Leadership in the NHS - who is responsible?

I heard a story last week that made me reel.

A loyal clinician was given a token as recognition of service over fifteen years. A group of colleagues gathered and a manager presented a pen, in a box. The recipient opened the box, took  the pen and tried to write with it, to find it contained no ink.

“Typical!” was the response. “They give me a pen, but there’s no ink in it. What good is a pen without any ink? Typical NHS. Scrimping and saving, undervaluing us. I am not even worth the ink to go in my pen.”

Within ten minutes, the gathered group had dispersed to carry on with their work. As each of the group met another colleague they repeated the story of the pen until the latest urban myth was established.

I say 'urban myth' because after the comment about the lack of ink, the manager picked up the discarded pen, opened the box, lifted the false bottom to the box and found the ink refill. Looking up to find an empty room, it was already too late to run after everyone and shout, “There is ink! They did give ink. We are worth the ink in the pen!”

There is so much to say about this story. The dismissive attitude of  the recognition of loyal service. The institutional cynicism. The externalisation of motivation which leads to transactional rather than transformational working. But it is from a leadership perspective I wish to look at this tale more closely.

A week after I heard this story I read an article on “hittability.” The author is a healthcare leadership expert in the USA who teaches and writes extensively on the topic. His thesis in this article is that hittability relates to whether we see a leadership challenge as solvable. He says that hittability is a  “function of our framing lenses – a person’s beliefs, values and worldviews” (Souba, 2016:1) that frames the way we see a leadership challenge and that this is in turn influenced by the way we perceive the future. I would add to this the level of personal responsibility we feel for such challenges, our sense of self efficacy and our desire to act to change the future.

The first thing that Souba highlights is the difference between technical expertise – our fund of knowledge and skills, and what I call transformational expertise – the ability to “see” beyond the restrictions of the challenge. Souba says that what marks out exceptional leaders is that they “see, understand and deal with leadership challenges differently” (ibid) to most people. They are able to separate the facts of the challenge from the various narratives that are constructed by the stakeholders.

Souba identifies a ‘Prevailing paradigm’ which emphasises what is known, and focuses on skills, know-how, competence and expertise and an ‘Emerging paradigm’ which emphasises what is seen. This paradigm suggests that leadership is largely a function of the  hittability of leadership challenges and that effective leaders reframe situations so they can see them as hittable.

If we return to the pen story, we can see that the prevailing narrative, which was quickly adopted, was that the NHS as an employer did not value its workers. This narrative ignores the fact that the clinician was given a pen in the first place and focuses on the perceived lack of ink (which was also factually wrong) to perpetuate the prevailing narrative. That the narrative was further and immediately amplified by those who had been in the room, and those who had been told the tale, suggests that not only was the narrative  a familiar one but also very popular with the majority of the group who spread it. With such a strong and pervasive narrative, one wonders how a leader can re frame this?

If we look at the prevailing paradigm, we can see that narratives about the lack of ink and its representative lack of value of the clinician betray an attitude  of helplessness. The recipient framed himself as worthless, and powerless in the face of a huge, faceless power called “They.”

However the manager, who looked under the false bottom of the pen box adopted an attitude of curiosity, assuming that there might be some ink, not dismissing a solution out of hand before a period of investigation. This reframed the situation, placing the employer in a more positive light and more importantly placing herself as an active, enquiring agent.

An alternative interpretation might have been that the recipient, on finding no ink, accepted the situation and resolved to buy some ink on the way home, thus reframing the employer in a neutral context and himself as a responsible agent of his own destiny.

So, in order to be able to face leadership challenges with autonomy and self respect, we need to learn to reframe the challenges we face. Seeing challenges   as “hittable” depends on us and our ability to reframe the lenses through which we view such challenges.

“Great leaders don't just listen carefully; they also recognise that their framing lenses and their listening are inseparable…..Listening from the place of ‘this person has something important to say’ and listening for the future she or he is committed to constitutes a very different framing lens than listening from a place of ‘this conversation is a waste of my time’ and listening for the first chance to end it” (Souba, 2016:2).

How often do we listen with a mindset that has already decided there is nothing worth hearing? Who crafts our lenses? With what are they smeared? Because we look through our lenses rather than at them, they are often imperceptible to us, says Souba. But what would happen if we took some time to look at our lenses, to ask whether  they are the lenses we chose for ourselves, those we most need, for our own benefit and that of the work we do? How often do we just accept without scrutiny the lenses we have had thrust upon us by the prevailing culture in which we work?

Souba suggests that by not making a conscious choice about our lenses, we are being schooled to accept the lenses of others around us. Our view of the future is in itself a lens which frames the present for us. But if we could make a choice about the future, would we really choose the one we have been enculturated into? Ask any clinician if they are happy with the current situation and they will say no; ask what they think the future holds and they will shudder in despair. But Souba says “having a clear picture of the future you want to create is critical because it acts as an inspiration that alters your ways of being and acting right now” (Ibid), which in turn brings the desired future into the present. Committing to a positive future makes challenges more hittable.

The act of reframing is not just about the challenges we face, it is also about us and the people we are. This is what makes it essential if we are to continue. Souba’s key question is twofold: how do we reframe our healthcare challenges so they show up as hittable, and how do we reframe ourselves so we show up for ourselves as able and confident?

If we are not interested in doing it for the greater good, we should be motivated to do it for our own good. Clinicians are asking for resilience  training, not realising that only they hold the power to develop what they need. Giving up at the first hurdle (“there’s no ink in my pen”) and blaming it on the organisation is self sabotage. Saying to oneself, “I am honoured to be recognised beyond my pay packet, and here is a token of that - a pen, in a box, with even some ink in there,” reveals a happier, more resilient professional, who has a stake in his or her own future, and the agency to create it.

Souba, W. Hittability: The Leader's Edge. Academic Medicine. Nov 2016

doi: 10.1097/ACM.0000000000001498