Reading the room: mood music for the battlefield of organisational change
by Helen Buckingham
One of the things that leaders learn through experience is when to pick your battles. This is an art, not a science - and, as I’ve said to more than one CEO in my time (and learnt myself, the hard way), being ‘right’ doesn’t make you right.
You might have a shed-load of evidence on your side, but that is no guarantee that you’ll be listened to - or more accurately, heard. The mood music matters too.
We might not like the sweeping reductions which are planned in the numbers of staff working in NHS England and ICBs. I’m on record myself expressing concern bordering on anger at the crass handling of the announcements (plural) and the charge placed on leaders to make those reductions, without yet having clarity on the roles which ICBs (and indeed NHS England itself) will play in future.
But we are where we are. The Government is not suddenly going to row back and say, ‘ooops, we got that wrong: carry on chaps’.
Nor should they. It is indisputable that there is duplication of effort between DHSC and NHSE (there’s duplication of effort within both organisations too). It’s equally indisputable that there’s duplication between ICBs and regions, and between ICBs, providers and local authorities.
Ends not justifying means
I’m not going to begin to say that these ends justify these means, because the way real human beings, people who are working hard to make a difference to health and healthcare, has been treated is shocking.
But we can’t re-run history and get the announcements handled better. While we must acknowledge and listen to how people feel; and treat all staff as well as possible from here on, learning the lessons from that; we also have to move on from where we are.
NHS England
So in the circumstances, I thought Jim Mackey’s letter to leaders across the NHS in England this week was pretty reasonable, if somewhat football manager-like in tone. It provides at least some parameters within which leaders can make decisions whilst we await – in hope, at least – greater clarity in the 10 year plan.
The letter acknowledges the challenge which leaders face, and the efforts to which they are going to squeeze a quart out of a pint pot. It speaks to every part of the system (well, it’s maybe a little quiet on primary care), rather than communicating in silos.
There were some things in it which worried me. History tells us that significant reductions in planned deficits are more often wishful thinking than reality-based projections, and the actions which trusts will have to take to achieve them – if they can – will undoubtedly impact on patient and staff experience.
No-one would argue with the wish to target a net surplus in the future, but no-one should underestimate the challenge of getting there from here. Remember that the last time the NHS turned a significant surplus around, it was done through a combination of very strong grip and more generous allocation increases than we’re likely to see this time.
Wholly-owned subsidiaries can indeed deliver benefits, but they also carry a risk in relation to the terms and conditions of staff employed by them.
And the hint that there may be changes in the way in which continuing care is managed could be positive; but it could also point to even further tightening of the belt in an area which has profound implications for individual patients and families.
But for a CEO stepping into a role where from the start he finds himself between a rock and hard place, it’s hard to see what else he could have said or written.
And we know the buck for delivery will sit very firmly with Jim.
Which battles to pick?
So, which battles to pick? Perhaps it’s due to their professional skills and adept use of social media, or the bubbles I move in, but the group I have seen abreacting most over the last couple of days are the comms professionals.
They’re absolutely right to highlight the critical role of comms and engagement in working with both staff and the public to deliver change, and God knows it’s more important than ever before to bring people with us when the service is going to have to make some very difficult decisions about how services are provided.
We know from the public engagement so far on the 10 year plan that however enthusiastic we in the service might be about shifts from hospital to community, from analogue to digital, from treatment to prevention, the public as a whole have some concerns about all three.
The hard truth, however, is that reductions in headcount are going to have to happen. That’s where the NHS spends its money, so if it’s going to spend less, that means fewer people.
But that doesn't mean rolling over and giving up for any function. It does mean doing what’s being asked – taking a good hard look at the resource which is going into the function across the whole system, and asking some tough questions about how that resource can be used differently, and what the consequences would be – both negative and positive.
I’m not piling on to the comms teams and saying that they need to up their game. It was somewhat invidious to single them out as a function at a time when national communication with staff has been spectacularly poor (not through the fault of any individual comms leader either).
And as aside, in picking out that function together with nurses in corporate roles,safeguarding and infection prevention and control I would note that those are likely to be areas with a predominantly female workforce – so I would be treading very carefully around due process.
No team is an island (hopefully)
No team in the NHS works in isolation (or if they do, then they definitely need a bit of a shake -up). Cutting resources in one area will have consequences for the way in which other parts of the organisation function.
Perhaps a better way for Jim to frame his request would have been not to pick out specific roles, but to make the entirely valid point that there are a range of functions where there are likely to be overlaps and opportunities to work differently, and ask local leaders to come up with concrete plans to address that which demonstrably reduce cost while minimising – given that it will be difficult to avoid – adverse impact on services.
Read carefully, his letter uses assurance, performance management and comms functions to illustrate the point, not to single them out. But there is a risk that that’s exactly what happens.
Has Jim accidentally picked a battle he didn’t need to here? And if he has, can he work with local leaders to defuse it?
I’m well aware that none of this is easy, and teams are stretched now. Almost certainly, some activities will have to stop, and we need to be honest about that – with ourselves and with the public - and take the consequences of it. Picking battles internally helps no-one.
Helen Buckingham is the director of Helen Buckingham Consulting. She has worked across a wide range of provider, commissioner, policy and regulator roles within and around the NHS, and can be contacted on HelenBuckingham@hbuckingham.com.