If the future sustainability of the NHS means its leaders will need to make tough decisions, how can leaders make sure they are making the right ones? In my chief executive roles in the NHS, I’ve made some difficult decisions – some clinical, some financial, many staff related. All had patient and service impact.
You could probably guess at the areas they might have covered: where to invest new resources, how to structure new organisations, which of the best people to promote, whether to reduce funding for services with limited clinical value, how to tackle the viability of a service, and so on.
They were all difficult, but they mostly related to ‘tame’ problems. I’m not being flippant, I’m using language coined by academic, Keith Grint, who says that if a problem can be solved using a process, then it is ‘tame’. The problem might be complicated, but there’s a process and we know the answers. So in the organisations I’ve worked for, we engaged with patients and the public, consulted using statutory guidance and followed organisational policies and procedures. There was process and we followed it.
Then there were the incredibly difficult problems, those which were complex, longer term, strategic, multi-dimensional and with no obvious answer or process. The sort that Grint refers to as ‘wicked’.
As chief executive of a primary care trust (PCT) in Sheffield, our goal was to reduce the 13-year health inequality gap between the best and worst outcomes in the city. We wanted to work out how best to measure the impact of our investments – either unilaterally as a PCT or as part of multi-agency approaches – so that we’d make a difference 30 years from now. It took difficult to a new level.
Do you focus on housing, social care or education? Or what about the justice system, benefits, improving NHS services or health promotion? Where will the greatest impact be made? Impossible, right? These sorts of complex problems, says Grint, are wicked. We’ve not come across them before, we don’t know the answers and we can’t solve them alone. The best we can do is to come together to try.
In Sheffield, and with support from the Health Foundation and the London School of Economics, we tried a new approach that brought together clinicians, patients and managers from across the health system to work through problems, looking at how we could combine value for money analysis with stakeholder engagement.
The approach was designed to help us move forward, not necessarily to find the answers, engaging with patients, staff and data, investing a lot of energy and staunch commitment. In short, we were working it through.
When staff are looking for solutions, when boards are holding you to account, would you be bold enough to respond “we’re working it through”? It takes someone with great leadership skills to know it’s the not only the right answer but the only answer for wicked issues. For many of the system-wide issues we face today, we won’t solve them with management processes.
We need leaders who are comfortable with the journey, who want to work in collaboration across system boundaries and who know that making a difficult decision is sometimes the wrong thing to do.
If senior leaders are always dealing with problems where there’s an answer, they’re dealing with the wrong things. Finding the right question is as important as finding the right answer.
Jan Sobieraj is managing director of the NHS Leadership Academy. Follow Jan on Twitter @JanSobieraj