Conundrum 7
Responding to diktats

‘I thought we were supposed to be meeting local needs, how can we do that if we’re constantly inundated with diktats from the centre?’ said Simon, the Director of Public Health for Wenside PCT. He always did, thought Alison, the Chief Executive. She ignored this interjection. ‘So, Mike, I suggest you take responsibility for the primary care element of this new initiative, and Jenny, can you include the commissioning implications in your current negotiations?’ (Mike was the GP chair of the Professional Executive Committee, and Jenny the Director of Commissioning).

‘Well, I could’, said Jenny but my team will have to collect a completely new set of data and they’re already overloaded, it isn’t going to be easy’.
‘Yes’, said Mike, ‘I’m already working flat out, what do you want me to give up to make room for this?’

This discussion was travelling down a well-trodden path, and Alison inwardly sighed. She had taken on the PCT role, excited at the prospect of radically improving local services by moving them closer to patients, out of hospitals and into primary care. The reality had proved highly disappointing. Unable to persuade the hospital trusts to move services out into the community at a reasonable cost, nor to transfer anything like the resources the PCT would need if it were to provide the services, and unable to get them to think seriously about increasing their productivity and release resources to develop primary care, she had, again and again, had to watch community services being cut in order to balance the PCT’s books.

As for the way the goal posts were constantly changing: forever a new set of ‘guidance’, or new information about the way a particular policy would be implemented, or a new policy announcement - and always making life more difficult rather than easier. And now talk of roles changing again - of mergers, and of centralising some core functions, like commissioning. Just when the PCT had developed skills in this area and was beginning to be effective.

Disappointing, frustrating, thankless - that summed up Alison’s feelings about her role, and she must think hard about whether she should apply for something else. She had a heavyweight CV and there were interesting roles in other parts of the service that could be more satisfying. Did she really have to apply for one? Or was there anything she could do to regain her enthusiasm for the PCT?

Question: What can Alison do to feel more in control and more satisfied with the PCT’s progress?

Commentary 7

As part of a public service, PCTs naturally have to achieve the targets set by a central government which has a democratic mandate. These targets are an important feature of the environment within which the PCT operates. They are not however the PCT goals.

Let’s just think about this. Whenever any organisation is deciding on its strategy it must take into account three elements:

1. Its goals
2. Its resources
3. Its environment.

By thinking about all three at the same time it can decide on what action it needs to take in order to achieve those goals with those resources in that environment.

PCTs (or any organisations) that allow their goals to be imposed on them by others inevitably feel buffeted by forces outside their control. Whereas those who see the targets set by others as a context in which they operate can develop a sense of controlling their own destiny. Both will try to achieve them, they may even deploy resources in similar ways, but they will see these goals in different lights, and approach them in different ways.

In the language of the strategy matrix management teams who feel that their bosses are interested only in the left hand column, that the analysis of box 1 is being done elsewhere and that they are being expected only to implement box 4, will be frustrated and resentful. Those who perceive the targets and guidance as an input to box 1, so that they are free to make their own analysis of priorities, working to goals that encompass but extend beyond those imposed, and that they are free to work through the boxes of the matrix as they see fit, will feel (and be) much more empowered.

Many managers are frustrated at having to deal with changing goal posts, feeling that they have plenty on their agenda with delivering new policy initiatives at the same time as maintaining and improving services. However dealing with changing goal posts, and spotting what goals posts are about to change, is also part of the managerial role. Scanning the horizon, identifying the trends that politicians and others will respond to, sharing intelligence about what policies are in the pipeline - these are all managerial tasks. A change that appears out of the blue needs to be seen as a failure of local management intelligence, rather than the imposition of an unreasonable change by a dictatorial policy maker.

Accepting this tripartite role (anticipating change, delivering policy, maintaining and improving services) will not only change the management agenda locally, it will allow more senior levels in the hierarchy to place more trust in local organisations, as described in the paper on trust and trustworthiness.

It will also allow organisations to ensure that skills and learning are not lost in any restructuring. If all organisations planned for their own demise, ensuring that new skills are described and learning is documented, then handovers to successors could be much more fruitful and organisational memory could be maintained. Unfortunately the history of the NHS is littered with excellent initiatives that yielded great learning, which has been almost lost in successive policy shifts and management restructuring. The more we can do to prevent this recurring the better.

So, Alison could feel more positive about her role and be more effective within it by:

1. Developing with others a set of aims for her PCT that encompass national priorities but are not limited to them; and developing a strategy based on an analysis of its resources and of its environment, in which central targets are now, properly, only a part. This means that if Mike and Jenny are still required to take on new responsibilities, they will also give up others, or approach them differently, and they will see for themselves that this is essential if they are to meet the aims that they themselves have helped to articulate.

2. Scanning the horizon, sharing intelligence with others, developing links with people well connected to policy makers and making sure that everyone is anticipating change and thinking ahead.

3. Ensuring that the achievements and skills of the PCT can withstand its demise as an organisation.

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conundrum@reallylearning.com