm Gladwell tells the story of a marriage guidance counsellor who is able to predict success or failure of a couple after only a few minutes of interview time. The key he believes is contempt, if couples show contempt then all is lost, the relationship is doomed.

This week I have been speaking to people in primary care and secondary care.

In truth there were times when it did feel like being a marriage guidance counsellor.

All the red flags for relationship arguments were being waved in to the debate. The sin of absolute generalisation-"You always (then insert the apparent sin) in primary/secondary care" - really?- We always send out letters late? We always fail to refer appropriately? The sin of dragging in the in-laws "social care doesn't do its job and that's your responsibility to commission" is guaranteed to raise hackles.

Once absolute generalisation is used it tends to suggest that a fight is on the cards and that ignorance of each others feelings and functions is the underlying cause.

The main tragedy this week is that there is starting be be a little hint of contempt. "I never take my child to the GP he's rubbish- I don't know why any parent would."

Really? All GPs are rubbish?

Perhaps we should take a leaf out of the marriage guidance book and concentrate of creating a conversation in every health community which might just avert contempt, otherwise we will really find Irreconcilable Differences

Innovation or Novelty?

It’s a tough call commissioning new care processes.

Do you do the same as usual but faster? Do you do something different, by definition an untried process .

Doing something different is often described as an innovation, but is it really innovative?

A new contract to an existing supplier which is accomplished by the supplier in its current form is not innovation. It may have the novelty of newness, the frissant of freshness, but if the provider is just doing more of what it is set up to do, then there is no innovation. More of the same does not change the landscape and although novelty is amusing for  a while it soon fades and the system returns to normal.

Setting out to commission something which requires existing suppliers to change their processes and structures or which can only be fulfilled by a new provider is innovation. Beware that all existing pressures in our complex adaptive health system will attempt to force the new initiative into a shape that neuters the effect of innovation, so the emergent commissioning decision will need to be protected and steered to produce an innovation solution.

Why bother about innovation?

It is the nature of healthcare systems to be complex and adaptive. These systems want to revert to their current attractor state and the only way to move the system is a significant disruption. If you’re not ready to break it- and we’re not quite there yet with healthcare, the next best thing, possibly the best thing, is to innovate.

Go ahead, give it a try, but not as a novelty item.