Which City?

Sunday, 31 March 2013

At the end of Winter, is there hope for Spring?

We are still waiting for Spring, when new beginnings give us hope for the future. The persistent cold weather in the UK is almost a metaphor for the long dark winter of austerity which many are feeling, and which for some will deepen tomorrow when the first wave of benefits cuts bites.

On Easter day I woke with a sense that we are all in this life together, dependent through the cycle of birth and death on one another for our existence and our survival. Yet the system of monetary exchange which we use to make the world go round seems increasingly to divide us - the rich get richer, the poor never do.

After a Quaker Meeting which I attended in York today, I queued for coffee with a lovely Geordie  who I hadn't seen for a while. He told me he had been struggling and had been out of circulation for a bit, trying to prepare for the reduction in his income which would mean that from tomorrow he would treat 'every pound like ten pounds'. I don't know by how much the gap between Geordie's income and outgoings will grow as a result of bedroom tax, loss of specific benefit or requirement to pay Council tax, but it's enough to worry him deeply.

This week I went to my last meeting as an NHS Non-Executive Director 
and felt positive about how hard staff had worked in the most uncertain of circumstances to make sure that the handover to a plethora of new organisations goes smoothly. I am hopeful that the Clinical Commissioning Groups will work positively with provider NHS Trusts to form the backbone of excellent NHS services, but I am less sure that the commissioning landscape overall has any more clarity or stands a better chance of joining up effectively with social care and other vital public services. I asked the Director of the new Local Area Team of the NHS Commissioning Board (renamed NHS England as I spoke) what the process would be if somebody wanted to complain about their GP, and he was honest enough to admit that he wasn't sure. Patient access is a key requisite of a responsive NHS and a good companion of patient safety. 

I spent Wednesday morning in Doncaster with health, social care and voluntary sector partners talking about how to create a Dementia Friendly Community. This work, which is a joint venture by AESOP Consortium and The Open Channel is based on our work for Joseph Rowntree Foundation published last year as Creating a Dementia Friendly York. We heard from a woman who is caring for her husband who has Parkinson's and dementia with Lewy Bodies. They are a well-off, educated couple who need no financial support from anybody, but who are frustrated by the lack of consistent information and moral support which good coherent health and community services should provide to them as tax and community tax payers. It is not the money that's important, it's the understanding, fellowship and humanity that people need in their darkest moments, and rich and poor are no different in this respect. We all wondered how people living alone or with fewer personal resources were coping, and we realised that this is why too many people with dementia are in hospital or nursing care when they don't need to be, because there is not enough support in the community. We must turn this situation round before the NHS and local authorities are swamped - will CCGs be able to commission this change?

On Thursday I chaired a meeting of a national drug and alcohol treatment charity where I am a non-executive trustee. We reviewed the caseload of serious untoward incidents affecting people using our services over the past year. This included about 12 deaths. Almost invariably these were deaths, not always accidental, of heavy drug or alcohol users who risk their lives by their lifestyle. But they are also the sons and daughters, husbands, wives, mothers and fathers, sisters and brothers of many of us, and they have been unlucky enough to encounter addiction, whereas we have not. Some of these people would have led difficult, impoverished lives with or without addiction, but some could have lived well, happily, productively if things had turned out differently. 

This weekend I spent with friends in my hometown. Ironically, I went to a beer festival in a pub which I used to frequent as a teenager in the 1970s. My brother and I both drank there - I escaped addiction, he did not. We heard stories of our friends and their families which illustrate that alcohol is blighting the lives of people with good jobs and incomes, outwardly respectable and happy but suffering under a burden of habit and aggression. We are not all as we seem to be.

This weekend a group of Churches in the UK spoke out against the government for perpetuating myths about poor people -   that they are lazy; that they are addicted to drink or drugs; that they are not really poor; that they cheat the system; that they have an easy life; and that they caused the deficit.

How important it is that we speak truth to power, that we stand against the stereoptyping and blaming of vulnerable people, that we recognise addiction to be a curse and not an indulgence, that we understand how all of us can fall victim to the seductive draw of money, but that the rich have much more scope for exploiting others that the poor will ever have.

We are all in this together - isn't that what the Prime Minister would have us believe? Then yes, let us support one another, recognise or interdependency. Don't set us against one another, making us ever more distant and afraid. We will thrive through joint endeavour, mutual support and understanding but if we continue to punish the poor we waste their potential and impoverish our human spirit.

Sunday, 17 March 2013

How Do Boards Really Know What's Going On?

Corporate failure continues to be in the spotlight, whether in private or public sectors. How do Non-Executives, Independent Directors and Governors really know what's going on? Are Unitary Boards best, or can they become too managerial? How do Boards set a good cultural tone by finding the right balance of challenge and support? How do Board members 'test' the information they are given to assure themselves of its accuracy?

I hold four board roles - one, as Chair of a drug and alcohol treatment charity, is wholly concerned with the delivery of public sector contracts and has a board with private, public and third sector experience. We seem to face in all directions at once, responding to and affected by public sector commissioning and payment by results, concerned about our charitable objects, and needing to create an operating margin to secure a sustainable financial future. 

When I joined the organisation I was soon conscious that senior staff and Board members portrayed the charity in different ways, emphasing various strengths and weaknesses and holding different views of how we might manage the future. It was important for me to  establish quickly a position where there was a shared understanding about the basic 'facts' - our financial standing, what we were delivering, how our customers and commissioners saw us, and our position in the current and future markets. This has stood us in good stead. It has enabled us to take some difficult but necessary decisions. We may still hold different views and have a range of ideas about the future, but at least we are able to identify our differences from a common starting point.

For me as Chair, this experience in the first six months, has been very hands on and not what I might have expected of the role. The culture of the Board is managerial with non-executive trustees who are very experienced and intellectually able and who are very challenging and highly supportive at the same time. We are a unitary board, with a third executive membership and this is a relatively recent evolution which may not be fully embedded. Executives tend to contribute in their areas of expertise, rather than in general on any matter. As we develop the board over the coming months we will think very carefully not only about our constitution but also about our behaviour, and how our structure affects the way we act .

In the NHS Unitary Boards are the norm in hospital and community trusts and have been in the shortly to disappear commissioning bodies, the Strategic Health Authorities and Primary Care Trusts. Having been a Non-Executive Director on both and SHA and a PCT over the last six years, I reflected on how things might change in the new NHS in a Guardian Public Leaders Forum at the end of last year. The new Clinical Commissiong Groups generally have two lay members to eight GP members with other professional members from local authorities or other sectors. If the lay members represent the only source of independent challenge, they are going to be a small voice. I noticed this week my local Commissioning Support Unit - the arms length structure set up to provide back office services to CCGs- advertising for a Lay Adviser. Positive that outside expertise is being sought, but interesting that it is clearly not a decision-making role.

Governance is so much in my mind this week for two reasons - the first is having the opportunity to participate in a Leadership Foundation event on the role of Universities in the current economic climate. This thought-provoking conference allowed us all to think about the purpose of universities and how independent governors in particular might encourage a more outward facing approach. Our creative thinking was balanced by very focused sessions on the very complex regulatory framework and on Key Financial Indicators. 

What this brought home to me was that, whilst I had been recruited as a university governor for my expertise, knowledge and connections in particular areas, my obligations as a governor require me to understand the business  well and to be able to ask the kind of questions which our regulators, funders and students would be asking. Talking to staff and students, taking the temperature of the organisation is a valid way to hear whether the information in board papers rings true. Comparing performance with other univerisities or similar sized organisations in different sectors is important in evidencing how progress is being made and what your organisation is choosing to do and why. You can be an outlier, but with good and conscious reason.

Also this week I spent 24 hours with the Board and senior officers of a large social housing provider whose Board I joined last year. Like the university,  we are a large organisation with charitable objects operating in an increasingly commercial context with reducing public funding. We are a refreshed board with a majority of new members and a new execuitive team, so building relationships and finding out about one another is important. The organisation is in a state of rapid transformation and the context is also changing with Welfare Reform and a challenging housing market being  twin peaks of concern. How can the Board, meeting six times a year, keep a focus on what matters and oversee the development of strategy and the management of risk at a volatile time. At the moment, our approach is to involve as many members as possible in the business through role on subsidiary boards and Committees. This is all very well, and engages us in the detail, but it also generates a lot of governance business which distracts from delivery and results in information being reproduced and processed by the same people in different groups. 

We are conscious of our responsibility for good governance, so we are prepared at the moment to have more detail rather than less. But data and information are not the same as knowledge - we have to understand and know what the numbers mean whether they are about finance or activity. So again, seeing how the organisation runs, what our homes and estates look like, listening to residents where they live and around the Board table are essential parts of testing the reports we receive.

Boards are not there to do Management's job - what many Chief Executives fear- but we can't govern well without understanding what Management's job is and how well they are doing it. Governance is about assurance, assurance is provided through evidence, evidence is multi-dimensional . Boards need to understand the dimensions of the organisations they govern in order to do their job well.

At The Open Channel our support for Board Development and Leadership reflects many of these experiences. Let us know how they reflect your.

Sunday, 3 March 2013

Organisations Need Excellent Leaders But Not Just at the Top

Leaders are always in the spotlight, whether they are in charge of the country, the banks or the NHS. The people at the top of organisations are rightly held to account for the performance, productivity or profit of the public services or corporations they run.

The ongoing debate about leadership in the NHS following the publication of the Francis report last month, highlights how patients and the general public assume that the ‘top person’ determines what happens in an organisation. 

The Daily Mail continues to bay for the blood of Sir David Nicholson, responding to the understandable need expressed by relatives of patients so badly treated at Mid-Staffs for some kind of retribution. The more balanced and specialist press, as well as senior managers in the NHS find themselves uncomfortable in wanting to defend Nicholson without appearing to challenge the righteous indignation expressed by the relatives.

As someone coming to the end of a six year tenure as a Non Executive Director in the NHS my perception is that the NHS itself has subscribed to an autocratic style of management which can only ever be partially successful. The perception and reality of political interference in the day to day running of the NHS has led to its separation from the Department of Health in the new reforms, with Nicholson at its head. This both clarifies and intensifies the ‘chain of command’ felt by all senior management within Sir David’s sight line. For many of us who serve as Non-Executives who are not from within the NHS, his personal influence is overwhelming, and it doesn’t feel that healthy.

There is no doubt that a top down performance driven culture can achieve results. It is true that many people have been better treated, more quickly, for less cost in recent years as a result of the ‘grip’ on the ‘system’ which is the everyday parlance of NHS management. As someone who is very keen to see people enjoying better health and experience excellent services, this evidence is welcome. But it often feels hard won, and difficult to hang on to.

The NHS is an extremely complicated business, demand is growing as the population ages and technology offers more possibility for treatment and cure. We expect more, faster and we don’t really want to pay for it. The pressure is intense, and it is felt every day in every hospital, clinic and GP surgery. Strong management is only one aspect of the kind of leadership needed to deliver an excellent NHS, and on its own is not only insufficient, but as Francis has demonstrated it is very, very risky.

As in all organisations, the NHS needs good leadership to run through everything it does, like 'Blackpool' through a stick of rock. Strong management is not the same as good leadership. Strong management can be prescriptive, telling people what to do, encouraging them to wait for orders. Good leadership is empowering,  encourages people to generate ideas and to respond appropriately to changing situations.

In a National Health Service we are looking for consistency, fairness and access for all, so there have to be national policies, guidance and sometimes rules. But health varies from person to person and from community to community, influenced by lifestyle, economic and social circumstances and genetic inheritance. A public service needs to respond to what it finds at the point that people ask for it, and our NHS needs to enable the doctors and nurses that we train so well to practice their clinical and caring skills in a wise and sensitive way. 

I am disappointed that the NHS reforms seem to have resulted in more managerial and bureaucratic layers than they were designed to replace, but I hope that there will be more opportunity at a local level to determine excellent quality services within a national health context. I hope that leadership at the top of the NHS will recognise that it is a service, not a system and will empower those locally to serve people well. 

At The Open Channel our commitment to building on the strengths in people and organisations recognises that leadership exists at every level and in public service we fulfil our purpose if we support one another to achieve our best. We are all accountable. And we have the power to succeed, if we share that power.