How to reform public services by liberating local teams to do the right thing
A lot of people, including the national political parties, are talking about public service reform.
But many of the solutions they propose just won’t work. Forcing through efficiency measures, setting targets, implementing digital solutions, ‘engaging with’ the private or charity sectors. All this has all been tried for years now. And services have become even more dysfunctional, not less.
As we discovered in this session on 2nd May 2024, with systems change expert John Mortimer, better solutions are available. In several places, councils have had a go at operating very differently. They set up strengths-based locality working, with multi-agency teams, able to operate close to people in their community, with a simple instruction to discover what individual people’s circumstances actually were, and then to take action, and do the right thing, with the goal wherever possible of helping people to help themselves.
In every case, costs reduced, demand fell, and value was multiplied.
So, we have a pretty good idea of what needs to be done, and the good news is that it doesn’t take significant resources to do it. But, as the real-life examples shared in the webinar demonstrated, it does require an alternative ‘local by default’ approach and courageous public sector leaders who are willing to take a deep fresh look at what is really going on, and establish a different operating method for their teams.
You can view a recording of the webinar by clicking on the photo below:
The presentation drew on material which first appeared in the 2014 Locality/Vanguard report:
Here is a full set of slides to accompany the webinar - the slides set out the evidence, as well as the practice and policy implications:
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John Mortimer is a Systems Thinker at Impro Consulting. He is an expert in public sector redesign, reducing failure demand, enabling those at the front-line to work together, in service of what most matters to people. He can be contacted at: john.mortimer@improconsult.co.uk
Better leadership for health and care (second meeting)
This was the second of two meetings on the topic ‘if we don’t like command-and-control leadership methods in our health and care systems, what are the alternatives?’ The note of the first meeting is here.
Tom Neumark, CEO of the 999 Club, a charity which works with homeless people in Lewisham, was our introductory speaker.
He described how he built relationships, over time, with key individuals at the South London and Maudsley NHS Foundation Trust (SLaM), and eventually this resulted in the charity bidding for and winning a contract to deliver a new mental health service. During this process the charity wanted to engage with the statutory health and care system in a spirit of partnership, but ‘on our own terms’, not allowing mission creep, and therefore not simply responding to a tender specification.
The 999 Club wanted to achieve the goal of creating a friendly, and safe well-being space with enough freedom to build a community where people with multiple and complex needs could be supported in their journey towards better health according to their individual circumstances.
So, the 999 Club set out an offer along these lines, and was eventually successful in the tendering process. The willingness of senior leadership in the statutory sector to consider different ways of doing things was vital to achieving this, and Tom praised the qualities of many of the leaders he worked with. Tom also noted that many NHS policy statements and principles are very supportive, placing emphasis on participation, inclusion, community, and relationships, for example.
But the system on the whole does not always match this – transactional service design still predominates, and the contracting process is very hard for a small charity to navigate. It is clearly designed for much larger organisations – even though it is so often the smaller charities and community-based organisations like the 999 Club which are best placed to ‘bring alive’ the abstract principles espoused by the NHS and Integrated Care Boards. Tom said he was very grateful to his charity Board which provided strong support during what was a very demanding process.
Here are some of the key points made by speakers and in discussion, following breakouts to consider what can be done to make better leadership more widespread in the systems of health and care:
It was emphasised that leadership which is committed and determined to follow through on the principles that the Better Way promote, is needed both in the health institutions, and also in the community and voluntary sector, to break through the old ways of doing things which remain so prevalent.
It is extremely difficult when leaders are in the thick of things, overwhelmed with constant pressures and urgent demands, to make a real change in how things are done. It is ‘hard to talk about the colour of the wallpaper in the living room where there is a fire in the kitchen,’ as one person said.
So, a fundamental mindset shift is required, an epiphany or moment of realisation – not least that the role of a leader is to create opportunities for others in the system to produce the solutions and design the services, not to take the responsibility for doing this all to oneself. Realising that a good leader listens, takes hands off, supports others – understanding that the task is to be in service of the front line. And appreciating the value of a permissive and supportive culture, e.g. ‘from now on, everyone’s going to be brave’.
And rather than only trying to fix the immediate problems, leadership should be seen as building a better understand of why the problems have arisen in the first place and what can be done to prevent them recurring. And leaders should be encouraged to do more to bring people together into a creative space to share experiences, and generate the ideas that can drive positive change, using different methods (arts for example) to make this possible.
The NHS has promoted a culture of leadership as ‘expertise’ – it now needs to move from this to a culture of ‘shared wisdom’. And we need to be talking about system leadership, not just individual leadership.
The NHS is massive, and needs to find ways to support its managers to be people, not machines, and ‘to experience the joy again’. Better leadership is more likely to flourish where organisations are willing to let go of monolithic control from the centre, and work in a more distributed way, with largely self-managing teams.
A lot of good practice can be found, but remains sporadic, marginal, or out of sight. We need to ‘elevate what exists’.
But it is a mistake to try to ‘cut and paste’ a successful model or method, and hope it will achieve the same results elsewhere. Generally, processes don’t travel, but principles do. Local leaders need the freedom to design what feels right in their locality, informed by the set of shared principles. And commissioning needs to get better at allowing and supporting things to evolve and adapt, and move away from fixed targets.
We should remember that a shift in the direction we have been discussing is certainly possible – community engagement and distributed leadership used to happen more naturally before the advent of new public management in the 1980’s. In the NHS and elsewhere it has been all about frameworks and targets and milestones. This hasn’t worked. We need to be able to get back to talking about relationships, care, even love, and bring our humanity to bear.
And the Better Way principles and behaviours are a very useful guide, it was felt, and within our network we should grow our own confidence that ‘we are the leaders that we are talking about’ – the starting point is to do it ourselves, and tell the story of the Better Way in action. The more we show the way, the more others will follow.
Better leadership for health and care (first meeting)
This was the first of two meetings, and the topic was ‘if we don’t like command-and-control leadership methods in our health and care systems, what are the alternatives?
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Nick Sinclair spoke first. He is the Director of the Local Area Co-ordination Network, the founder of the New Social Leaders network, and a thought leader for the Better Way leadership strand.
As Nick explained, in recent months in the Better Way we have been exploring a style of leadership which places high value in building positive and productive relationships, in nurturing power and accountability in others, in listening closely to others and engaging in the reality of people’s lives, and in acting in collaboration with others.
Luan Grugeon was our second speaker. She is a Board Director of NHS Grampian, and Chair of Aberdeen City Integration Joint Board, with a background in the third sector.
Luan described how ‘conversational intelligence’ can be a foundation for a different kind of leadership, less about command-and-control and more about building relationship, trust and collaboration. ‘To get to the next level of greatness, depends on the quality of the culture, which depends on the quality of the relationships, which depends on the quality of the conversations. Everything happens through conversations!’ - Judith Glaser
There are level 1 conversations which are transactional, Luan explained, level 2 which are positional, and level 3 which are transformational. When the work involves complexity and risk, and there is a need for stable alliances and fresh approaches, ‘level 3’ conversations are vital. This requires an openness of mind and willingness to look for mutual benefit and co-creation. It means investment in building trust, empathy and relationships, using accessible language, ensuring community participants have an equal voice, and welcoming different perspectives.
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Here are some of the key points made by speakers and in the discussion that followed, and by three respondents to the discussion: Sam Spencer Continuous Improvement Officer at Kensington & Chelsea council; Will Nicholson, independent Health and Wellbeing Consultant; and Olivia Butterworth, Head of Public Participation at NHS England.
Those in leadership roles should recognise the best starting points for service design are people and their experiences, not requirements imposed from above. Leaders should therefore ensure that real life experiences are always present in the room, in some form.
We need to abandon outdated hierarchical models of ‘strong’ or ‘natural’ leadership, and leaders as ‘fixers’. It is possible to flatten hierarchies, to ‘turn the pyramid upside down’ or even create circles instead.
We need a more human approach to leadership. Leadership should mean being in service to people and communities, and the truly strong leaders are those who can resist the controlling pressures from within or from outside, and create a safe space for the workforce to be curious, engage in creative conversation, make connections, and do the right thing.
Sometimes people feel trapped by a system that is just not working in the way it should, and oppressed by pressures of demand from below and target setting from above. There is a lot going on that needs to be called out - engagement exercises for example when the answers are decided in advance.
Yet despite the many difficulties it is not hard to find good people, who care, and who are often able – in their immediate sphere of influence – to make a positive difference. These are the true leaders, and the task of those who are in management roles should be to make it easier for them to do more.
We need bold, brave, radical conversations about the scope and purpose of our health and social care system. Not least to address the huge racial, gender, and class inequalities.
Building a movement of people who are encouraging each other to practice better leadership, is a powerful way to achieve widespread and lasting change, and more effective some thought than attempting to force change on reluctant politicians or on other national leaders who simply don’t want to change.
It some parts of the country there are determined efforts to improve the ways things are done, with public authorities demonstrating that it is possible to share power more – in Dorset, Somerset, Fleetwood, for example. Sometimes the initiative is coming from the NHS or council leadership, sometimes from a GP, or from a community activist.
A more honest open transparent style of leadership in the fields of health and care is therefore possible, to replace the closed, opaque defensive leadership styles that remain prevalent. But it won’t be easy – there will be resistance to change and negative scrutiny of those attempting to drive change. So supportive networks for leaders who are attempting to work in a better way are very valuable.
The note of the second meeting, on April 17th 2023, can be found here.
Leadership and Well-being
The topic was ‘What does a well-being approach to leadership look and feel like?’
Over the last two years well-being has come onto the agenda like never before. This seems be a big and welcome shift. But what does this mean for the practice of leadership?
The first speaker was Nick Sinclair, Director of the Local Area Co-ordination Network. Nick shared insights from the New Social Leader network which he founded, noting that New Economics Foundation and Mind have set out five ways to well-being (connect, be active, take notice, learn and give) and that these can all be leadership practices.
Jordan Smith, Health Equalities Lead and Quality Consultant at Dimensions, and also Chair of Council at Dimensions, spoke of his experiences as someone who lives with autism. His first job at Colchester Football club made him realise that while there is no set path for leadership, it is possible to lead more effectively by promoting the well-being of those you lead. He is ‘not a fan of deadlines’, or of telling people what they must do or not do, nor of telling people how well they have done and what they must do to improve. It is better, he said, to allow people to set their own agenda for what they want to accomplish, and allow them to lead the leader.
He offered some tips. Make time for a 10 minute check-in before a meeting. If you ask someone if they are OK, ask it twice. Find ways to make a personal connection, e.g. ‘what’s been the highlight of your day?’ Jordan concluded by saying, ‘You can do all the training in the world, but it doesn’t mean anything unless you care’.
Jen Wallace, Director of Policy and Evidence at Carnegie UK, shared learning from Carnegie’s work on this theme. The state of being well, she said, is not just about being healthy, it’s also about being able to flourish. This requires, for example, feeling in control over our lives, having personal connection with others, having love in our lives.
But it’s not just about individual experience, Jen said. The wellness industry is growing fast, turning wellbeing into consumer products, for individuals who are often already doing OK. We need to go beyond this. Carnegie UK has been exploring the concept of ‘community well-being’ – how can we live well in a place, in a community of interest. Carnegie UK has also promoted measures of economic well-being, to better assess what is required for us all to ‘live well together’. A well-being approach to leadership, Jen suggested, implies that leaders take a holistic view (not putting people in boxes), act radically (moving away from benchmarks and KPIs), and behave in a human way (understanding ourselves and others as human beings).
Here are some of the key points made by speakers and in discussion:
Workplace well-being feels under threat, not least in public services - people are burning out, financial and emotional pressures are becoming greater.
The best leaders pay attention to relationships, and while these take time to develop, they know that without well-being people cannot perform well at work, and organisations cannot thrive.
Those in leadership roles often neglect themselves – it is OK to be kind to yourself.
We should not just focus on individual well-being. This is a social justice issue. A well-being focus implies a major shift in our sense of what matters. Are we here to serve the economy - or is the economy here to serve us?
We are exploring a wholly different way of practicing leadership, in place of the command-and control management model. Those in leadership roles will need to unlearn a lot, and develop a new set of priorities. But this change is not just up to the senior managers, who themselves are likely to be under pressure from funders, investors, regulators, and so on. Re-inventing leadership needs to become a shared endeavour, ultimately beyond individual organisations, a collective shift in practice in favour of well-being goals.
We also raised some questions which could be explored further:
How can we create a better working environment for those in front-line roles who have, for example, caring responsibilities.
As leaders, where does our responsibility for the well-being of others stop?