Getting from understanding to true collaboration
Dr Masood Ahmed, Chief Medical Officer for NHS Black Country and West Birmingham CCG, reflects on how a shared vision helps health leaders make better and more collaborative decisions.
I was once invited to a leadership training programme while chair of the negotiating team for the BMA Junior Doctors' Committee; facing my own team were colleagues from NHS Employers. The negotiation, for a new national deal, was a successful one, although events in recent years make that hard to believe.
The focus of the training was ‘principled negotiation, based on Getting to Yes: Negotiating an agreement without giving in by Roger Fisher and William Ury. Essentially it boils down to this: rather than trying to ‘win’ the negotiation (traditional ‘positional bargaining’), you will deliver long-term success if you attempt to understand the issues faced by both sides and using this as a basis for working together to achieve mutual gains. Basing negotiation on ‘understanding’ also helps develop long-term trusted relationships, something that will be essential for stakeholders across integrated care system.
"The best decisions can never be made in isolation” Dr Masood Ahmed, Chief Medical Officer for NHS Black Country and West Birmingham CCG
Integrated care means integrated decision making
Across the rapidly moving parts that make up an ICS, plans will change, often out of necessity and, inevitably, unforeseen circumstances. Secondary care, primary care, mental health, social care and other community providers on integrated care boards (ICBs) will be looking to make collective decisions based on individual and shared priorities. Uniting these goals in a health and care ecosystem still reeling from the pandemic will be easier said than done.
If ICBs can truly unite around the obvious shared goal, i.e. better patient outcomes, the focus will shift to the citizen and population rather than the organisation or provider; purpose rather than position. This could mean changing suppliers, how staff work, strategy, and everything in between. But end goal isn’t everything. Crucial to determining the quality of care delivered, and outcomes eventually achieved, is the decision-making process prompting these changes. If we as leaders cannot make better decisions then we are bound to fall short, no matter how good our intentions are.
Good decision making must be based on collaboration and the best decisions can never be made in isolation. If there is only one takeaway from this article, let it be that. To build and grow ICSs in a meaningful way, health and care leaders must listen to all stakeholders – including staff and citizens. This is all too often lost within the NHS (and indeed, the wider health and social care landscape) when executives make decisions based on their own experience, the data presented to them and what they believe to be the right call, without a broader perspective.
Establishing a meaningful and tangible vision for decision making
Decisions need to be made with a clear vision in mind: getting to a ‘win-win’. In the NHS, vision can often be seen as a tick-box exercise included in a master plan, rather than a central priority. Sure, it’s great to talk about visionary objectives and it's great to use this vision to get employees and patients excited. But for most, can we say that our organisational vision truly translates into action? Does it have an impact? Does it guide us? Is it really driven by our values?
My own system, Black Country and West Birmingham, has developed stronger system-level decision making by setting a realistic vision – something tangible yet ambitious that staff can work towards and stakeholders can support. The introduction of primary care clinical leadership executives (PCCLEs), for instance, was driven by the idea that primary care expertise should be leveraged in a way that uses both clinical acumen and leadership ability for maximum impact and patient benefit. This mindset helps place the population at the heart of decision making. It’s too easy to pay lip service to organisational vision, but when this approach is implemented effectively, it can transform the way one makes decisions.
Vision-driven building supports the idea of making decisions based on first principles – understanding the ‘what’ and ‘why’ of what we’re trying to achieve. In a reactive world, where everything is moving at breakneck pace, it’s easy to get caught in the moment and make decisions on the fly. This happens in too many organisations, and stakeholders end up with choices being made without the long term being considered. We avoid this by placing vision and principles at the heart of these choices, bearing in mind the need for better decision making for both the short and long term. When we determine our vision, we’re using first principles. When we make decisions that align with our vision, we’re being driven by the ‘what’ and ‘why’, striving for outcomes that give short-term benefit and build towards long-term transformation of health and care for our communities.
Our PCCLE for digital/IT, one of the few primary care chief clinical information officers (CCIOs) in the country, approached the issue of patient information visibility with the aim of tackling the existing issues of duplication of tests, delays in diagnosis, harm from medication and inappropriate admissions to hospital. The understanding that improving patient information sharing is key to fixing these issues, while consulting with secondary care, mental health, ambulance service, social care and voluntary sector colleagues, supports an informed approach to the procurement of a shared care record that will create lasting change across the system for all stakeholders.
If we approach decision making this way, it allows function to then lead form. How we make these changes, and how we improve things for our citizens, can be driven by how we see the future, and what we want to achieve. Initiatives are underpinned by solid principles that are substantial, accountable and considered, and have definite benefit.
Gone are the sometimes shimmery yet ineffective programmes, and in their place we have people and processes that can make a real, lasting impact. Our PCCLE for dementia was brought in with the ambition to use her field of expertise to benefit our population. She has achieved this by helping to create stronger pre- and post-diagnostic support, leading to reduced risk of crisis management (which can invariably lead to hospital admission but also keep a patient well for longer in their own home). By letting function drive form, and taking a problem-solving approach, her work has led to immediate patient benefit as well as long-term improvements for our system.
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