Billy Boland: The power of “systems” in healthcare

billy_bolandI looked down at my name badge. Although it said chief executive officer, I felt like an impostor. Across the table sat a suitably intimidating panel. The members of the Health Overview and Scrutiny Committee (HOSC) wanted me to justify why we were keeping open a crumbling hospital with poor outcomes, while the community was crying out for more resources. Expectant faces were staring at me, waiting for my presentation. A presentation? No one told me about that. I looked down at my notepad searching for something to say. It was blank.

This scenario was all part of a simulation, and one of the many training experiences I’ve undertaken at the NHS Leadership Academy.* The truth was, two days earlier, I’d never heard of the HOSC. Yet in this particular exercise, our trust board had come up with an options appraisal to tackle its ailing services and financial problems. Now it had to convince all and sundry, including this committee of councillors, that they were doing the right thing. The HOSC is an operation of the council in England and Wales, and has a role in independently reviewing and holding health services to account.

Such experiences are gravely familiar at the NHS Leadership Academy, which I am a part of. I have grown used to being dropped into difficult situations, and having to rely on my burgeoning skill set to figure out what to do.

It’s now mundane to say that the NHS is subject to political influence. Gripes about interference are so common, you’d be forgiven for thinking it’s not worth getting involved. But the learning at my last residential for the NHS Leadership Academy helped me understand the power of systems in our communities. Local government, the local authority, education, and other such “systems” are key in shaping how our local NHS evolves. Healthcare leaders ignore these forces at their peril.

In this case, we were lucky to have people who had worked as councillors and MPs to help us get to grips with how their systems work. Their insight into their motivations, what bothers them, and what they want to achieve reminded me that services don’t develop just because it’s the right thing to do. While stakeholders want the best for patients, there can be many other simultaneous agendas that an NHS organisation can get dragged into. There are reputations to enhance, political points to make, and egos to be served. It’s not all about you.

When the systems aren’t working well together and are under stress, your organisation can become a football, used by other stakeholders to score goals. Stay on guard and have clarity of communication to get your messages home. But at their best, system movers and shakers can be critical friends, and champion what you have to do if they understand and believe in where you’re going. Just be prepared— take your presentation—and be clear about what’s needed.

We’re having another reflective Twitter chat, this time on system leadership using the #ReOTD hashtag on Wednesday 11 June, 7-8pm GMT. So if you want to reflect on the nature of systems in healthcare, or want to help others with this, please join in. Follow @ReOTD_latest on Twitter for updates. You can follow me @originalbboland

Billy Boland is a consultant psychiatrist and lead doctor in safeguarding adults at Hertfordshire Partnership University NHS Foundation Trust.

Competing interests: I declare that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.

*Clarification: This blog was amended on 19 June 2014 to clarify that the scenario in the first paragraph was a training exercise.