Control Versus Autonomy – Seeking the Balance
Blog 4 in the Quality Matters: From Insight to Impact series

Quality Improvement (QI) is critical to delivering on the NHS Plan. This series of articles from Associate Directors, Ian and Laura, provides a personal and practical insight into how QI is needed more than ever.

Veran Patel, Director, Health & Social Care

Serving almost 20 years as an Army officer, I experienced a culture shock joining the NHS. My first two interviews were unsuccessful, apparently giving below par answers to a similar question in each. The first asked, “how could someone from such a hierarchical environment as the Army, possibly succeed in the NHS?”.  The second, “when have you used empowerment to your advantage?”.

I would love to go back and answer those differently! To the first I would say, “the NHS is far more hierarchical than the Army, so I will get on just fine… but why is the NHS so hierarchical?”.  To the second, “are you implying it is unusual to be empowered, or unusual for it to be an advantage?”.  I know, my answers are still not ‘job winners’ but I would love the discussion that might ensue.

In my first NHS roles I sat down with curious Executive Directors and senior OD professionals interested in learning about military leadership and decision-making.  I recall:

  • drawing inverted organisation charts, emphasising a military leader sets direction, has others come up with a plan, then supports them to realise it; they don’t tell people what to do and how to do it.
  • holding education sessions on universal military decision-making and planning processes, starting with Eisenhower’s quote that ‘plans are useless’. I’m guessing that bit wasn’t heard.
  • being asked, “how do senior military leaders find time to lead?” to which I observed that, in my experience, “NHS senior leaders are first to work and last to leave – in the military it is other way around”.
  • sitting in a covid strategy cell some years later observing similar discussions between a clutch of senior NHS and military leaders.

Is it pointless examining further then? Well, maybe not, thanks to a 2 x 2 matrix I picked up in 2009 from a company called Stanton-Marris, as part of the NHS Academy of Large Scale Change.  I have found it very useful myself and have shared it a number of times with organisations wishing to develop an improvement culture and consider leadership behaviour within that.

The matrix plots ‘Level of Direction and Control’ against ‘Level of Autonomy’ and assigns a likely resultant organisation environment to each quadrant:  INERT, COMPLIANT, CHAOTIC, PURPOSEFUL.  What has been most interesting is asking people at different leadership levels to plot where they consider their organisation lies, using this as a starting point for further conversation.  People have found it quite fascinating and I share below a couple of ‘patterns’ we have seen with an example of each.

Pattern 1

In one example the most senior people considered the organisation CHAOTIC, with too much autonomy delegated to operating divisions and services; it was felt people were making unilateral decisions, perhaps against organisational strategy, and there was a need to ‘clip wings’ and exert control.

Only a layer or two down the hierarchy, people were saying the opposite, it was COMPLIANT; they talked of an erosion of autonomy with more and more decisions requiring approval, for more and more trivial matters, and an increasing fog of governance.

A new situation then started to emerge, a shift towards INERT.  With more decisions requiring approval from relatively few senior leaders, delays to decision-making became commonplace.

Senior leaders complained of more diary time booked out to meetings. A study showed one director had 150% of time booked to meetings in a 3-month period, attending half and rarely sending a deputy; decisions were rolled-over and over to subsequent months.  Asking operational leaders awaiting decisions, what they could do about it, one said, “I’ve had my knuckles rapped for not getting approval, now I prefer to protect my hands by sitting on them”.

The pattern started to shift towards ‘PURPOSEFUL’ when they co-produced a shared vision of a transformed future state, with new, operationally-led improvement programmes and streamlined governance.  A key conversation was the specification of roles, responsibilities and accountabilities, with criteria different when managing ‘daily operations’ than for ‘transformation activity’.

Pattern 2

In this example, people across the hierarchy considered the organisation to be COMPLIANT, which no one considered a good thing. Senior leaders wanted people to take on more responsibility and accountability and, at the layers below, people talked of wanting to be more empowered. It begged the question, “why has it not happened then?”  Perhaps this offers an explanation:

Managers said there was a difference between what senior leaders said and did, and an inconsistent approach.  When the organisation faced pressure, leaders quickly reverted to full command and control.  People felt senior leaders were quick to attach blame and some managers had been seen to suffer.

Senior leaders said there was reluctance of managers to take decisions and be accountable; affirmed by one manager who said, “you cannot be sacked for not making a decision, so I don’t”. But we mostly heard people say that working in a compliant organisation was all they had known, so it was hard to shift mindset. They talked of needing better development.

The pattern here started to shift towards PURPOSEFUL when a limited level of greater autonomy was delegated for quality improvement activity.  Specifically, for improving daily operations by ‘making work easier to do’.  People who do the work know best how to improve it so delegating this is a ‘no brainer’. Those same people might already suffer at the hands of poor systems and process and having the opportunity to make their working lives easier is likely to be accepted and well-received.  Not only that, this aligns perfectly with big ticket, strategic objectives, such as improving productivity and staff well-being.  Nothing is likely to improve productivity and staff well-being more than eradicating time-consuming work that burdens people and adds no value to patients.

I wonder what pattern might emerge in your own organisation, what conversations might ensue, and how that might help direct you to become more PURPOSEFUL.  Maybe you could try this out in your own organisation or leadership team – what might you learn?  Perhaps it could be added to your staff survey so you can see what emerges from different parts of the organisation – that might be really interesting!

Click here to read the first blog in the series – Quality Matters: From Insight to Impact; Before solving a problem, you must first understand it

Click here to read the second blog in the series – Quality Matters: From Insight to Impact 7 Traits of an Improver

Click here to read the third blog in the series – Quality Matters: From Insight to Impact – The problem with demand and capacity is that it is mostly misunderstood