The Messenger Review is the latest perspective on the ongoing challenge of leadership and management in the NHS.

Although the report describes itself as focusing on health and care, one of the interesting aspects of its conclusions is that they are almost wholly focused on leadership in health (the NHS) rather than the broader care world which, of course, includes the voluntary and community sector and private providers as well as local government.

The challenges of system leadership

One of the biggest challenges currently facing NHS leaders is system leadership. Whilst the principles and recommendations apply universally, there are arguably some elements of system leadership that require skills that sit outside the Messenger Review.

System working is particularly complex because it requires people to hold multiple identities simultaneously. Many of the traditional models of organisational leadership are not only less relevant, but often actively unhelpful in a system context.

Health and care in England and Wales is system-based by default, simply due to the way it is structured, with responsibility shared across multiple agencies and often uniting only in the experience of the individual needing support and care. When we talk about system working, we are actually talking about maximising the effectiveness of what we already have, and ensuring that it can deliver the outcomes we expect.

The challenge is doing this in a context which has traditionally sought to improve performance through command and control, hierarchies, and competitive approaches. Health and care is also a context where people have self-actualised professionally with a single perspective of their identity, whether working for a particular organisation, having a particular clinical specialism, being part of the NHS family or belonging to a particular local authority. This is now being challenged by the request to think and work differently.

Karl Weick’s work on Sensemaking – Sensemaking in Organizations – talks about the process of creating meaning, and of what it means to understand the environment around you. Weick depicts sensemaking as an active, involuntary process and a natural response to the evolving nature of the world around us.

To achieve the level of change that the government, the NHS and the Messenger Review are describing will require an ‘active reset’ in the way people make sense of themselves and their colleagues professionally. In our personal lives, we hold multiple identities instinctively. We can be daughters, mothers, sisters, and friends without it driving us insane. These identities can sit comfortably together unless they come into conflict with each other.

In the context of system working, we are asking people to hold multiple identities simultaneously and we are asking them to relate differently to their profession, organisation, role and geography. When we think of it like this, it is unsurprising that, despite recognising that system working is a rational approach to improving outcomes and is better for the people we serve, people individually find it incredibly challenging.

Sensemaking and system leadership

Weick’s framework describes the seven elements of ‘sensemaking’, so how we make sense of the world around us:

  1. Identity – who we are
  2. Retrospection – what we focus on when we look back
  3. Enactment – what we do and what we experience
  4. Social activity – the stories and shared experiences we have
  5. Ongoing process – we are sensemaking all the time – it doesn’t stop
  6. Extracted cues – we will use cues to navigate the environment
  7. Plausibility over accuracy – we are less bothered by accuracy, we make sense from plausibility

As a starting point, this helps us to think through some of the leadership behaviours, at all levels of a system, that will enable sensemaking that supports the development of that system. These leadership behaviours need to move systems away from sustaining the traditional, organisationally-based model. That traditional model can feel more comfortable but it doesn’t allow for the connections and relationships that can actually deliver care across organisational boundaries.

We have already talked about identity as one of the challenges, in terms of making the system real. It is also a leadership opportunity: a chance to represent and embody something which is otherwise quite ephemeral, and to reflect back to people an idea as reality.

There is a clear theme around behaviours, and the importance of activity in creating a reality. Within the seven principles of sensemaking we see this reflected in Enactment, Extracted Cues, and the fact that sensemaking is Ongoing, a continuous process.

For leaders, this means being conscious of ensuring that actions match words and that the behaviours they display and celebrate within the system are those that will sustain and enhance it, so collaboration and connection over competition, for example.

There is another theme around narrative and community, so the importance of social activity and story-sharing as well as the seduction of plausibility over accuracy. This means leaders need the space to convene and create shared narratives, but also highlights the importance of rooting that narrative within something that feels credible to those within the system. Describing a reality that connects to people’s current experience, and that feels plausible is more likely to be successful than one which may be technically perfect but feels disconnected from what people already know. This is a vote in favour of credible ambition over sunshine and rainbows!

Finally, there is a skill in making sense of the past through retrospection. What we all know is that our experiences are subjective, and that our understanding of the past will vary. In helping those within a system to make sense of its present and future, leaders need to have the capacity to incorporate all of those realities into the present experience, validating them as building blocks of today, rather than creating (unconsciously) gaps between what people have experienced and what they are being told they have experienced.

How can we put sensemaking and system leadership into practice?

This sounds like a complex process because it is. Leading a system is a different skillset from that of leading an organisation, and one that is far less understood. One system leader described the process of sharing best practice across a system as being one of ‘breathing it in’ rather than mandating it, which conveys the sense of dynamism and energy required to lead something which, by definition, is heading towards multiple goals, from multiple perspectives and at multiple speeds.

This comfort with leadership as an energy and a responsibility, rather than a hierarchical state, is rare and not often discussed. It seems to be key to creating the new set of relationships and identities that will be necessary for system working to become the norm.

As with so many complex elements of management, understanding what may be required, and accepting that it is hard to achieve, are the most useful starting points in a journey to achieving it. We are asking people across our health and care system to make sense of a radically different way of working, and to layer an additional identity onto an already complex picture. To do this, they will need leaders who are able to guide and support them with confidence.

The Messenger Review reiterates some well-known arguments about the challenges in creating the kind of operational organisations we will need to form part of the systems of the future. The Messenger talks less if at all about the task of knitting those organisations into a system that feels real and makes sense in the same way as those more established entities do.

If that is the future we want, and it is very much that described in the Health and Social Care Act, the leaders tasked with leading those systems themselves will need to be supported with a clear understanding of what they are being asked to do. They will need the space to grow and learn how to do it well. And they will need understanding (from themselves and others) that they will not get it right first time every time.