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What do we mean by systems leadership in health and social care and why is it needed?
This chapter will explore the world in which health and social care organisations find themselves – where change and complexity are the ‘new normal’ and where volatility, uncertainty, complexity and ambiguity are the backcloth. It will examine the notions of competence and capability as means of addressing this world and will consider the different kinds of problems which such organisations face. Seeing local health and social care as a complex adaptive system is offered as a useful way of working in the face of such a challenging environment, given the particular nature of such organisations. The development of these organisations and the people within them calls for going beyond collaboration towards co-evolution and systems leadership is posited as the way ahead.
Change and complexity as the ‘new normal’
Anyone faced with the challenges of working in, and leading and managing, all organisations, but particularly health and social care organisations, in the early 21st century faces a whole series of challenges. These include:
- Working in the continuing aftermath of the 2008 global financial crisis, with the austerity and employment uncertainty which that entails. It means working in an extremely harsh resource climate where both financial and political demands focus attention largely on short-term targets, yet the need for more creative and longer-term thinking is probably greater than ever, while short-term pressures and expectations actually generate and encourage pre-existing ‘silo’ working within and across health and social care.
- High and growing levels of public expectation of what health and social care services could and should deliver to local and national populations, in terms of quality, choice and accessibility. In this respect, the public has become increasingly less tolerant of the range, quality and accessibility of current provision and more demanding of future provision. There is therefore an urgent requirement to balance the short-term operational delivery of health and social care services with longer-term and more strategic innovation in those services. Yet there is little or no time or space available for the much-needed long-term joint horizon-scanning activity which could identify exactly what is and is not possible in terms of service delivery.
- Significant social and cultural change, including the growth of multicultural communities in some parts of the UK, and changing (and contested) attitudes towards such issues as obesity, alcohol and drug abuse, abortion and towards welfare provision (previously called ‘social security’) generally.
- Changing demographics, with an increasingly aging population (often exhibiting long-term conditions and combinations of long-term conditions) and a major shrinking of the younger workforce recruitment pool from which health and social care professionals and other staff have historically been drawn. Frozen or capped salaries available for front-line staff and resultant staff shortages make recruitment and retention (for example in domiciliary care) much more difficult, and taken together with negative media coverage, consistently generate a public ‘crisis’ image.
- An increase in the numbers of dual earner couples and of workers with family care-giving responsibilities. Despite this, an increase in reported loneliness, especially in the case of both the elderly and the young, but not confined only to those age groups. Loneliness can be about feeling alone even when surrounded by other people and is about the quality of connections with others, rather than the number of social relationships. It is something of a paradox that in a modern, densely populated urban society, there is a shortage of friendship and good relationships, because although people are together, they are also separate (Wilkinson & Pickett, 2018). A danger is that, as a consequence of austerity, the reduction or closure of local services providing such a sense of community and providing vital support may further enhance such loneliness.
- For those in full-time work, the UK has some of the longest working hours in Europe. There is also an unusually high percentage of part-time workers for whom average working hours may be short but many of whom appear to want full-time work but simply cannot access it. This relates to the growth of the ‘gig economy’ of self-employed people on short-term or zero-hours contracts, with around 25% of the UK employed population being identified as part of this ‘precariat’ (Standing, 2011). This ‘insecure cohort’ is less-qualified, has limited job autonomy and significantly less financial security (Williams et al., 2017). They are potentially vulnerable to fluctuations in working time and therefore pay levels, short notice of working schedules and experience a degree of precariousness in terms of a lack of employment rights (Broughton et al., 2018).
- Social mobility has become so frozen that apparently it would take five generations for poorer families in the UK to reach the average income, while higher earners get bigger rewards and consolidate wealth for the next generation (OECD, 2018). Such growing inequality in UK society produces powerful psychological effects. When the gap between rich and poor increases, so does the tendency to self-define and define others in terms of superiority and inferiority. Low social status is typically associated with elevated levels of stress and rates of anxiety and depression are intimately related to the inequality that increasingly makes that status paramount (Wilkinson & Pickett, 2018).
- A decline in a previous culture of deference to both authority and expertise, largely fuelled by an explosion in the availability and usability of information, much of it digitally-based. A corresponding collapse of confidence and trust in any kind of traditional authority, but especially with those institutions and individuals with claims to expertise (Peston, 2017).
- A growing emphasis on diversity and equality at work and in society as a whole and a growing intolerance of sexism, racism and misogyny. Alongside this, evidence of a growing intolerance of minorities and of increased polarisation within society verging, at times, on xenophobia. This can be amplified by what some observers consider a ‘toxic’ media, especially via certain newspapers and social media.
- Powerful drives to increase efficiency and to improve quality simultaneously – to do ‘more for less’.
- Continuing intra-organisational restructuring or reconfiguration, often known as ‘re-disorganisation’ and typically involving de-layering, down-sizing and the merging of roles or of whole organisations, often resulting in job losses, enhanced uncertainty and a sense of heightened anxiety for the staff concerned (Ballatt & Campling, 2011).
- Uncertainty with regard to the future associated with Brexit – the UK’s departure from the European Union. This includes the reluctance of people from the EU to consider full or part-time employment in the UK, especially important where historically health and social care services have been reliant upon them. The potential ending of free movement has a major impact on the adult social care workforce. Seventeen percent (222,000) of social care staff in England are foreign nationals and in 2018 there were 90,000 unfilled social care vacancies, a vacancy rate of 6.6%, compared to an average of 2.5% across the economy (Global Future, 2018).
- As a consequence, increased experience of complexity and ambiguity both within and between health and social care organisations.
All this produces a sense of being caught in a ‘perfect storm’ of increasing public need, demand and expectation, coupled with a decreasing resource and staffing capacity. As a result, health and social care organisations seem to be on a journey from an old to a new world, as Table 1.1 reveals. This, in turn, means that the work roles that people enact are also shifting, as shown in Table 1.2.
TABLE 1.1 Moving from an old to a new order
| Old world | New world |
Low complexity, slow change Learning has a long shelf-life Senior people know best Someone, somewhere, knows Doing more of the same is the rule | High complexity, fast change Learning has a short shelf-life Knowledge is scattered No individual can pretend to know Innovation is the rule |
TABLE 1.2 Shifting roles
| From ‘I manage’ | To ‘I lead’ |
| My team reports to me | I am part of a virtual network |
| I have a hierarchical role | Influencing is the way forward |
| I understand what is happening | I can only have a partial understanding of what is happening |
| I have fixed objectives | I take the lead on issues |
| What I have to do is clear | I cope with ambiguity |
| I manage by fixing things myself | I lead teams to deal with things |
| I manage from my knowledge and experience | I lead without knowledge and experience |
A VUCA/RUPT world
The characteristics described obviously do not apply only to health and social care organisations, but are manifest in some form or other across both public, private and third sectors on both a national and international basis. They are summarised by the notion of ‘VUCA’, which stands for:
Volatility: The type, speed, volume and scale of economic, social and organisational change forces and catalyses events to an extent never experienced before.
Uncertainty: There is a lack of predictability with regard to the future and a much greater likelihood of surprises occurring without everyone having an enhanced awareness and understanding of both issues and events.
Complexity: There are multiple forces and factors in play and, as a result, issues become confounded, with no simple cause-and-effect sequence to events and activities being observable.
Ambiguity: There is a lack of precision and there are multiple meanings of the same event possible. Reality can appear ‘hazy’ with a greater potential for misreading and misunderstanding exactly what is going on.
Social pressures and trends, heightening expectations, the power of social media, globalism on the one hand and localism on the other, together with the continued existence of social, health, housing and policing issues all affect people and their communities – and all contribute to volatility, uncertainty, complexity and ambiguity.
The leadership implications of these characteristics are:
Volatility: Leaders face challenges that, while not necessarily hard to understand, may be unstable, unexpected or last for an unknown length of time.
Uncertainty: Leaders face challenges where the original cause may possibly be known, but a lack of supplementary information serves to shroud the process of change management and the effects can appear diffuse.
Complexity: Leaders face challenges in dealing with a multitude of interdependent and interacting variables across and beyond the boundaries of their organisations.
Ambiguity: Leaders face the challenges of ‘unknown unknowns’ where there areunclear relationships between cause and effect.
An alternative concept is that of a ‘RUPT’ world, which is rapid, unpredictable, paradoxical and tangled:
Rapid: Leaders face overlapping challenges, in multiple domains, which occur and re-occur and need to be overcome at pace.
Unpredictable: Leaders face unexpected challenges which, despite thorough and well thought-out strategies and governance, can rapidly challenge underlying assumptions and cause a reframing of thinking.
Paradoxical: Leaders face challenges in polarity. Rather than providing one solution (either this or that), challenges need to be embraced as polarities (both this and that) to be addressed in both the short and long term.
Tangled: Leaders face interdependent challenges across and beyond the boundaries of their system.
Within this often chaotic environment, rapid and unpredictable paradoxes are embedded in tangled multi-causal relationships. In order to work effectively in such contexts, leaders need to develop (both within themselves and also across the system) a learning capability (see below) where the majority of learning occurs in association with real-life challenges (Till, Dutta & McKimm, 2016). This is addressed in detail in Chapter 3.
Competence and capability
The most popular means which has been adopted to deal with this omnipresent VUCA/RUPT reality has been an emphasis on increasing the competence of key people (i.e. those who are called leaders) in work organisations – and hence to the recent popularity of competency-based approaches to education and training.
Competence is concerned with what individuals know or are able to do, in terms of their knowledge, skills and attitudes, as expressed in their observable behaviour. Much work has been undertaken to analyse, define and publicise what organisations, functions, professions or whole sectors of society deem as desirable competences. Competence obviously works well with ‘tame’ issues (see below) where the challenges concerned are both clear and unambiguous and where tried and tested solutions can be applied. It suffices when there are high degrees of certainty and agreem...
