Posted on: 5 January 2023

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I’m Gareth, I’m writing to you every couple of weeks about ‘dialogical practice’ and my learning over the years about the Open Dialogue approach to mental healthcare; something we're starting to adopt here in CNWL.

If you want to catch up on any of my previous blogs, please scroll to the bottom of this page.

To all CWNL staff, have you visited our Open Dialogue Trustnet page yet?

Open Dialogue: CNWL Extranet

This page has a lot more information about Open Dialogue including podcast episodes and links to further discussion.

Leading Dialogically

It’s been far too long since I last wrote to you all so apologies for my silence these last few weeks. I found myself overwhelmed by requests for response to winter pressures planning. I have been so impressed by how many people have rallied around when we have needed them to, to help our service users as well as the patients in the wider NHS. We’ve had to undertake some very rapid changes to a number of services, some where they have had to bear great inconvenience and uncertainty to help out patients and services that are not ‘their own’. 

I have found myself pondering how difficult it can be to get change to happen in the NHS in such circumstances. To plan and sustain much needed long-term improvements to the way we train and support our staff can feel thwarted by the waves of urgent demands that sweep through the system. Those waves seem to be coming more frequently over recent years. To reference the old Chinese curse, it can certainly feel like we are living through “interesting times”. 

I am aware of how much frustration and anger this has left many of us holding. I have heard how annoyed people feel by the pace of some changes and how little they have been heard or included in shaping much of that. 

Those of you who regularly read my blog know I am interested in how we bring dialogical ideas in to our clinical practice, but I’m also interested in how those could influence and change our leadership culture in CNWL and more widely in the NHS. I have often found it challenging to hold on to my own principles around “nothing about us without us” when decisions need to be made quickly to keep people and systems safe. But then isn’t that the same conundrum and dynamics that have taken clinical care to where it is today?

A few weeks ago, our Open Dialogue trainees in the Trust gathered to reflect on what they had learned and experienced since their first week on the training. There were some beautiful moments of connection through the morning. I saw colleagues who had known each other for many years, but always kept each other at a distance, finally make meaningful connection. It moved most people in the room to tears, including myself. I do think there is hope to be found in having the opportunity to better hear and understand how each other feels.

In another space we trialled some Open Dialogue techniques to help facilitate conversations in ‘line management’ catch ups:

  • Firstly, space was given for each team member to say how things were
  • Then the ‘managers’ had an open reflecting conversation about what they had heard in front of the team
  • The team then responded to those reflections

I was really pleased with how well these were received and the positive feedback we got about the experience. It seems entirely logical to me that if these techniques are helpful for those we try to help with their mental health problems and in team intervision, then they will also have a place in supporting leadership conversations. The fact is that most of our leadership in the NHS is a team exercise, often with multiple leaders holding shared responsibility for many issues and people. Such a complex system needs systemic thinking and techniques to support it. For me, Open Dialogue really helps with unlocking some of this. 

For my part, I wish I had more time to connect with all of you. The dilemma I often find myself facing is that there are enormous numbers of priorities that fly across my desk and thousands of mental health staff. However, I feel that is no excuse; it is no different to the pressures you all face every day in your busy jobs. If I would like you all to slow down the process and focus on meaningful connection with those we are trying to help then that same standard needs to be applied to how we lead and support you all. Unfortunately, nobody has written the Dialogical Leadership Manual yet; I will need you all to help us with that!

Having spent the last few years making my way in to Leadership and Management in the NHS, I have thought more on the large number of complex ‘rules’ that govern NHS Trusts: Policies, Guidelines, scrutiny from external bodies (CQC, Royal Colleges, Coroners). There are also long legacies of management styles that would take an archaeologist to properly trace. 

Much of what we do in the NHS can often be tracked back to that fateful phrase “we’ve always done it that way”. I can find myself in many dilemmas of not knowing when it’s ok to do things in the way my gut is telling me to act, or to wait and take advice from more senior colleagues. I reflect on this because I know it’s no different for most of you day in and day out in the clinical sphere. What a dilemma for trying to change the way we do things! when do we keep doing what we’ve always done, and when do we try something new?!

I have often returned in my thoughts to a quote by Niccolo Machiavelli:

It ought to be remembered that there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new. This coolness arises partly from fear of opponents, who have the laws on their side, and partly from the incredulity of men, who do not readily believe in new things until they have had a long experience of them.”

He wrote that 500 years ago, so maybe none of this is so new after all…

I am very grateful for how hard you have all worked this last year.  I have loved having all your feedback to the blog. I am still collecting questions for a Q&A edition, so please do send them in to me. 

Moving forward, we will have a new look to the blog and some guest contributors throughout 2023!

You can write to me at: Gareth.jarvis@nhs.net