Our NHS People

Leading in uncharted times: returning to a new business as usual

Sally Hulks, Senior Consultant, The King’s Fund

One definition of leadership is ‘the act of making something happen, that would not otherwise occur’[1]. That’s fine, but the question right now is, ‘What should happen next?’. It is difficult to consider the future when the focus for health and care services is on the here-and-now, on picking up the pieces from the first months of COVID-19 and being ready to survive the next phase of the pandemic. Some leaders feel depleted and uncertain about just about everything in the present, without the space to think about or act on creating a new future.

Yet some very concrete things changed through the first peak of the pandemic, and it served to put the spotlight on some long-held challenges of delivering care to patients.  For example:

at the system level:

  • the gap between the health and care systems and the impact a lack of joined-up care had on patients
  • the scale of health inequalities in the UK
  • the potential for community mobilisation, volunteerism, and mutual aid

at an organisational level:

  • the engagement clinicians experienced when they felt trusted to take decisions locally 
  • the different staff and stakeholders who found their voices for the first time.   

The list goes on. Perhaps then a more immediate question is how leaders can apply the learning from their Covid-19 experiences, taking the best of this forward and evolving their approach to leadership, while working to eradicate the worst. If leaders pause to take stock and think, perhaps they can avoid sliding back to old ways of being; where decisions are taken with the same people round the table, and the financial planning spreadsheet is sent out to be completed in the hope that normal order is restored. That may not be good enough to create a new future.

Why is this a big ask? There are three key challenges to overcome: our own selves, our set views and ways of operating, and the level of discomfort we’re prepared to put ourselves through to change that; the complexity and seemingly intractable issues at system level;  and the pressure to re-establish business as usual as a quickly as we can at local level.

Addressing these challenges

Ourselves

First, leaders need to move past their own mindsets. What often gets in the way of thinking differently is letting go of what we like to think of as our certainties. Argyris[2] talks about people’s need to be in unilateral control of situations; maximising winning, minimising losing; avoiding anxiety and embarrassment; being seen as rational. So, the most important task for leaders is to let go of some of the internal needs for certainty and familiarity, in order to even begin to think and lead differently.

Then there is a need to put aside or suspend past assumptions – those held by individual leaders and by all parties involved with the thinking. This may mean involving different people, listening to views that do not align with your own, and purposely abandoning past ways of looking at issues. As Myers[3] points out, for James Dyson to develop a fan without blades, he first had to let go of his conception of what a fan ‘is’. Perhaps this analogy can be used to understand how health and care systems can work together and how you could radically change that for the better.

The system

The processes used to engage with others can help or hinder the chances of thinking differently, especially when there is high complexity and low certainty. For example, strategy development is often supported by working with what is known and undertaking a SWOT analysis on the options. But the current health and care landscape does not lend itself to this: it holds an overwhelming set of variables, interdependencies, and challenges. There are other approaches and just one example is scenario planning[4], which encourages people to move away from the data, and to think from new perspectives. Rather than using definitive information, groups of people from across systems and hierarchies can use this approach to engage with credible alternative stories about the future and expand possibilities through the freedom to think and dialogue with others. When a group of colleagues undertook this exercise here at The King’s Fund in July, many new ideas emerged and we noticed that the thinking did not stop when the exercise was over, rather, it created the impetus to continue to think differently about future possibilities.

Our teams

During the first wave of COVID-19 there were so many examples of teams pulling together, wholeheartedly engaged in delivering the seemingly impossible. The crisis conditions meant there was a high degree of local autonomy and opportunities to give things a go, to experiment. Gary Hamel[5], the strategist, suggests that these local responses created during COVID-19 are indeed the way to work with change and complexity: leaders must build local ‘distributed learning networks’, with high autonomy, that are actively encouraged to experiment and adapt. As Hamel points out, changing the way we operate isn’t an organisational problem, it’s a human problem. The role for the leader then becomes one of co-ordination and support, ensuring local teams and networks are interconnected, so that as new best practices emerge, they are adopted quickly.

Leaders are facing the challenge of thinking and doing differently, in order to find novel ways forward both for the system as a whole and for teams close to home, so they can restart business as usual without recreating the past. As Hamel put it in his early work on strategy: ‘The only way you’re going to see the path ahead is to start moving. Strategy is as much about experimentation as it is about foresight and passion’[6].


[1] Burke W (2008). Organization change: theory and practice, 2nd ed.  London: Sage Publications.

[2] Argyris C (1994). ‘Good communication that blocks learning’. Harvard Business Review, vol 72, no 4, pp 77–85. Available at: https://hbr.org/1994/07/good-communication-that-blocks-learning (accessed on 25 August 2020).

[3] Myers P, Hulks S, Wiggins L (2012). Organizational change: perspectives on theory and practice. Oxford: OUP.

[4] A strategic planning exercise, through which different possible versions of the future are imagined

[5] Denning S (2020). ‘Gary Hamel: leadership lessons from the coronavirus crisis’. Forbes website, 23 April. Available at: www.forbes.com/sites/stevedenning/2020/04/23/gary-hamel-hard-lessons-from-the-coronavirus-crisis/#7a254ae923c1 (accessed on 25 August 2020).

[6] Hamel G (1997). ’Killer strategies that make shareholders rich’. Fortune, vol 135, no 12, pp 70 –84.