In Pieces of Us, our co-author discusses the mixed fortunes of Greenhill, a distinctive Swansea inner-city neighbourhood, created through the successful integration of Welsh and Irish people, who’d moved there to provide labour for Swansea’s industries. The story has particular insights for our current health and care systems landscape, and some historical ‘scene-setting’ will give a useful context.

The process of ethnic integration was relatively trouble-free, though with several critical leadership interventions. When cholera struck in 1849, the newcomer Catholic priest, Father Kavanagh, worked with Dr William Long, tending the sick, washing them, combing their hair and administering last rites. This demonstration of compassionate leadership and community-cohesion helped enmesh separate parts of the community in a single survival story.

As the area grew in both size and political power, infrastructure increased: Swansea’s only cathedral, a school and a church social club. This triad of formal institutions balanced educational, spiritual and pleasure needs, offering an elevating sense of purpose and belonging to Greenhill’s residents. Roads, shops and pubs followed, establishing both formal and informal meeting places – school gates, the church, pavements, doorways and windowsills – resulting in thousands of ‘chance conversations’. These exchanges developed social capital and established a shared sense of identity and mutuality between community members; finding form in neighbourly acts of practical and moral support. Thousands of people engaged in a continuous rich exchange, crossing generational, ethnic and faith boundaries.

Neighbourhoods are complex systems where an unpredictable order emerges from many disordered interactions. Over a period of 100 years, Greenhill evolved an extremely cohesive community, exhibiting strong civic engagement and social connection. However, from the 1970s onwards, the area entered into gradual decline, as the infrastructure and social fabric of this community was dismantled in a series of naïve social development projects.

Technocrats from outside the community intervened to raise housing standards, reduce air pollution and improve traffic flow in the area. This was done with little regard for the impact on Greenhill’s entangled lives and intangible community assets. ‘Sub-standard’ dwellings were demolished, displacing residents from inter-generational neighbourhoods. A major road was widened, removing shops along with the opportunity for neighbours to cross paths and exchange news and points-of-view.

In the vacuum of absent conversations, social capital depleted, urban blight spread and crime rose. Since then, significant sums have been invested on a series of social and economic regeneration projects aimed at reversing the decline caused, in part, by these well-intended ‘outsider interventions’.

While this is a particular case, spanning some 170 years, (and focuses on just one aspect of Greenhill’s decline), we believe these insights offer lessons for leadership effectiveness in today’s health and care systems.

Firstly, system leadership must be a collective effort. There are lots of ways to describe our health and care systems and each has its merits.  Acknowledging the lens we see through is therefore vital. Incorporating the alternatives, even better!

Given current political, regulatory and management pressures – the demand for “more grip” – it’s perhaps understandable if leaders privilege a mechanical view of their system. However, this perspective tends to reduce participation; hoarding control ‘at the top’. And – because it denies the distributed nature of ‘system knowledge’ – its solutions are likely based on only partial understanding. Accordingly, leadership development must focus on enabling leaders to work in partnership and to draw out the knowledge and histories stored-up in diverse pockets of the system.

Secondly, leaders need to be more curious about the emergent phenomena of the socio-technical systems within which they operate. Where social is the time-woven tapestry of local stories, rituals, symbols and language; and technical is about structure, organisation, policy, etc. And – crucially – where small-scale localised events may result in large-scale whole system changes! We recommend that leadership development focuses on a collaborative enquiry into a system’s inherent dualities and non-linear system dynamics.

Greenhill’s civil re-engineering scheme was – no doubt – undertaken in good faith. However, it lacked an understanding of the social-technical system as a whole. This resulted in negative unintended consequences that have since proven extremely difficult and costly to remedy.

Thirdly, senior sponsors and boards have a responsibility to develop board assurance approaches that are fit for complex health and care systems. Traditional board assurance ensures that the risks to achieving key strategic goals are properly understood and controlled. However, complexity necessarily involves ambiguity and uncertainty, which cannot be controlled because causality is both unclear and unpredictable. Senior sponsors and boards must seek reassurance that staff are cognisant of the complexity of the system – that proposed interventions are “built to learn” and can be contained if they go awry. Moreover, do ensure that feedback mechanisms provide robust, short, medium and long-term data on system impacts and emerging risks.

Lastly, system leaders must design for greater connection. In the case of Greenhill, much of what was most valuable was the unintended – yet deeply desirable – fruits of people coming together to ‘work things out’: a more diffuse form of leadership than we generally envisage when addressing organisation challenges.  Thus, system leaders must foster the skills of convening and containing – inviting people to take a seat at the metaphorical table (striving for representation and diversity) and then making it safe for people to ‘bring their difference’ in open, honest and collaborative ways – especially when this involves conflict. Difference, after all, can be a source of learning and innovation, if supported by social bonds that are strong enough to resist the urge to fragment.

Too much of leadership development (as with how we select, evaluate and incentivise our leaders), still focuses on the heroic individual’s abstract knowledge, skills, behaviours and personality. Perhaps however leadership is better understood as an emergent phenomenon – a product of the live system! Accordingly, relationships and relatedness ought to be the primary focus of our change-methodology. Whilst they may be capable of affecting localised change, leaders certainly cannot control or predict the wider or longitudinal responses to it, and making sense is generally only possible in retrospect.

It’s been said many times: system leadership is a collective endeavour. In practice however, this never involves marching in regular fashion to a single tune. Accordingly, a greater maturity is called for in how we ‘lead’ health systems, in all of their diversity, disorder and discordance. Indeed, it may very well be that the parts we least control represent our best hopes for the future.

Authors

Jem Peel

Jem Peel is a leadership and organisational development practitioner, working across a variety of sectors and industry; supporting leaders, boards and teams to make a positive and sustainable difference to staff, service users and the wider system. (See more: http://www.everythingisconnected.co.uk/)

Rob Sheffield

Rob Sheffield is a leadership and innovation facilitator, working in healthcare, energy and education. He helps groups break from current habits and develop creative approaches that bring sustainable value to their stakeholders. (See more: https://bluegreenlearning.com/)

Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.