There is quiet optimism at the top of the NHS. The hope is that we are through the worst of the winter. Some indicators have improved, such as public satisfaction with GP access and ambulance response times, while activity levels in hospitals were maintained at 95% through the resident doctors' patchy industrial action.
As is often the case with the centre's way of viewing things, the critical success factor is seen to be individual leadership, with Sir Jim Mackey modelling the way with his clarity, work rate and direct engagement with local leaders.
I have questions about this account, for example, the implicit suggestion that somehow we can abolish the standard distribution of quality in a large leadership cadre. However, we could all do with a message of hope right now so let's hope the cold snap doesn't take too much of a toll and that recovery continues.
But the big question – as always – is whether quantitative improvements in how the service now operates can translate into qualitative shifts towards how we need to do things in the future. After all we have had many periods of relative recovery in the NHS but few yet of successful system-wide transformation.
This takes me back to a concept I first heard from David Albury, a thinker and consultant who has worked with many parts of the NHS. Albury talks about the importance of ‘split screen' thinking by which he means the ability to lead with both the short term and the long term in view. Few would disagree with this as an ambition, but what does it involve and how can the centre best support it?
The first requirement, obviously, is to be able to lead in both timescales. This means capability, grip and agility in addressing the immediate challenges and priorities along with clarity and consistency in pursuing a concrete transformative vision. More specifically, split screen leaders will maximise the extent to which short-term actions align and can be seen to align with long-term intentions. Their colleagues will be able to identify moments when responses with a short-term rationale have been rejected in favour of other options that may be less immediately powerful but reinforce that alignment.
Sometimes this will mean pushing back against external pressures which reflect other priorities. The best public sector leaders are willing when necessary to be subversive in the face of the infinite pressures placed on them by national rules and incentives.
Split screen thinking also tends to involve leading in very different contexts. This is particularly true of the health and care service. Short-term action will tend to focus on things that can be addressed within the walls of the organisation while long-term transformation requires collaboration with others and working in the spaces between. This is something the centre still doesn't grasp. Indeed, my conversations have underlined the view in NHSE that the leadership needed for service recovery in organisations is not qualitatively different to, for example, the kind of place leadership required for the left shift.
My conviction that we need to invest more money, energy and insight into the capability for local collaboration, especially in the face of central scepticism, has led me to do more research. I can recommend this review of the evidence that has emerged from an approach called ‘relational co-ordination'. While NHSE leaders seem to think local transformation can be achieved simply through new funding and contract mechanisms, the research suggests effective collaboration involves a long list of specific actions and skills, including training for team work, relational job design, boundary spanning roles, shared accountability and rewards, conflict resolution, shared spaces, protocols and information systems.
While I have seen lots of good practice as I undertake system visits, rarely if ever have I seen anything even approaching the range of capabilities, assets and processes the literature argues are necessary to make tough and enduring collaboration work. Add this to the continuing lack of central policy clarity or consistency over local structures of accountability and delivery and the prospects for effective and radical collective action seem highly questionable.
NHSE claims that the team under Sir Jim Mackey have elicited a ‘leadership response' from the service. There is some evidence for this, which should be applauded. But it would surely be a mistake to believe that the forms of leadership that have so far delivered important but incremental steps towards service recovery are the same as what is needed for long-term transformation.
