interviews

Too Good to Fail? Leadership lessons for the NHS

Jan Filochowski, former chief executive of Great Ormond Street NHS FT and a noted expert on turning around
struggling organisations, talks to NHE about his new book, ‘Too Good to Fail?’ and the lessons it offers for predicting and managing failure.

Great leadership is often cited as a way to avoid the terrible failures the NHS has seen in recent years; stories of horrific care and blundering financial management have left their mark. But turning around failing organisations is about more than the best people – it requires using the entire workforce’s knowledge and insight to focus on the outcomes that really matter.

NHE spoke to Jan Filochowski, who retired as chief executive at Great Ormond Street Children’s Hospital NHS FT at the end of 2013. His book ‘Too Good to Fail?’ examines the patterns common to many failing institutions, as well as highlighting what success should look like.

He explained: “Every organisation, every business has challenges and difficulties. It’s inconceivable that you can sail through work life without there being problems. Sometimes the nature of the challenge is unforeseeable and demanding. A decent organisation, one that’s sound, robust, and with responsible people, finds the appropriate ways of rising to those challenges and coping with them.”

But the scale of the challenge facing the NHS does not necessarily mean that many, or even any, of its struggling organisations are
beyond hope.

“Most of those organisations will cope,” Filochowski said, pointing out that there is a repeated pattern of a slide into failure where organisations move beyond struggling.

Perception and reality

One pattern identified by Filochowski is detachment: where the true scale of problems are not acknowledges, or are actively covered up. This often leads to the problems becoming exacerbated.

“A defining feature of that is there’s a separation between actual performance and what it’s seen to be. When performance starts to get out of control, people who are responsible for that – the CEOs, the senior people – move from managing the performance to managing the perception of performance; giving excuses and explanations, reasons.

“It is when perception and reality diverge materially that you move from struggle to failure. You stop managing the reality, because you can’t, and you’re managing the perception. That can be done in two ways; one, delusionally – ‘We are really managing’, or ‘Christ! We’re not managing! But as long as no-one finds out, as long as we keep up the illusion, we can continue’.

“When that happens, performance falls off a cliff. Because management doesn’t know how to deal with it and has stopped trying to deal with it, and is now dealing with what other people think. Things start to get much, much worse.”

Attempts to conceal reality can only go on for so long, and when the illusion is shattered, the organisation reaches “the point of exposure”.

“That’s when, publically, an organisation becomes failing – but its performance has already by then become awful.”

Not the end

Despite this bleak prognosis, Filochowski is keen to impress on his readers that “failure isn’t the end”.

Organisations with something fundamentally wrong are still typically fixable, he believes, and realising what has gone wrong is essential to this recovery. He cautioned against commentators who judge too harshly when failing organisations are exposed; seeing nothing wrong is unhealthy, but so is “baying for blood”, and that too can block improvement.

It’s a pertinent observation – the level of shock and horror such failures stir up can lead to unnecessary and unfounded blame being heaped upon the people and practices involved, sometimes at the detriment of that organisation’s recovery. A demoralised, beleaguered workforce is unlikely to be in the right frame of mind to help an organisation recover.

He said: “Once you can identify the problems, you’re in a position to renew and improve the organisation. That’s part of the good news; that you go through it the right way and come out of it significantly better than you went in to begin with, rather than just hanging on.”

To identify a failing organisation before its lowest point requires more than just data, and depends on how success is defined. “I don’t think you can do it on numbers alone,” he said.

Permanent vs point

The very way society conceives of failure and success is something Filochowski suggests is mistaken. Viewing failure as a permanent state and success as an end-point can actually make the ability to maintain a good organisation more difficult.

“The thinking is completely wrong there. We have to make failure a point and success a state. It’s better to talk about ‘successfulness’, and what you do to behave successfully over a long period of time. If you conceive of it that way, it’s achievable in most cases by reasonable, committed, good managers.”

This trick of reframing over-used concepts in the field of management and leadership can also be applied to luck, he said.

“Luck and chance are very often ways of describing what we don’t understand and haven’t yet worked out how to deal with. If we conceive of them in a different way then we’ll find that they play a much smaller part in what we do than we think. And actually even that small part is as often advantageous as it is disadvantageous. You have as much good luck as bad.”

Getting the definitions right

If leaders are defining success differently to the wider system’s definition, they could be deemed to be failing – but will not believe it. These definitions change, and it can be “very difficult to keep up with what you are being judged on”.

Failures do not exist in a vacuum, and establishing the key measures for good performance will depend on many factors, some of which are outside managers’ control.

“You have to know what the key measures are. There’ll be a few, and in the they’re
changing at the moment; they are predominantly about safety and avoidance of harm and some outcome measures. I’m sure that will evolve further.”

Focusing on the criteria for success will allow good managers to start to get a handle on things, Filochowski suggested.

Recovery from the inside

Although he did not go as far as to say that any NHS organisation can be turned around, regardless of its circumstances, Filochowski said “the overwhelming majority can”.

The total failures that can no longer be saved are “extremely rare”. Such cases make it harder to recover, because the insight and capability of the organisation becomes scattered by that decision.

“In large managed organisations there’s a huge amount of capability, insight and know-how. If you could access that and enable it, actually the solutions are there! They don’t need to be externally imposed and it’s much better not to externally impose them.”

Capitalising on the already present expertise of an organisation is something Filochowski has personal experience of – when working to turn around the Medway trust in 1999-2002. He said: “The solutions to really knotty problems: people in the organisation already knew them. My task, I realised, was to liberate them. It was the same people in the failing organisation and the newly successful one.”

It was a pattern he saw repeated in several trusts in his role turning around failing organisations throughout the country.

Good, not best

On the quality of leadership currently in the NHS, Filochowski said that it was probably as capable as in any other sector. This links with a point about the audience for his book – not the exceptional, awe-inspiring managers, but simply those who are capable and decent  and want to sustain that. This is also the majority of people working in management.

He said: “I’m a great believer that the right aspiration for a manager is to be good, not the best. So many management books are about being outstanding and actually mislead people from what is the mainstream case.

“Actually the best thing to assure yourself is that you’re doing well, that you’re doing good work. There’s something much more fundamental about good management.”

The book describes challenges that can be solved if they are recognised and honestly acknowledged. Filochowski concluded: “If you accept what you’ve got and really dig into it, you will – generally speaking – find ways through it.”

‘Too Good to Fail’ has been shortlisted for the Practical Manager category of the Chartered Management Institute’s Management Book of the Year competition: www.managementbookoftheyear.org.uk. The award, held in association with the British Library, aims to celebrate the best of management books published or distributed in the UK.

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