One of the first things noticed when interviewing Dr Pete Thomond is that to him, employees aren’t just staff, they’re always people. It says a lot. The entire premise of the company he has founded with ‘recovering IT geek’ Alex Velkov and ‘recovering management consultant’ Rob Vickers is to help business leaders engage their ‘people’ in an organisation-wide conversation about how things could be improved. Using a social media platform, Clever Together asks staff what they think the company’s biggest issues are, and for solutions that can be implemented immediately or in the long-term. The best ideas, as voted for by the crowd, rise to the top and are seen by chief executives, managers, leaders.
When collaborating as independent consultants, Velkov, Vickers and Thomond realised they individually had a “deep respect for the fact that there’s always more knowledge outside of [their] own heads than inside it” – an idea which Velkov quipped as: “We’re smart when we’re apart, but we’re Clever Together.” The company was born.
Their idea seems to be gaining traction in a health system that has been notoriously bad at both listening to and sharing new ideas. NHS staff seem ready to make the change, too. “It seems there’s been a wholesale shift in thinking, that enough’s enough and we need new approaches to leadership,” Thomond said.
How does he know? When going through notes gathered from more than 60,000 staff, Thomond and team found many mentions of what people want from their leaders – 12,233 people in 242 organisations shared 92,577 data points to be precise (see Box right). Staff are clear on what they want.
“This slice of data on leadership is fascinating. When we dig into this data we see the same story coming out, whether it’s a trust that’s reportedly performing well or a trust that’s reportedly under-performing; whether it’s a primary, secondary or community [organisation].
“There’s a perception in NHS staff in all organisations that we’ve got too much command and control. Too much top-down, ‘This is what you’re going to do.’ Too many leaders in opaque meetings where no one [on the front line] knows what’s going on. People want less of that. People want to feel like they’re being coached and motivated and inspired. They want their leaders to be role models.”
For practices merging to create superpractices – which aim to deliver more services to patients at scale – the message is clear: “In order to make the next step, their leaders must start acting this way, where they’re co-creating visions and values, embedding them at every level, ensuring the clarity of the plan across their organisation.”
But this isn’t without challenges, which Thomond has acknowledged. He believes – as does NHS England general practice improvement lead Dr Robert Varnam – that it’s time for practice managers to “transition” from being managers to leaders.
“Don’t get me wrong,” he says, “To suggest that it’s two specific roles is in some regards a useless dichotomy. You have to be able to effectively do both. The challenge is that the system has mostly rewarded technical skills and management over leadership. It has rewarded clinical practice and administration over leadership.”
More than that, he believes that the NHS is ready for distributed leadership as well, where every staff member has a stake delivering that co-created vision by living the values day-to-day.
The story is well known – 1962, NASA. President Kennedy walks over to a man sweeping the floor, introduces himself and asks, “What are you doing?” The man replies, “Mr President, I’m helping put a man on the moon.” That’s distributed leadership. The janitor had a sense of his personal leadership. As Thomond explains: “That guy knew that keeping the floors clean was helping that department produce components that go towards putting a man on the moon.”
A lack of personal accountability at work, however, has been linked with a rather shocking consensus from the staff comments on leadership. Leaders have been asked to stop overlooking poor performance.
“What we’ve learnt is that when people in the profession have said, ‘Stop overlooking poor performance,’ it’s not ‘Sack rubbish people.’ On the contrary, if you make a commitment to everyone being accountable – to living the values that we’ve subscribed to, or to achieving certain goals – and some people fail to live those values or help deliver those objectives, then something must happen. Step one is [saying], ‘Let’s be clear, you’re not delivering or we’re not aligned here. What do we need to do to help support you to pick this up?’
“And [then] put that support in place. If the support doesn’t deliver perhaps they’re working in the wrong job. It’s not a case of just cynically cutting people out.” Working without such a system allows poor performers to “undermine” the good work being done in other parts of the organisation, Thomond believes.
As anarchic as it sounds, Dr Thomond has a PhD in ‘disruptive innovation’. Disruptive innovation, he explains, is “game-changing innovation to products, services or processes that change and transform the marketplace or business into which they’re launched”.
Upgrading an IT system changes how people use services, right? Does that make it disruptive innovation? Unfortunately, no. Rather than “sustaining innovation”, which improves things in an expected direction, disruptive innovation is more along the lines of digitalising whole chunks of service delivery as Health United Birmingham and Digital Life Sciences are doing.
Health United Birmingham operates with a central hub as 60,000 people’s point of access for primary care. Patient records are stored on a digital channel which allows GPs, specialists and community workers to see patient records at the same time. And patients are able to use instant messaging or teleconferences of communicate with a range of healthcare professionals from their own home.
Some of the data Thomond has seen leads him to believe that the costs of providing general practice could be “massively cut” while increasing patient satisfaction in niche groups by moving some services through digital channels.
“Go back a generation, we can identify tasks we needed doctors for that today can be completed by nurses. The next generation of patients are likely to be doing these tasks themselves. Yet, in healthcare, for some reason, we hold on to the traditional provider of services for far longer than we probably need to. What delighted us as service users in the past is expected today, perhaps tomorrow we’d be delighted if we can simply access these services in a more convenient setting and perhaps this is not via a GP, even through digital channels.”
Niche patients would be delighted for their general practice to “flick the virtualisation button”, Thomond says. It’s not that every patient would like a Skype consultation – as he notes, Halifax maintained the service for patients waning to use paper paying-in books until very recently – but there is a “meaningful majority” who would be “absolutely delighted” to speak to a nurse on the phone about a rash rather waiting a few days.
“We need to let go of the idea that there’s such a thing as a silver bullet out there for whole populations.
“We must start to think about the niches of service users where technologies can offer a meaningful improvement in their experience or outcomes.
“Or indeed, where a traditionally less skilled healthcare worker with perfectly relevant skills can help the patient instead of a GP.
“What we’re looking for are patients that don’t need face time with a highly skilled doctor – lots of folk are being overserved by the current system. We can bring them on board first, and grow from these niche markets until it becomes much more the norm.”
With a hint of amusement in his voice, Thomond states that most GPs would say: “‘Bloody hell, about time, I’ve been trying to do this for ages,’” if asked whether they want to start using email, telephone calls or Skype more, day-to-day.
And he admits there are some patients and staff members who aren’t excited by new ways of working for general practice.
“There’s a strong, well-connected, meaningful group who say that change of practice is not welcome. Internally there’s some serious challenges here. This situation is made worse by the external context – new approaches are not welcomed by everybody in one go.
“While some will embrace novelty, others reject it quite fiercely, especially the older generation who don’t want to use things like Skype to talk to their doctor.”
The new focus in the mainstream media and in the halls of government on improving general practice – promises of thousands of extra GPs and thousands of extra pounds coming from all political parties at the minute – reflect the fact that general practice has so much to offer to the health and wellbeing of the nation, Thomond feels.
“[But] I also think that because it’s so tied up in a particular way of working that in many respects it’s often it’s own enemy,” he adds.
“I think there are green shoots out there of thinking differently about general practice that are springing up across the country that highlight that if you think about general practice a bit differently you could completely radicalise the health outcomes of our country.