‘Hierarchical trust can’t claim credit’ (letter published in The Cornishman, 19 April 2018)

We shouldn’t underplay the seriousness of the situation at Treliske revealed by the Care Quality Commission’s recent warning notice and last week’s  Cornishman, but it’s not all bad news from Treliske, as a recent report tells us.

‘In March there were significant improvements in ambulance lost time, delayed transfers of care and the provision of timely care within the Emergency Department. GPs have been working alongside their hospital colleagues; community services and social care have provided extra resources to support patients’ discharge, and improvements have been made in transport booking to support patients to be in the best place for their needs. Many staff made themselves available for extra shifts. In the lead up to Easter, Cornwall was on the lowest level of operational alert: Operational Pressure Escalation Level 1 (formerly ‘green’). Emergency Department performance has been above the national standard of 95% and local hospitals greatly reduced the number of long stay, medically fit patients. Performance on the 4 hour Emergency Access Standard was the best for any Trust in the South of England.’

Credit where credit is due! So well done everyone who helped turn things round. But now the right lessons must be learned. The chief executives are celebrating the turn-round as a triumph of their ‘Gold Command’ approach, which brought together Chief Executives, senior clinicians and operational managers from across health and social care. But it is also a triumph of ‘pitching in together’: involving GPs, who aren’t part of any hierarchy, for example, and staff making themselves available for extra shifts. These don’t come about as a result of instructions from a ‘Gold Commander’ at the top of the hierarchy. They are the result of teamwork.

In a team, the organization is relatively flat compared to the pyramid you find in most hierarchical organizations. There are different levels of seniority, but the lead in a situation is taken by whoever is best informed and most capable, not necessarily the most senior person. Communications tend to be ‘lateral’, with your ‘opposite number’, rather than ‘vertical’ (‘decisions handed down’), so they are more like consultation than command. And the incentives that motivate people – to put in extra hours, for example – stem from a community of interest rather than a contractual relationship.

There is an important lesson here. With Cornwall Council and health bodies negotiating to create an integrated, ‘strategic’ health and social care system, it is tempting for their leaders to celebrate the turn-round as a triumph of the ‘Gold Command’ way of doing things. They must not overlook the importance of creating conditions where cross-authority teams can flourish within that hierarchical structure.