leadership

Everyone counts…but some might count more than others?

Mike Chitty · February 1, 2020 · 3 Comments

We maximise our resources for the benefit of the whole community, and make sure nobody is excluded, discriminated against or left behind. We accept that some people need more help, that difficult decisions have to be taken – and that when we waste resources we waste opportunities for others.
NHS Constitution – Values

I think the NHS Constitution is a wonderful document. Beautifully written, it speaks powerfully to many of us about the NHS that we want to use and work in.

One of my frustrations in working with the NHS is the infrequency with which we consult the values explicitly to help us with decision making. The values are beautiful, but in my experience, appear to be used infrequently as a management and leadership tool.

There are 7 values in all and they set an incredibly high bar. Take this one – Everyone Counts. It is the value that to my mind speaks most explicitly about the NHS ambition with respect to diversity, inclusion and equality.

I think that, in practice, we often stop reading after the first clause. We maximise our resources for the benefit of the whole community. We do our best with limited resources to provide the greatest health gains for the greatest number of people that we can. We work on ‘population health’ But in practice this means that the second clause of the value often gets neglected – We… make sure nobody is excluded, discriminated against or left behind.

Because, in practice, in terms of health outcomes we have been ‘leaving behind’ the same groups for decades. Whether this is through processes of exclusion or discrimination, or just lack of clinical knowledge I am not certain. I suspect that many factors, mostly found in wider society, play a part.

But until our health and care strategies start with a real commitment to help those that have been systematically ‘left behind’ to catch up as quickly as possible we will have widening health inequalities.

So let us re-visit the third clause in the value We accept that some people need more help, that difficult decisions have to be taken. When we take these difficult decisions, what will benefit the ‘whole community’? A focus on creating as much health gain as we can, for as many as we can, for a fixed cost? Or spending our money in a way that helps those that have been historically and systematically left behind by the system to catch up? How do we find the balance?

Who are we choosing to ‘leave behind’?

This is becoming an increasingly pivotal question for me as I work in primary care networks, integrated care systems and NHS Trusts. And if you care about equality and inclusion then perhaps its need to be a question that you are prepared to ask too.

I am also increasingly striving to increase ‘community engagement‘ not through the usual processes of patient participation groups and so on but by going directly in to communities and engaging them in playful conversation, often with academics, clinicians, commissioners and managers so that their voices can be heard directly and relationships formed that will start to change the system.

I would love to hear what you do, in your practice that helps to raise awareness, interest and action in tackling health inequalities.

Please leave us a comment!

Why Conversations to Transform Health and Care?

Mike Chitty · December 20, 2019 · 1 Comment

I was Head of Applied Leadership at the NHS Leadership Academy for three years and was asked to sit on the ‘Building a Digital Ready Workforce’ National Steering Group. This led to me thinking about what we needed to do to help the boards of NHS organisations in particular to lead the transformation of Health and Care Services making the most of ‘digital’ – whatever that meant.

After much thinking I started to believe that it didn’t really matter what we did to develop boards; workshops, bootcamps, maturity matrices or conferences about AI and genomics. Until we changed how they saw their world and tasted different ways in which they might be able to lead in it, they were unlikely to make substantial changes in their strategy. They might drop a few tens of millions on a new patient record system – but would that really transform? Would that allow new patterns of power and relationship to emerge? Or would it just take some kinks out of the current system?

For me it felt like doing ‘the wrong thing better’.

But what was the right thing? The thing that might ‘develop’ the system?

The thing that went against the habit of Board rooms, Board tables, agendas, PIDs, rag ratings and budgetary decisions?

Against hierarchical expressions of power delivered through plans and Gantt charts and (not so carefully) managed variances?

Well for those of us that have worked a lot in civic society, in community development, the place to look for some clues was clear. Self organisation. Emergence. Transparency. Relationships, Inclusion, Diversity and Trust.

Work in the spirit of pioneers like Harrison Owen, Peter Vaill, John McKnight, Peter Block and others. It was about leading with communities not over them or for them.

Connecting small groups of people with the passion, responsibility and power to make change happen locally and to invite the formal power structure to sit with them and listen. To be influenced and to influence. but mainly to encourage and support. To ‘unleash’ the power of these small groups that care to do their work.

And so we started, with the support of James Freed and Maeve Black at Health Education England and Ian Macintyre from the NHS Leadership Academy, on our project to use Conversations to Transform Health and Care. To see if ‘Leadership as Convening’ might help to really transform Health and Care.

Open Space Events were planned for York, Hull and Scarborough to see if we could find the people who might really have the passion and the responsibility to transform health and care and whether we could help them to find their power….

What is Open Space?

Paradigms and why they matter

Mike Chitty · December 15, 2019 · 1 Comment

Paradigms are tricky things, sometimes almost invisible, certainly not often directly observable. But they are well worth thinking about, and learning to work with for those who want to try to improve things a bit.
If we can recognise our paradigm and change it a bit, then all sorts of new possibilities can emerge.
They are a bit like ‘the system’ that we live in. The system of widely accepted and normalised beliefs, methods, values, customs and practices that we usually just take for granted.
And just like fish don’t recognise that water exists, until that moment they are removed from it, most of us don’t recognise the paradigm that we live in. It is an almost invisible context or medium that we operate in.
Paradigms matter because they give us a context and ways of working, but they also bring with them limitations. They rule certain things out, or at least relegate them to the ‘unusual’.

The Horse Paradigm

For a long time the main paradigm that shaped transport policy, planning and practice was the paradigm of the horse. Horses were the most cost effective way of providing power to our transport systems. The paradigm was so powerful that at one time it was thought that the limits to growth of major cities was the capacity to remove horse shit, urine and carcasses from the streets. By the late 1800s most major cities were drowning in horse manure and urine. With more than 50 000 horses on London’s streets each producing 7-16kg of manure and a litre or more of urine it wasn’t just the smell and the mess that was the problem, but also the flies. But this is what ended the horse as the dominant paradigm. But it didn’t start that way. To begin with only the rich could afford to travel by horse. The rest of us had to walk. The horse was not the dominant paradigm to begin with. It was walking.

And this tells us something about paradigms that seems generalisable. They first appear in our world as a minority activity that gains in popularity before fading away. Sometimes this happens in the course of a few years and sometimes it take decades or even centuries.

Back to the horse paradigm.

Most of the experts of the late 1800s were seriously consumed by the challenges of the waste products of the horse paradigm and how to remove them from our cities – preferably without using more horses! Most were really not focussed on alternatives to the horse which all appeared outlandish, dangerous and rife with problems of their own. When the first steam engines were being turned into locomotives hardly anyone thought they were going to be the next big thing in transport. Canals were seen to be much more viable propositions than railways. When Henry Ford was messing about with the first motor car his customer research didn’t go well. People didn’t want his dirty, expensive, unreliable cars, they wanted ‘faster horses’.
And this tells us something else about paradigms that seems to be generalisable.

The clues to the paradigms of the future are to be found co-existing alongside the current dominant paradigm. Often ridiculed or feared, as the dominant paradigm outlives it usefulness or creates more problems than it solves, they gradually become more popular until perhaps they become the dominant paradigm.

And as one paradigm declines to be replaced by another there can be conflict. The dominant transport paradigm in most of our cities at the moment is of course that of the motor car, still largely petrol driven, already taking up too much space for our road system and still getting bigger, using a ton of metal and plastic to transport usually one <100kg passenger, killing and maiming people every day at a disconcerting rate and endangering our very existence through pollution and climate change while spending most of the time parked up consuming valuable land space.

Contenders for an emerging paradigm?

More but different cars, clean power systems, driverless cars and shared car fleets? Or public mass transit systems? Or bicycles, scooters and e-bikes? But we can be sure that the current dominant paradigm of the car won’t go without a fight. Often literally. And it will probably take a very long time to go completely. I mean we still love our horses.

Why does this stuff matter? Why should you think about it?

I suppose to some extent this depends on how you characterise the current dominant paradigm and whether you want to see it develop and grow, or whether you want to see it replaced by a new paradigm.
If you think that the current dominant paradigm is working well and has room to create more value then your focus should be on resourcing and supporting this work and perhaps ensuring that you don’t invest in emerging paradigms that might threaten this one. I mean if it ain’t broke, why fix it?
If on the other hand you think that current paradigm has become toxic, creating more problems than it solves then you might choose to invest your energy in supporting emerging paradigms and potentially undermining the dominant one, or at least trying to limit its growth.
Unless you think carefully about this stuff you may find that, while you would love to see a new and different paradigm emerge, you have been effectively captured by the current dominant paradigm and compelled to work in ways that support it, either directly, or by earning a living clearing up the mess that it makes. Our cities used to be full of people whose job it was to carry away the shit and the dead horses so that the dominant paradigm of the horse could continue unaffected. These days perhaps our cities are full of people clearing up the mess created by our own dominant paradigm; global warming, homelessness, mental health crises, plastics, crime…

Paradigm Shifting…

So can we shift a paradigm? Can we consciously act to accelerate the demise of one paradigm and the emergence of the next? Can we manage a transition from one paradigm to the next without a full blown crisis. And if a crisis does hit, is the new paradigm waiting in the wings, oven ready, to step up? Or do we have no alternative but to put the defibrillator on the old paradigm and spark it back into life? Like the banking crisis in 2008 for example.
Some people might focus their energy on bringing about the demise of the dominant paradigm while others fight to maintain and develop it. Some might focus on developing ideas and technologies that might lead to possible new paradigms while other innovate strictly within the dominant paradigm, reinforcing it further still. And often these players all co-exist side by side in the same place, at the same time. And learning how to work together to ensure that the dominant paradigm creates as much value as it can, while allowing new and perhaps better paradigms to emerge seems like a worthwhile leadership challenge. And at the heart of it is

paradigm awareness,
the effective management of power and resource imbalances and
the building of trusting relationships between those that could otherwise easily come in to conflict.

I work in a wide range of settings, from cultural education partnerships, local authorities, the NHS, the private and third sectors. In every setting I have found that an exploration of new and emerging paradigms and the implications this has for leadership, decision-making and partnership working has had profound and very practical implications. If you would like to explore whether some considerations of paradigm shifts might be helpful to you and your work please do get in touch.