The text below is reproduced with permission from Radcliffe e-bulletins “Leadership for Doctors” number 23 and is co-authored by Stephen Curran and myself. Earlier bulletins can be found under the Leadership for Doctors tab above.
January is typically the month for New Year Resolutions. To be proactive rather than reactive is perhaps one of the best! Stephen Covey, a very influential management writer of the 20th century, placed it first on his list of the 7 Habits of Highly Effective People (1). Many years ago, when one of the authors was elected as Chair of the Old Age Faculty at the Royal College of Psychiatrists, he resolved not to be always reacting to Government and other initiatives but instead to ask the Faculty what they wanted to achieve during his chairmanship. We called it “seizing the initiative”. So, in any new management role (and perhaps at the start of a New Year, too), it is worth thinking about what you want to achieve. The annual appraisal and job-planning cycle also provides an opportunity for deciding on what you want to achieve and reviewing how well you have achieved it. However, sometimes Personal Development Plans and Job Plans will be heavy on organisational rather than truly personal work ambitions. These will need to be reconciled.
Underlying assumptions and values
Virtually all senior doctors are (or should be) involved in leadership. The degree of involvement in leadership will vary from leading a clinical team, through leading a particular specialty locally (or nationally) to providing Medical Leadership to a multi-million pound NHS Foundation Trust. Individuals and organisations have (often unwritten) assumptions about the “way the world is” and the values that they think should underpin behaviour. There are also broader cultural assumptions and values. It is good to be explicit about these assumptions and values. Where there is agreement between the assumptions and values of the broad culture, the organisational culture and the individual, life will be relatively easy and there may be relatively few challenges for the leader to overcome. Where, as often seems to be the case, there are differences between the broad culture’s and the organisation’s or individual’s assumptions and values, things may be more challenging. Where there are major differences in values between individuals and their organisations it is time for change (of one sort or another).
Cultural assumptions and values
We do not live in an homogenous culture. Nevertheless, a particular view of the world often holds sway at least at the political level. Writing in the last century, E.F. Schumaker characterised the then dominant culture in the following words: “The modern economy is propelled by a frenzy of greed and indulges in an orgy of envy, and these are not accidental features but the very causes of its expansionist success.” (2) Has much changed? Schumaker alleged that underlying the dominant culture was a series of “metaphysical” assumptions, which are presented in abbreviated form below:
- Darwinian principles of evolution and “natural selection” apply not only to phylogeny but also to economics, organisations and possibly countries.
- “Higher manifestations of human life” (as Schumaker calls them) such as religion, philosophy and appreciation of beauty are fantasies (Marx) or the results of frustrated basic biological drives (Freud).
- There is no absolute truth (relativism) and the only genuine knowledge is that which can be derived from direct observation (positivism).
Schumaker, following Gandhi and Ruskin, proposed an alternative economics in which work was valued not only in monetary terms but also for the satisfaction which it gives the worker. In his vision cheap, small scale, intermediate technology would be used to provide a better quality of life for all and to avoid destroying the “natural capital” of world resources, making the earth uninhabitable through pollution and warming of the atmosphere. These principles can be applied to healthcare. In 1967 Maurice King published a symposium on Medical Care in Developing Countries (3) which included (amongst many others “axioms”) the principle that healthcare should be delivered in the smallest, most humble, most local setting that can meet the health need; but that is another story!
We have discussed in earlier bulletins how doctors, other clinicians and some health service managers will share many values as expressed in the ethical codes of the caring professions. It is worth reflecting on what values have been recognised as positive in different cultures, over the ages. When Martin Seligman (known to psychiatrists for developing the “learned helplessness” model of depression and subsequent work on “learned optimism”) was President of the American Psychological Society, he and his colleagues started a project to establish a positive psychology (4) to balance the pathological focus of the diagnostic scheme used by psychiatrists and clinical psychologists. In their project they looked at a variety of cultures, philosophies and religions in an attempt to discover character strengths or values that were universally (or at least very widely) held in high esteem. Twenty four specific strengths consistently emerged across history and cultures and were grouped under six broad headings: wisdom, courage, humanity, justice, temperance, and transcendence. These are expanded in Box 1.
There is a pervasive cynicism in modern culture that tends to attribute everything to pseudo-Darwinian motives, such as status through riches and celebrity to enable men to attract the fittest partners. In fact, as Robert Wright has ably shown in his works The Moral Animal (5) and Nonzero (6), this is a very simplistic interpretation of both biological and cultural evolution. The near universal human strengths recognised by positive psychology are an important reminder of a more enduring understanding of human strengths and values.
Interestingly, a leading Thatcherite economic theorist, Brian Griffiths (7) argued that “the Market” was incapable of generating its own ethical values and needed a set of values which were derived from a wider understanding of the human condition. He cited, as common values needed to underpin a market economy, principles of justice or fairness, mutual respect or reciprocal regard, stewardship or trusteeship of “God’s creation” and honesty or integrity (which includes truthfulness and reliability).
These correspond roughly to Justice, Humanity, Courage and Transcendence in the Positive psychology movement’s list above. Perhaps significantly, the values of Temperance and Wisdom do not appear in Griffiths’ list. If they did, we might have avoided the market collapse of 2008.
Do you agree with Schumaker about the dominant assumptions and values in modern (perhaps now, post-modern) society? Consider your personal values. If you want you can use the Values in Action Inventory of Strengths which can be accessed at http://www.viacharacter.org/www/. Alternatively you may want to simply reflect on box 1 above or on values derived from your own religious or cultural background.
How does the team or organisation you work with rate these values? How does the main service commissioner in your area make purchasing decisions? What values (apart from “value for money”, whatever that means) are important to them (you, if you lead a commissioning organisation).
How can we prevent the less attractive “values” of the “hard-nosed” marketplace from displacing those more traditionally associated with the “caring” professions?
Relationships and values (alongside organisational and external factors) are the foundation on which to build and achieve your vision as a leader.
Once the foundation of good relationships and shared values is established, it is time to decide. What is your vision as a leader? What contribution do you, as an individual, want to make to the group which you lead or help to lead? It is a uniquely human facility to be able to imagine the future or several different futures, and to choose one future that you as an individual or group want to work towards. Of course, it will rarely be possible to realise your vision in full; there are too many outside influences on our healthcare system. However if we know where we want to arrive we are likely to get closer to it even if we have to endure the “slings and arrows of outrageous fortune”. The following case study is a personal example of developing and implementing a vision taken from Practical Management and Leadership for Doctors (8)
Case study. One of the authors was asked to support medical management (one day per week) in a Primary Care Trust that provided Mental Health Services. The Medical Director (the only substantive psychiatric consultant in post in the whole Trust) had died unexpectedly, following an accident, not long after recruiting several new consultants on short- term contracts from the European Union. The vision was to get the medical aspects of the mental health services working effectively again. There was concordance between the values of the author and that of the organisation which focused on providing first class services for people with mental health problems and enabling them to contribute fully to their own recovery. This vision broke down into a number of very practical goals some of which are listed below:
- Support the induction of the new consultants into the Trust including an understanding of the organisation of the NHS and the Trust, Psychiatric Practice and Mental Health Legislation in England, etc.
- Establish and implement policies and procedures for medical employment, leave, continuing professional development, appraisal, job planning and performance management etc. (There were “legacy” policies from a previous organisational set up but they did not “fit” the new organisation).
- Re-establish the Trust as a respected provider of medical education and training.
- Support one locum consultant in gaining access to the specialist register via article 14, a route for non-European qualified specialists and others.
- Develop the consultant workforce to a point where long-term appointments could be made to consultant posts and a substantive Medical Director for Mental Health could be appointed from amongst the consultant body.
- Support the establishment of an enduring culture of co-operation between the medical workforce and the management of the organisation in which the needs of service users were the first priority.
The initial timescale for achieving this was 1-2 years. This was too ambitious! With an incredible amount of support from the Director of Mental Health Services, the Chief Executive, the medical personnel specialist, administrative and secretarial staff, the consultants themselves and the Medical School and Deanery, these goals (and a number of other important goals that developed over the period) were all achieved within 4 years. In addition, the culture of co-operation meant that special interests of consultants were harnessed to improve the service by developing specialist services for people with borderline personality disorder, eating disorders and family therapy.
Not all leadership roles will be so time limited or so circumscribed in their intention. Nevertheless, if you have not already done so, it is worth considering your personal vision for what you want to achieve over a realistic time period (maybe this year, since it’s January). It may be something as limited (but not necessarily easy) as developing a co-operative culture, or establishing a good reputation for training or it may be a “higher order” vision like “getting the medical aspects of the mental health services working effectively again”.
The foundation for any project involving people is relationships and (shared) values. Next comes a realistic appreciation of where we are and where we want to be (the “vision”). After this it is necessary to consider the possible obstacles and the resources needed to achieve the vision (after which the end point may need to be revised to a more realistic position!). Finally the tasks needed to achieve the goal/vision need to be prioritised and steps need to be designed, ideally with timings sketched in (see Practical Management and Leadership for Doctors (8)) for an illustration of this model
For Reflection (and action):
Choose an area of leadership where you want to bring about change. This corresponds to the first of Stephen Covey’s 7 Habits of Highly Effective People(1) being PROACTIVE and prevents the disappointment inherent in always REACTING to other people’s initiatives). State this vision as succinctly as possible and decide on a realistic date for achieving it. (This corresponds to the second habit “begin with the end in mind”). Look at the gap between where you are now and where you want to be. Consider what resources are needed to achieve the change (this may be good quality relationships, alliances and communications as much as, or more than, financial resources). Think about likely obstacles and how they can be negotiated. Prioritise and break the vision down into goals that are manageable and time-limited. (Third habit “First things first”.)
Working creatively with others, start progressing towards you goals, keeping a note of what you have achieved in your diary.
- Covey, S.7 Habits of Highly Effective People. London : Simon and Schuster, 2004.
- Schumaker, E. F.Small is Beautiful. London : Vintage, 1973, 1993.
- King, Maurice. Medical Care in Developing Countries. Oxford : Oxford University Press (Tanzania), 1967.
- Seligman, M. Authentic Happiness. London : Nicholas Brealey, 2003.
- Wright, R. The Moral Animal. London : Abacus, 1994.
- Wright, R. NonZero. London : Abacus, 2001.
- Griffiths, B. Morality and the Marketplace (2nd edition). London : Hodder and Stoughton, 1989.
- Wattis, J and Curran, S.Practical Management and Leadership for Doctors. Milton keynes : Radcliffe, 2011.