Dancing between the waves

The organisational peak is a perilous environment. It is more complex and challenging than anything that has gone before. And consequently, both executive tenure and corporate longevity are decreasing. To survive and thrive at the perilous peak, executive leaders need to balance their functional leadership, a focus on execution with enterprise leadership, that is ensuring the organisation adapts in our new world. That is what we will be exploring in the Advanced Executive Leadership podcast. Welcome. I’m your host Jacqueline Conway. I’m the Founder and Managing Director of Walden Croft, a consulting practice dedicated to helping Executives and Executive teams anticipate, navigate and lead at the perilous peak.

In this episode of Advanced Executive Leadership and had the great pleasure to talk to Heather Knox, who’s the Chief Executive officer of NHS Lanarkshire. For those not familiar with the area, it is the central belt of Scotland, and it reaches West Central Scotland between Glasgow towards Edinburgh and then down the Clyde Valley towards Lanark and Biggar. And it’s a large, diverse region with a population of about 650,000 across, both in urban and rural communities. Now NHS Lanarkshire employs about 12,000 staff across health centres and communities and across three large district teaching hospitals.

The area was particularly hard hit by Covid, and I had the privilege to see up close how the senior team grappled with the sheer enormity of the task of leading in such an unprecedented and unfolding pandemic
As you know, I’m about to publish the CEO research that explores the ways of thinking, acting and being that executive leaders must become fluent in in order to lead well such disruption.

Heather was one of the 17 chief executives who took part in the research, and she talks today about two of the fluencies that came up in our conversation. Cognitive fluency and futures fluency. Ironically, I was supposed to be meeting Heather in person for this interview to hear her reflections on leading at the front end during the Covid pandemic. But then I came down with Covid, so if I sound a little bit croaky, that’s why.
Let’s start by hearing a little bit about Heather and how she came to be the CEO of NHS Lanarkshire as the pandemic hit.

Heather Knox (2:53)

I guess I was interested in health from quite a young age, my mother was a nurse and a midwife and age 16 actually spent a day in the Victoria Hospital in Kirkcaldy with a dietician thinking I was wanting to be a dietitian. Then I went to university and was interested in attitudes towards health at university when I studied sociology and French actually. I did a postgraduate degree in health research leading out of that and applied for the management training scheme, which was a fantastic introduction to the NHS. I did that down in London because they weren’t running it that year in Scotland, and then spent the next kind of 10/12 years in London working and teaching hospitals and then moved up to Scotland latterly.

Jacqueline Conway (3:37)

You were a relatively new chief executive at the point when Covid happened, weren’t you?

Heather Knox (3:43)

Yes, I had been acting as chief exec in the first few months prior to Covid and Covid rapidly struck as you know, in March of that year. My boss, who had been spending some time out with the board, which is why I had been acting, moved across to NHS Lothian.
So, at that point I was asked formally to act full time at NHS, Lanarkshire, and obviously that coincided with the onset of the Covid epidemic.
There was a lot to do at that point in terms of planning for the first big wave of Covid. We did a great deal of contingency planning and we had two or three weeks where we could see what was happening in northern Italy. We were learning very fast what we needed to do in terms of mobilizing our hospitals to deal with the pandemic and we were lucky to have those two or three weeks. It then hit London and then about a week later it was very much in Scotland. Lanarkshire as you know, has been extremely adversely impacted and we’ve now had, I think, 5 waves of Covid.

Jacqueline Conway (4:49)

And what was that like, just at a personal level?

Heather Knox (4:52)

I think at the very beginning of Covid everybody was extremely anxious because we didn’t really know what we were dealing with. Remember there were no vaccines people didn’t really know how it was transmitted. There was an awful lot of emphasis on cleaning surfaces and laterally, we learned that it’s much more about an airborne disease.  That first wave of Covid we had a few surprises, we had a lot of patients in ITU.
We never thought we were going to have to be monitoring oxygen levels in our hospitals, and again that was something new that we needed to do so we had to put in place, plans to support that very quickly, so we had to maximize our ITU facilities. We had to move staff who hadn’t previously worked within an ITU setting, such as physiotherapists, into that area very quickly. The staff were amazing, I have to say and continue now to be amazing throughout the pandemic. It was difficult for us personally in the senior management team because we had an outbreak in our own team, and that was quite difficult. Not knowing if your colleagues were going to be OK, really. So, from a personal point of view, that was very difficult. I also had two members of my own family with Covid, so that was quite stressful.  You compartmentalise I think, so you’re trying to put your own personal feelings to one side and think about your work, and what you must do at work. I think everybody does that in that kind of situation you try to manage things a bit separately.

Jacqueline Conway (6:25)

I was struck by the way that Heather and her team, indeed the whole organisation, navigated the uncertainty and complexity they were faced with. The first of the fluencies is cognitive fluency, this idea that we have tobecome able to diagnose and to work with complexity, which requires a different way of leading than merely complicated or challenging situations. I was struck in Heather’s account of what we know about complex issues in that they are dynamic, and she speaks of the fact that we’re on the 5th wave of this pandemic now and that the circumstances of each one was different. So, the responses and the leadership that was required at each stage was different.
Of course, in a crisis situation planning often gives way to action, and I was struck in the way that so many decisions had to be made so quickly in order to keep pace with what was needed and the contrast this had with other ways of leading an organisation such as an NHS trust.

Heather Knox (7:40)

I think one of the things that we learned relatively early on was that communication was really, really important here. So, communication both with the analysts and the public health specialists and understanding as much as we could about this disease. But also, within the organisation. We very rapidly set up what’s called a gold command structure. We were meeting at least once a day, sometimes two or three times a day, because the advice was coming very, very fast, usually from Scottish Government through the chief medical officers of the countries, and we were getting guidance around infection control, we were getting guidance around testing, et cetera. We have a very structured process and I think that structure initially at least stood us in very good stead because the structure of the meetings is very fast. There isn’t really a lot of time for discussion, you can take things off table to discuss them and bring them back for a decision, but they really are half hour meetings, sometimes two or three times a day and that’s a command-and-control structure that we had to put in place, and I think it served us very well at the start of the pandemic.
I think laterally it can be quite disabling to have a command-and-control structure in place in what is a very large and complex organisation which has had a culture of devolved decision making. I think it can be a wee bit decapacitating for staff who are very experienced, very professional and used to making decisions very close to their area of service delivery. And we took that away from them a bit at the beginning and we had to because we had to respond quickly, and as you see, it was a way of managing the uncertainty and I think it did stand us in very good stead. Every health board in Scotland did the same and Scottish Government developed their own version of that as well. So, we were having calls with Scottish Government colleagues to get the advice. Advice was coming out frequently through emails to us for action almost immediately. Having these fast meetings in place was very important in those early months and our ability to mobilise was dependent on that.
Resources were never an issue; we were given the resources we needed to respond for Covid and that has really been the case throughout the pandemic in terms of the Covid allowances from government that’s never been an issue. The main issue that we’ve got, obviously, is availability of workforce and that’s been a problem, but that’s a different issue that wasn’t about funding.

Jacqueline Conway (10:03)

And I guess though the challenge with something like Gold Command is and I have a number of clients who work with that, it’s designed for a crisis. It’s designed for that’s of high adrenaline and hopefully relatively short lived, period where you hopefully get over it quite quickly and then things sort of in inverted commas go back to normal and yet you were trying to lead in this gold command in this heightened crisis situation for a prolonged period of time. What was that like?

Heather Knox (10:36)

We’ve kept gold command in place, so even now we have gold command three times a week in Lanarkshire. But we also have our corporate management team and in between the waves we have brought up our standard meetings as well, and remember we were also having to keep the board apprised of everything that was happening at the same time. There were quite a few informal briefing sessions with board members throughout the pandemic as well, and they were doing their best to keep out of the way and let us get on with responding. Equally they needed to know what was happening just in terms of the progression of the pandemic and then more recently, obviously the progress of the vaccination campaign, because they did still have a governance function to fulfil, so it wasn’t just about our corporate management team, but it was also about making sure that our board was functioning at a level that could provide us with some oversight of the functions that we were delivering. I think the blended approach, the hybrid approach which we moved to quite quickly and we embraced between the waves, gave us that ability to move forward. Remember, we were still building a hospital, so we’ve got a new hospital that we’re building in Western Moffitt which will come online in 2028, there was a lot of decision making around that that still had to continue. We couldn’t just let the day-to-day business of the board. There were still things that we had to get on with alongside obviously responding to the pandemic.
It’s been interesting learning from it, and in particular for me the whole system learning, I did an awful lot of work with the Council chief executives and the partnership leads and police and fire during that period. And again, their support for the NHS has been absolutely fantastic. They mobilise staff for us, they very rapidly found vaccination delivery centres for us and really have been fantastic in terms of supporting the NHS right the way through the pandemic. To this day the relationships we’ve built over that period at all levels between the organisations have been really, really good.

Jacqueline Conway (12:34)

When you’re talking about whole system learning, you’re talking about the learning that had to go on not just within NHS, but the interdependencies with other bodies outside of the NHS?

Heather Knox (12:47)

The voluntary sector played a huge role for example, in supporting people. Most people don’t come into hospital with Covid as you know, although more did in the first wave. But the voluntary sector during lockdown mobilised an army of people, and there were an awful lot of ad hoc voluntary groups as well that were set up during that period, and a lot of neighbourhood-based activity which we hadn’t really seen before. Again, that’s been built on going forward. One of the things that I would say now has been made easier through our resilience work across organisations is our current response to Ukraine and handling the refugees. We have always had refugees off and on over my career coming into Lanarkshire, but I think this time the relationships are stronger, and it’s been easier to respond because we’ve got that recent history of very much working hand in glove in in response to a different crisis. I think it will stand us in good stead as we move forward Jacqueline.

Jacqueline Conway (13:47)

I’m really interested in the word learning, how did you institutionalise or formalise learning both across this wider system that you’re referring to, but also within the NHS nationally? There were things I would imagine that was learning in other parts of the system that you could make benefit of. And there were things perhaps that you were learning in NHS Lanarkshire that the wider NHS could make benefit of, so how did learning happen practically?

Heather Knox (14:20)

Lanarkshire was very much the Canary in the coal mine for Scotland, we saw the waves of Covid before other boards, and I still don’t really understand why that is the case because you would think it would come up the country through Dumfries and Galloway. I think it’s possibly because Lanarkshire is a corridor between Glasgow and Edinburgh. I don’t really know, but most of the waves seemed to hit Lanarkshire in terms of numbers earlier than other parts of Scotland, so we were often telling people that we’re seeing numbers rising. Our community numbers would often tell us first, so referrals through NHS 24 through our Covid hubs would let us know that we were seeing another wave coming forward, so we were often able to signal a further wave that was coming and again that happened with the most recent wave. In terms of learning, I think all the boards mobilised very quickly in terms of ability to engage virtually. We’re delivering an awful lot of our services now in a virtual basis and have maintained that following on from the pandemic. I know many companies have done the same, not just the NHS, so that advance of tech and digital support has been hugely helpful, and that’s not unique to Lanarkshire, but we did mobilise very quickly. The Resilience Partnership for Lanarkshire has been hugely helpful, so we’ve met weekly right the way through the pandemic and have just stepped it down to fortnightly a wee while ago. But, that ability to speak to police, fire, local services in the local authorities on a weekly basis has been really important, particularly for joined up communications. We did a lot of communications around testing, working with our local population, and then hearing the same message from local leaders has been quite powerful during the pandemic.  It’s easier to do that in a board like Lanarkshire where you only have two local authorities, it’s harder in some of the bigger boards where you’re dealing with several local authorities. It’s difficult to orchestrate that, but I have to say our local leaders have been absolutely fantastic.

Jacqueline Conway (16:23)

You’ve talked about five waves, you were obviously learning as you went, and so as you think back to those five waves, were you doing things radically different in the 5th wave than you were in the first, for example.

Heather Knox (16:37)

The most recent wave we haven’t seen the same numbers at all of patients coming into ITU and you’ve probably heard that nationally partly as a result of vaccination, which is fantastic. What we’re seeing at the moment is a combination of people coming in with Covid, but also people coming in with what we’re calling incubated demands. People who are coming in with things that they maybe didn’t present to the health service with because frankly they were scared. During the early months of Covid, so people presenting to our emergency services and to general practice with things that probably might have been relatively minor had been presented earlier. Because they have delayed for very understandable reasons are now much more serious. Prior to Covid, maybe 30% of people who turned up for an accident emergency consultation would end up being admitted to hospital, and recently we saw that go up to 40%. People who are attending are much sicker. They need many more investigations and many more of them are attending, so our numbers in accident emergency are extremely high just now, and that’s at a time when we’re trying to also start to bring back some of our planned care operations. At the moment, it’s actually, I think harder for the NHS than it was in the first wave. In the first wave there was nobody in hospital apart from Covid patients, whereas now we’re trying to keep everything going, so it’s a very different scenario.

Jacqueline Conway (18:08)

One of the things I’m interested in because I know that leadership is important to you Heather, I wonder what reflections you’ve had about your own leadership and about leadership more generally, as you’ve had to lead during this enduring crisis.

Heather Knox (18:24)

I think the thing that that strikes me in terms of leading during a crisis is how close the team gets the team have been hugely mutually supportive, personally and professionally. Most of us worked together prior to the pandemic for a number of years anyway, so we knew each other quite well, but I think we almost spelled each other at difficult times. There would be times when you could see that a colleague was really struggling, and he might know that they had had issues maybe with family having Covid .  She would try and help and just make sure that they had somewhere to talk. Putting in supports for the team. Making sure that we maximize team resilience was really important. As you know, we ran our resilience workshop for the team and people were quite conflicted about attending what they saw as a development event during a crisis because they felt they shouldn’t be taking time out they should be managing the service and supporting the teams that were delivering frontline services, but actually their resilience as the senior management team was equally important and we’ve put in place a lot of wellbeing supports for staff. I think that’s something that will stay as we move forward because we’ve recognized the benefits of making sure that staff’s wellbeing is an integral part of the way that we work. Those can be as simple as rest hubs within our acute sites or counselling for staff. Psychological support sometimes targeted psychological support following a difficult situation All those things, I think we will try to keep in place. Spiritual care has been hugely important for staff as well.  Working with your team to provide a supportive environment and just taking a wee bit of time out sometimes can help staff as well. I think we’ve learned a lot about how to support our staff.

Jacqueline Conway (20:20)

You talked about the importance of being part of your own team and the quality of the relationships of the year was that just by virtue of you being in this together, or do you think that a foundation needed to be in place in order to be able to access that relatively quickly when the pandemic struck?

Heather Knox (20:42)

I think it’s probably a bit of both Jacqueline, because if I contrast that with my relationships with the local authority leaders and fire and police that wasn’t really in place prior to the pandemic. It is now and what I have done to promote that is I’ve been very keen to have an informal session with them as leaders every week or every fortnight to try and nurture that. That’s something I did very deliberately because I knew it would be important. We had the relationships in place and to be fair they were all very open to doing that. If I think about that set of relationships, which are my external leadership relationships and my team, most of them I knew quite well prior to the pandemic. There were a couple of people who were new, but they bedded in very quickly and I think despite us being in command and control, all of those team members knew that they had very much delegated responsibility for their area, so I wasn’t going to interfere in things, and I tend to let people get on with it. If they want to come back and have a conversation about maybe a choice of doing different things, I’ll absolutely engage in that, but I don’t sit on people shoulders. I very much set the parameters with them around what it is we need to achieve and then give them the scope to think about the best way that they can use their strengths to make that happen and that might not be the way I would do it, and I respect that because everybody is very different.

Jacqueline Conway (22:17)

Heather makes mention of the futures and foresight that she and her team were doing as they were planning and in consultation about a new hospital that’s coming on stream in 2028, it requires a very different way of leading than what was needed as they were dealing with the pandemic. The much more immediate kind of crisis leadership that was required and this future fluency relates to the second of the four fluencies, the ability to anticipate and to work effectively with a future that hasn’t yet unfolded .Futures work is sometimes seen as a sub slightly off the wall activity done where we’re imagining spaceships and traveling in aerial taxis, but as we hear from Heather, it has a wonderfully practical and crucial application in the planning and building of this.
With such a huge capital project taking so many years to come onstream those tasked with developing it must be able to anticipate the health needs and requirements of the end users and anticipate the technology that will support this, even where this technology is in its infancy today, and Heather mentioned one approach to future work developed by Bill Sharp called 3 Horizons, and it’s a foresight tool that explores 3 different timescales or horizons.  It means that we don’t just prioritize or privilege the immediate term, the medium term or the long term, but rather we bring each different time horizon and what needs to be considered into our thinking and planning at the same time.

Heather Know (23:06)

Obviously, we needed to continue with that development, and we didn’t want to lose any time because we’re very conscious that we have an existing hospital, a much beloved hospital at Monklands .But Monklands is an old hospital and every time it rains, it floods, and we have all sorts of environmental hazards on the Monkland site, and we absolutely need to replace it. That case has been recognised by government for a number of years now and the work that we were doing during the pandemic was around site selection primarily, and that was brought to a decision towards the end of last year where we selected the Western Moffit site. Obviously that work involved public engagement, public consultation. It involved a lot of dialogue with MPs and MSP’s, so you’re right, it was quite a strange balance. Going from short sharp command and control, we need to do this this and this we need to bring these wards online, we need to do that we need to bring these staff in, we move those staff from there. Those kinds of decisions versus are we complying with the engagement legislation? Have we got enough information to bring back to the board? Have we done this in a way that will stand up to external scrutiny? Have we exercised our fairer Scotland duty and we were the first board to do that around a capital project of this size? What does it mean to have a net zero hospital? Some of the building materials that we may use as part of that construction may not have been imagined yet, so that’s all quite tricky. How do we think the workforce will work within that environment? We’re running forward six years we know digital will have a major impact. We know robotics will have a major impact on healthcare delivery. We’re already seeing that with remote reporting and patients in some of our hospitals are now wearing cuffs around their arms, which will take their vital signs and that’s reported back to a central hub that changes the way that the nursing practice happens. It will free up some time, hopefully over time, to allow nurses to do different kinds of jobs. Robotics, most of meals by that time will be provided by robots. You’re already seeing that in Forth Valley.
Thinking forward and imagining is very important because we need to get this right. We need to think about the patterns of change and try and extrapolate those forward. I spent some time deliberately with international Healthcare Futures Forum and Graham Lester was very generous with his time, and we’ve used the Three Horizons methodology that he talks about to start to think about not a right to left scenario but a what are the emergent patterns here? What does innovation tell us? How are we going to be providing care in that setting and also learning from the best? So, looking at exemplars worldwide around the way that they have managed healthcare deliveries.
Command and control centres are very key part of healthcare delivery internationally in new hospitals we now have an exemplar command and control centre within our Monklands facility and that’s doing remote monitoring it’s looking at our ambulance services online, it’s looking at our bed state so we’re beginning to bring together a whole lot of information in that centre, which again will help us to plan for the future. All of that is quite exciting. But I’ll be honest, it has been difficult at times to find the headspace to actually stepback from the command and control very important immediate stuff that we were trying to do and think about that now that was easier for the team because there is a separate team that’s dealing with the capital projects, so they were protected from Covid to a large extent. The first few months they were involved in mobilization and then we said you have to go away and do this work, because otherwise we won’t have a hospital and we see now with Covid just how much we need a new hospital.
The argument about single rooms that’s gone out the window, we were having a debate about whether we needed single rooms.  We know that Covid taught us we need single rooms in a new hospital. There were some things that were answered by the pandemic, but we needed to say to people go away and do this work and we will protect you from the pandemic and let you as a team take this forward. We will engage with the board and the non-execs so the non-execs were very involved in a whole series of meetings during last calendar year to get us to the stage where we made the decision about the site. Nina Mahal, our previous chair was very instrumental in taking us to that site decision towards the end of last year and obviously there was a lot of work done with Scottish Government colleagues as well to get to that place. It actually gave staff joy Jacqueline to think differently and a number of people said I felt guilty about doing it but once I stepped into that space, it actually was really nice to have time and space to think differently about the future about something different, and to think that we are still moving forward. We are still planning, despite this horrible pandemic, we’re still going to take these services forward.

Jacqueline Conway (29:07)

Let me ask about the transition for staff because you’re alluding to the year one of the things that many of us noticed when we had to sort of step out of our normal lives in March 2020, and then when we started to sort of move back into it, the world has changed, and one of those things was hybrid working. The fact that we’ve all become comfortable working from home using the technology that’s available, but one of the things that we heard a little bit about was the readjustment period for people who were so used to getting on a train and going to work and being in the world in a way that was completely uprooted. And when they were then invited to go back to that, actually, there was a sense of people struggling a little bit to move back into that, and I wonder if you saw any of that within the NHS as you tried to move things towards a new normal there was perhaps reluctance to step back into that.

Heather Knox (30:11)

I suppose there’s two types of staff in the NHS. There are the staff who are frontline caregivers, so they have been working the whole way through, so they haven’t had that adjustment piece. There are some people who do hybrid working, so some of our senior staff will be doing remote consultations. Some of our dietitians, some of our physicals, for example have been doing things remotely. We’ve developed a whole lot stuff around mental health support that’s been remotely delivered and that again has been maintained. In terms of people coming back into the office, we have been having conversations with teams about how they want to do that. I have to say we’ve been quite careful in the NHS we’re probably at the risk averse end of the spectrum. Even now, my daughter is back in work, and she told me, she was in a meeting with 7 people this week and they didn’t have masks on and that fills me with horror, but that’s just because I’m a chief executive in the NHS. The numbers of Covid are higher now than they’ve been so I think we’re in a bit of a funny situation so, although people are being encouraged to come back to work, I would say to people take care and make sure that you’re comfortable with being in an environment with other people. It’s absolutely fine to wear your mask all day if that’s what you want to do, and certainly in our hospitals, all our staff wear their masks all day. We had the Director General of the NHS visiting us last Friday she wore a mask all day. Even when we’re in meetings, we don’t take our masks off now. OK, we are at the risk adverse end of the spectrum. I understand that and other people won’t have the same views as me, but the way I think about it is I think about protecting other people. I’ve got elderly relatives, I don’t want to catch Covid and give it to them, so I I’m very careful. I understand that other people are keen to come back to work and I also understand the benefit of being in a team and working in a team. I would just say to people do it carefully and don’t do anything you’re not comfortable with. Have that conversation with your line manager, because if you’ve got underlying health conditions, even if you’re vaccinated, you can still get quite a horrible dose of Covid. That’s my kind of push for people looking after themselves, really.

Jacqueline Conway (32:34)

But let me ask this, we’ve talked a bit about your team and your organisation looking forward doing the futures work. You mentioned 3 horizons and the other work that you have to do to try and anticipate what will be required in a future that has yet to come into being. I wonder, in the here and now, what surprised you about what we saw with Covid because there were some quite unusual responses. I think the government right at the very beginning, for example, didn’t think that society would be prepared to lock down. And lo and behold, we all went home and locked her doors. Was there anything that was really surprising around the response from the public, either positively or not so positively?

Heather Knox (33:25)

I think there were a lot of very positive things certainly in the first wave from the public and a lot of support and we were literally overwhelmed with support from local businesses. I can remember going into Monkland Hospital one day and there was this room just full it was like a florist’s front room. It was full of bouquets of flowers. A local florist had just brought them in, so somebody said to me, do you want a bouquet of flowers? I said no these are for the staff working on the wards, they said we’ve given them all, you can take one there’s plenty, there’s hundreds of them. We also got pizza delivered, food delivered, regularly for staff who were working. I think local businesses wanted to help they wanted to show their support and that was lovely. In the first wave. I think now we’re in a very different place, a lot of people are feeling now that they need to see a doctor and they’re struggling to see a doctor for all the reasons that we know and understand. There are delays for us for planned care procedures and people are getting very frustrated and we’ve had to be quite specific around our kind of 0 tolerance to aggression. Recently, in a couple of videos you might have seen them just saying that we will always support staff and giving staff additional training, particularly our call centre staff, that deal with enquiries around appointments, just helping them to handle difficult conversations and giving them a bit more tools to use in that scenario and trying to defuse what is just really anxiety that’s converted into aggression sometimes, unfortunately. I think we’ve seen that change during the pandemic, and we do feel as if we’re in a bubble in the NHS at the moment.
We are in the most difficult wave that we have had so far, yet outside the NHS everybody is desperate to go back to normal and I regularly hear people saying well Covid is over. It’s not over for us. It really isn’t over for us, and we are going to have to do an awful lot of work to re mobilize and make sure that we get back to a situation where we can deliver the health care that we want to. I think one of the big problems we’ve got with staff just now is they are hugely frustrated because they can’t do their job. We have a lack of workforce because people are off with Covid and people are quite burnt out as well, so that’s making it quite difficult. The workforce pressures are significant within the NHS. I have to say that it’s the worst I’ve ever seen it in terms of staffing levels on the wards, it’s been very difficult to staff all our wards over the last week.

Jacqueline Conway (36:02)

Earlier in this conversation you mentioned when you were doing command and control, you’ve said you have a very competent and able whole workforce, but the senior workforce that you took some of the responsibility off right at the height of the crisis because you went into crisis management mode. How has that been in giving that back? what’s that process been like of returning power and authority within the NHS to the wider community?

Heather Knox (36:34)

I think the nature of this virus has been that it’s come in waves Jacqueline, so I think in between the waves we talk about dancing between the waves, but actually in between the waves we’ve stepped down gold command usually just maybe once a week, but we have supported staff to have the more routine conversations around decision making and working through problems together, managing complexity offline and then just bringing back the decision piece. I think we’ve become more nimble around saying we don’t need to talk this through in gold command, do what you would normally do. Go away and have a conversation with people around how you might come to a solution around this and then bring it back for the decision. I think it’s maybe about that hybrid working but recognising quite a bit needs to be done off table even in a gold command structure and giving people the autonomy to do that. Trying to maintain autonomy within a gold command structure, I think, is the balance that you probably need to strike with senior staff and that that needs to be echoed through the organisation we are seeing, sometimes though, people escalating who wouldn’t have escalated before because they don’t have a solution. But also, because we’ve disempowered them a bit through the gold command structure, and they think that we should have the solutions and at the moment the senior team don’t have all the solutions to everything, particularly the workforce issues.
There was an issue in terms of lack of available workforce within the NHS prior to Covid and that has been made worse during the pandemic and it’s been exacerbated. We are going to have to have a major recruitment campaign to bring people into health and social care jobs going forward, and to make that really attractive. The feedback we get from staff that work in the NHS and in social care is that they get a huge amount of fulfilment and job satisfaction from working with people. That’s not coming across in our national recruitment campaigns. One of my asks of the director general last Friday was can we do something nationally to really promote these careers? Because we’re going to need as many people as we can coming back into the service to help us to recover.

Jacqueline Conway (38:41)

Heather, this has been fantastic, thank you so much. I’ve got one other question, I just wanted to ask about the executive team and about being a member of a very senior team. Has your view or the view of your team changed about what executive leadership is really all about since the pandemic?

Heather Knox (39:04)

I think our team would recognize that the previous competence is if you like, and fluences as you talk about them, Jacqueline was always there. I think we’ve had to rely on some specific fluencies more during the pandemic than previously, but I do think it’s important to recognise that the toolkit is wide and varied and you have to be able to go between those to be really successful, it’s not enough just to be able to do command and control, you need to do autonomous complexity management. You need to be able to think about the future, otherwise all you’re doing is responding rather than driving the organisation forward.

Jacqueline Conway (39:43)

Oh absolutely, I mean one of the things we say in Waldencroft is that there’s a balance between on the one hand, the kind of functional leadership which is about the here and now, the day-to-day, but balancing that with adaptation. So, the future leadership about there and then, up and out, how does this organisation adapt and evolve to the changing needs and requirements.

Heather Knox (40:06)

I think that’s right, and I think that adaptive leadership approach has come through. We’ve just started to do some additional work around our strategic direction and people are probably keener now than they were before the pandemic, to really think about health inequalities in a systematic way and to think about the way people experienced services rather than thinking about the services. So instead of talking about services, how do people experience those services? What do we know from them? and how can we intervene in terms of life circumstance earlier so that people don’t get sick so that we can maximize things like employability because we know that people who are in jobs are healthier and there’s actually a renewed focus and emphasis on that upstream work. Jacqueline, I think as a result of the pandemic.

Jacqueline Conway (40:53)

The advanced Executive fluency research that I’ve referred to in this episode is being published on the 13th of May. And if you haven’t already signed up, then you can do so in the link that I’ve put in the show notes below and in subsequent blogs and podcasts you’ll be hearing more about it as we run up to the launch in May.

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