One of the trickiest challenges in management is getting people to work together effectively across professional, organisational and hierarchical boundaries. And that makes Malcolm Wright’s job one of the toughest healthcare leadership roles in the UK.

As the Scottish Government’s director-general for health and social care, and chief executive of NHS Scotland, Wright handles the full range of policy, organisational and service delivery issues—unlike in England, where these briefs are split between the departmental permanent secretary and the head of NHS England. And Wright’s priorities have been defined by Scotland’s energetic promotion of cross-cutting agendas, including the government’s flagship integration of health and social care; closer collaboration between primary and secondary providers; better partnership working between managers and clinicians; stronger relationships between senior leaders and unions; and, at local level, the involvement of health and care providers in community-led planning forums.

At least, he reflects, he’s not trying to do all this in England, where trusts’ governance and business models set them up to compete rather than co-operate. “Having worked at an [English] NHS trust and seen the unintended consequences of competition, I would wholeheartedly advocate a collaborative model rather than a competitive model,” he says. South of the border, he believes, we’ve seen a “fragmentation of systems and services”. But “at its heart, healthcare is a team game. Our clinicians are trained to work in teams of professionals. If you split them up across organisational boundaries and get them to compete with one another, I don’t think you get the best outcomes for patients.”

Scotland’s health system has long been more cohesive than England’s: primary and secondary care are managed together by regional health boards, with specialised services provided by a handful of national bodies. But the government’s agenda means reaching across a new set of boundaries to integrate care with local authorities, other providers and local communities. Wright brings long experience of NHS management: he’s been a chief executive for 25 years, running hospitals, trusts and boards. And his broad remit, he says, provides “an opportunity to work really closely with ministers, other directors-general, board chief executives and local authorities. Collaboration across government needs that policy sign-up, and this is a unique role with the potential to make things work even better.”

They will certainly need to work even better: Scotland has an ageing population with rising rates of multiple morbidity, plus patches of severe deprivation and many isolated, rural communities. Financial and staffing resources are always thin and, Wright notes, “there’s a number of things that are potentially going to happen—not least Brexit and [its impact on] the availability of staff from the European Union, whom we hugely value—which will make things more challenging”. Caught between rising demand and tight budgets, the Scottish Government has embraced integration as its way out of the trap—shifting resources towards community-based and preventive care, in a bid to relieve pressure on acute and emergency services.

Above all, this means bringing together health and social care. Since 2016 social, primary and community healthcare, along with unscheduled adult hospital services, have been overseen at the local authority level by 32 new ‘integration authorities’ (IAs). Some of these also cover social work, children’s services and all acute hospital provision. Success, says Wright, will depend on “the relationships we have: how the chief officers of integration joint boards work with their counterparts in the health board and local authority, how we work with the third sector, and how health services and local authorities are working together. When those relationships are right… we can get some remarkable results.”

Inevitably, getting those relationships right has not been straightforward. Last autumn, a report by Audit Scotland found weaknesses in strategic planning and collaborative leadership, highlighting “disagreement over governance arrangements” and noting that “all partners need to be signed up to, and engaged with, the reforms.”

Equally inevitably, these tensions are highest when the conversation turns to who’s paying for what. “Financial planning is not integrated, long-term or focused on providing the best outcomes,” said Audit Scotland, adding that financial pressures “make it difficult for IAs to achieve meaningful change”. Last year, the IAs were asked to find £215m in savings.

The government is addressing Audit Scotland’s concerns, Wright says, through a national review of integration carried out in February. He acknowledges the need to ease financial wrangling at the IA level, noting that health and care cabinet secretary Jeane Freeman and Stuart Currie, the local authorities’ health and care lead, now oversee a national body looking “at very practical things, like making sure that integration authorities have a transparent reserves policy; that the money is there on the table; that all three partners know how it’s being spent; and that where the integration authority runs into any financial difficulty, the partners come together to work on those things.

“There’s a spectrum of some areas doing really well and some that are struggling a bit,” he adds. “But we’ve got the structures in place, and I see significant signs of progress.” He cites the ‘hospital at home’ schemes in Lanarkshire and Aberdeenshire, and the Scottish Ambulance Service’s work to divert patients from A&E: “There are lots of examples where this stuff is happening today; our ambition is to see that develop across Scotland.”

But IAs are just one item on Scotland’s multi-faceted integration agenda. Local authorities and health services are also involved in ‘community planning partnerships’ (CPPs), which Wright says are built around “a principle of place: how you work in a particular community to bring together statutory services and third sector organisations”, building service delivery models that respond to the needs of individual communities. “If we involve communities in the changes that affect them, we’re more likely to get better, well-informed outcomes than if we impose a grand plan on people,” he comments.

Here too, Audit Scotland has its doubts, explaining in a summer 2018 report that CPPs are struggling for attention in an “increasingly complex landscape of public service reform”, and pointing to tensions between national targets and the goal of allowing communities to shape their own services. “Some short-term national performance targets are making it difficult to reform services to deliver more preventive service models,” the report said.

“We’ve got a number of good examples around the country where we’re bringing GPs and secondary care clinicians together to design pathways of care that work across the piece.”

On CPPs, Wright gives less ground—arguing that partnerships can meet their national targets even while building services around local needs. “The health service has got a set of indicators, and they’re not necessarily at variance with what other partners need to do,” he says. “It’s not an either/or, it’s a both/and.”

Not every field of integration is as complex: primary and secondary care, for example, enjoy unified governance and budgetary structures. “We’ve got a number of good examples around the country where we’re bringing GPs and secondary care clinicians together to design pathways of care that work across the piece,” he says.

Even in relatively straightforward environments, though, managing integration demands a specific set of skills. Wright draws a “distinction between organisational leaders and system leaders,” noting that health board chief executives must—for example—“be able to run that health board—to get the governance, the management systems, the culture and leadership in place—but they’ve also got important roles to play with their local authority chief executives, third sector partners, and the police and fire and ambulance and all the rest. So these are very complex roles.

“What we value in our leaders now is people who’ll lead collaboratively across the system,” he adds, signalling a shift away from “the kind of competitive organisational behaviours that we maybe saw previously”. Supporting this change, the government’s dedicated professional development scheme, ‘Project Lift’, aims to shape the next generation of leaders and managers, equipping them “not just to run their own bits of the organisation, but as system leaders with a much broader view of what public service in Scotland looks like”.

Health and care managers must also focus on developing and strengthening their relationships with staff, Wright says. “I know from personal experience of working with the staff side that when you get into really hard, difficult positions, working with your trade union colleagues is really, really important,” he argues. “If you involve staff in decisions that affect them, you’ll get much better outcomes than if you try to impose things top-down.”

Another key goal for managers, he adds, is to ensure staff “relate to each other with dignity and respect.” Following the publication of John Sturrock’s report into the culture of bullying at NHS Highland in May, he says, the government will appoint a national, independent whistleblowing champion and each NHS board will designate a non-executive director to take specific responsibility for whistleblowing. Here—for once—Scotland appears to have learned from the English system, where in 2016 Henrietta Hughes was appointed as the NHS National Guardian.

Finally, says Wright, managers must work closely with their clinician colleagues. “I very much support the development of professional management that can sit alongside clinical leads, and the notion of clinically-led, managerially-enabled services,” he says. Managers’ understanding of system leadership must be aligned with clinicians’ expertise in providing care, he argues, with both sides collaborating “in a climate of mutual trust, respect and accountability.”

After all, he adds, “we’re only going to get the outcomes we need if managers and clinicians stand side-by-side to address the challenges.” And this, too, depends on strong leadership from the top, requiring senior managers who “value clinical leadership, and proactively encourage managers and clinicians to work together.”

Asked about the way health managers are viewed in the public debate, Wright says he

thinks “the narrative is better in Scotland” than in England—particularly around that intersection between managers and senior clinicians. “Actually, working relationships are pretty good on the whole, and I think there is a valuing in Scotland of system leadership,” he says. “I think there’s much more of a culture in Scotland where we need and value good management, just as we need and value good clinical leadership.”

So Scotland’s health and care managers face a testing period. Both IAs and CPPs require a fresh approach to joint working and service delivery. Reforms will demand strong partnerships with unions, plus good collaboration between managers and clinicians. Cultural issues are key to bearing down on bullying. And the challenges of tight finances and Brexit are unlikely to go away any time soon.

What advice can Wright offer on the skills and style managers will need to face those challenges? “My advice would be: don’t neglect your personal professional development,” he replies. “Make sure you’re learning not only hard-edged professional skills, but also inter-relational skills; and that you can think system as well as organisation.

“The evidence suggests that we get better outcomes for patients on a collaborative model rather than a competitive one,” he concludes. “I think this is a distinctive approach vis-à-vis the NHS in England, and I think it’s one that produces a set of results that maybe we don’t see in other parts of the UK. At every stage along the way, we’re emphasising to all leaders of public services in Scotland that organisational leadership and system leadership go hand in hand.”