1. Systems thinking
Limits to growth. The level of proactivity among community based staff has been increasing as a result of all the efforts made by Karen and the rest of the management team. However, it has not spread beyond the AHPs. Could this be an example of a ‘limits to growth’ system? If it is, what could be the limiting loop? You may want to stop and sketch the loop here.
Experimenting with the Fifth Discipline: 1
■ The Fifth Discipline
Illustration and analysis
So if Karen wants to encourage the wider spread of proactive behaviours she will be wise to focus first on reducing the feelings of envy and only then resume her enthusiastic efforts at development.
Shifting the burden. Karen is irritated that the method chosen to achieve the access targets will work only in the short term, and indeed that in the longer term it will cause problems that will need to be overcome if access is genuinely and sustainably to improve. We can recognise this as following the ‘shifting the burden’ template. Again, you might like to sketch your illustration of the template before looking at the one below.
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Figure 3.8: Limits to growth – limiting loop
R B
i) lead to
ii) which encourages Karen and the management team
to greater efforts
iii) but as some staff groups become enthusiastic
(iv) this antagonism prevents proactivity spreading further Efforts of
Karen and management team
they antagonise others who find all sorts of reasons why things are different for them*
increased proactivity of
community based staff
* described as ‘star envy’ in the organisational behaviour literature
2. Personal mastery
(a) In our view, Sarah is probably the character most able to see current reality as an ally. She sees now, although she did not see so at the time, that the fact the PCT does not manage GPs is not a problem but an opportunity to develop skills that are sorely needed throughout the NHS. She also does not waste energy fighting national directives but decides to treat them as a baseline from which North City will then meet its local priorities.
(b) Colin is an example of someone who regards current reality as the reverse of an ally. He sees a prospect of reorganisation and interprets this as a problem because he and his team won’t have had time to integrate the clinicians, who are still in two factions as a result of the merger of two previous trusts. He may be correct about the chance of reorganisation, but he does not need to see it as a problem, merely a reality with which he has to deal.
(c) When it comes to management capacity everyone agrees there is not enough – and the solution is for everyone to work very long hours. Perhaps there is another way of looking at this that depends on current reality being seen as an ally. What might this mean in practice, for example, if we were to say that managers in the PCT must not exceed their hours?
Figure 3.9: Shifting the burden – an illustration
i) lead to
ii) these waiting times could provide the energy needed to be made within 48 hours
(the target)
v) the walk-in clinic removes the need for practices to approach the way they handle appointments differently (and also encourages people to use
A&E inappropriately).
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B
B
The functions of the PCT would have to be approached differently. The PCT is advocating redesign for clinical services, for acute trusts. Perhaps it would benefit from using those principles of focusing on outcomes and thinking creatively about the resources available and how they are deployed, to redesign their management pathways. In the process they may need to think ‘whole system’ and the redesigned management and commissioning pathways may lead to genuine partnership working.
3. Mental models
There are many examples where people’s mental models are inhibiting their effectiveness. We give just one here.
Colin could set about the integration agenda in such a way that it can succeed whether or not there is another reorganisation. He would probably concentrate on different things as a result of thinking about the issue differently.
4. Shared vision
A shared vision is one that draws on the personal visions of those involved and we see in the case that Sarah has helped the AHPs to reconnect with their personal visions. These teams have also been supported by Karen in the development of a shared vision, and in making progress towards it.
The Board however appears not to share a vision. It is possible that North City itself does not. When we look wider it appears that potential partners too do not share a vision – except perhaps one that laments the difficulty of the economy-wide situation.
5. Team learning
There are several examples of lack of dialogue, and of the lack of awareness of he need for both discussion and dialogue:
• Colin’s scepticism that the outcomes of partnership discussions are decided in advance and that the PCT issues diktats
• David’s view that the PCT is ‘an interesting bunch’ but, given the chance, will label the County as ‘the bad guys’ and manoeuvre them into a tight corner
• Jake’s frustration that any questions he asks of executive board members are only met with answers
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However there are examples too of dialogue:
• Helen’s awareness that the PCT Chief Executive and Chair were skilled in being able to convert the PEC discussion (heated) into a dialogue (constructive)
• Karen’s recognition from her interactions with nursing teams that it is not the volume of talk that matters but its quality and ability to ‘switch’ people on
• Yvonne’s discovery that for discussion to become meaningful dialogue it needs to have a solid grounding in information and that she has an important role in interpreting this information to others.
Now let us go back to North City and see how they might address the situation outlined here.
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‘I know Jake has thought about resigning before, but this time I think he may do it’, thought Sarah, Chair of the PCT Board.
It would be a pity, Jake a non-executive director, had a huge web of local contacts, people he had cultivated over the years, all interested in good local services for local people, people he had met fighting one closure or another – a local hospital, a social services office, libraries. If anyone qualified for the title ‘community activist’, it was Jake, and Sarah had been delighted to appoint him to the new PCT Board. He was chafing though at the lack of ability to make a difference, at the slow pace of change, at the way he couldn’t get the execs to listen to what he had to say. Jake had returned from a national conference recently spitting feathers. He had overhead one manager talk to another about their ‘Muppets’, and realised they were referring to their non-execs. Sarah didn’t think for one moment that Anne and her team would be so disrespectful, but equally she knew they were under pressure from the SHA to ‘deliver’ their Board, and that they felt aggrieved that PCT NEDs were so often so much more outspoken than their acute sector counterparts.
There was such an ambivalence toward the role of non-execs: locally there was constant pressure for them to attend this meeting or that, as an informed but lay, local voice. Nationally every new initiative required a non-executive ‘champion’. And yet there was a real resistance to hearing the views of those non-execs, to using the different kinds of perspective they brought with them as a result of their other experiences. And not just ambivalence, there was some real ambiguity about the role – Anne had been furious with Sarah after the public consultation meeting about the most recent service reconfiguration. Anne had felt let down, that Sarah was not supporting her and the exec. team. Sarah was very clear that her role was to