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The earth from space

There is a growing focus on ‘place-based leadership’ in health and social care systems.

Place can be defined variously in terms of its geographical and demographical aspects, as well as personal identification – what place means to people – and its social and economic significance. Developing ‘place-based leadership’ also has different meanings. Some see the task as “…bringing together...clinicians and managers...from the clinical, social care and public health systems to help redesign and lead changes for a better future (for) local communities” which reflects a fairly traditional approach, where senior leaders ‘at the top’ of organisations in geographical localities define, prioritise and control resources in order to benefit citizens (who are, by definition, different from professionals). 

Alternatively, place-based leadership may be developed through encouraging leaders to “leave their lanyards at the door”: step out of their professional, organisational and hierarchical silos, build relationships, make connections and get to know the place through myriad lenses and perspectives, in order to deliver services that are aligned to the needs, wishes and ambitions of the local population who, by definition, include practitioners.

The shift towards place-based leadership generally recognises that one place is not the same as every other. Although ‘sharing of good practice’ is sometimes an attempt to codify and standardise system leadership in one place so that it can be rolled out ‘at scale and pace’ to other areas, it is, fairly well-accepted that what proves effective in Manchester may not be appropriate for Margate or Malmo and that therefore one of the tasks for leaders in complex systems of health and social care is to really understand the place in which they enact their leadership, and what it means to people.

A recent discussion with a group of clinical leaders elicited the information that none of them worked in their place of origin and many of them did not live in the area in which they practised as clinicians; they, however, observed that many of their patients lived, worked, raised families, got ill and died within a fairly short radius, and this conversation brought new insights into exploring what place means to people, and into how to connect with a local sense of place.

The place-based approach has certainly enabled different ‘voices’ to be heard in the conversations about designing new models of care and delivering better outcomes for people in their neighbourhoods, localities and systems. Place is not, however, a collectively-defined or objectively-determinable phenomenon.

Place is what we pay attention to according to Yi-Fu Tuan, and that is driven by what we deem to be important and therefore by who we are.

Likewise the phrase “knowing your place” points to the way place can very precisely determine the position a person occupies in the social hierarchy and this can be so clearly  defined through habit and practice that it is barely noticeable to local occupants of a place, although it may be obvious to ‘outsiders’.

Place can exclude, then, as well as unite. Yi-Fu Tuan notes, in his exploration of place, that to the casual visitor the limits of village domain are not evident in the landscape” and that “an awareness of other settlements and rivalry with them (can) significantly enhance the feeling of uniqueness and of identity.” (my highlighting). So attempts to foster place-based leadership may at some level serve to reinforce the boundaries between different places which get in the way of collaborative leadership. Place-based leadership could be seen as an attempt to ‘simplify the complex.’

Space is frequently cited as a key enabler of leadership across systems. At one level this can be interpreted as  a reflection of the necessity for designated space in which leaders can do the thinking – individually and collectively – they need to do, to shift from a heroic to a more distributed paradigm of leadership. Evaluations of development programmes often mention ‘space to think’ and networking as highly-valued elements of an intervention.

Similarly, there has been interest in the Swedish concept of Fika which is so culturally ingrained in Swedish organisational life as to be mandatory in some companies. Ikea, for example, states that fika is more than a coffee break…” fika is a time to share, connect and relax with colleagues. Some of the best ideas and decisions happen at fika.” Whilst there is little hard evidence of the direct impact of fika on innovation or on GDP, Sweden is noticeably higher on most indices of productivity than the UK, which has largely failed to value the notion of a collective break for coffee, cake and conversation among colleagues.

But there are also less literal meanings attached to space, and ones which may be helpful when considering the importance of space to systems leadership.

Think, for example, of the first astronauts on the moon. The picture that is most often shared of those early lunar explorations is not, in fact, of the moon but of the Earth. In other words, the unintended consequence of going into space was the opportunity to get a different perspective on our own planet.

Space-based leadership, then, can be understood as ‘looking outwards in order to look inward’.

It is about paying attention to the connections between people (and not just to the people themselves), to the liminal spaces where systems work is often carried out – the corridors, car parks and canteens – and to the locational aspects of leadership which are not bound by geography, experience or personal characteristics. Stepping into space means stepping into the unknown, letting go of certainties, moving into uncharted territory and therefore a potentially alarming and risky undertaking.

How leaders might undertake space-based leadership in order to deliver change in systems of health and social care is the subject of the next blog.

Belinda Weir
Lead for Systems Leadership, Centre for Health and Social Care Leadership, University of Birmingham
Director of Leadership and Senior Lecturer, Health Service Management Centre, University of Birmingham