High Performing Teams

High Performance with Massive Heart

I strongly believe that the ability to develop, support and empower high performing teams is fundamental to organisational success. The art and science of high performance at team level is part of Massive Heart Consulting’s key offering to client organisations. We understand the theory but, more importantly we have spent many years doing this. Our learning, training and insights are now available to consulting clients. I have had the privilege of leading several high performing teams. This article will look at some of the theory but will also give personal reflections.

More Gardening than Sport

I love sport and consequently have a natural inclination to use examples drawn from sport in terms of high performance. Whilst I hope readers will indulge me a little with this preference, I would like to suggest that the development of high performing teams is better described in a gardening metaphor. Teams need to be nurtured, their leaders need to tend, encourage, and develop them. They need to be “planted” in fertile organisational soil.

This means that merely pulling together a bunch of talented people, setting them a task and expecting high performance is naïve. Teams need leadership and need particular types of leadership. They need to be effectively coached, supported, focused, and protected to do their best work. High performance cannot be built by following a recipe, neither will it evolve in keeping with a magnificent garden it needs to be nurtured.

Indulge Me in a Sporting Example

The best description of a high performing team that I have read does come from a sporting background. David Kirk, who captained the New Zealand All Black Rugby team in the late 1980s and later worked for Mckinsey, writes eloquently about his experience of leading high performance, world class, rugby teams (David Kirk). He draws the distinction between “good” and “world class”. In doing so he identifies some key attributes. World Class team members have a compelling common vision, are consummate in what they do as individuals, are forever seeking improvement, are diverse and can manage internal team tensions. From the outside they deliver consistently with apparent ease and enjoyment. A type of collective “flow state”

High Performance Built by Master Craftsmen

Articles about high performance tend to describe attributes observed in high performance. There are many entitled the “X” (insert a number of your choosing) features of high performing teams. These are useful primers but, in my view, oversimplify the nurturing process that develops and maintains high performance. They almost suggest that a team can be built in the same way as a piece of flat pack furniture. In reality, they are more like fine furniture than self-assembly bookcases. Leaders must be time served master craftsmen. This is not just my opinion, David Hanna in his book “Designing Organisations for High Performance”[1] comments “developing high performance is not a quick fix activity”.

A Compelling Shared Vision

The literature on high performance is consistently supportive of the idea that a high performing team will have a shared vision. This is not just a “nice to do” or a “direction of travel” it is for the team a raison d’être. It may transcend the goals of the organisation, for example, a world class clinicals safety team in a software company may be focused on the patient whose care will be supported by the software not just providing safety assurance of the product. High quality work matters to team members, and they believe that their work matters within the business sector in which they work.

Focus on Continuous Improvement and Learning

High performing teams are also focused on continuous improvement in what they do, they are individually and collectively reflective with respect to their performance and potential improvements. Moreover, they understand that what has worked well historically may need to be adapted or even radically overhauled in the future. Key to the team function is a focus on the vision and the performance, they are not wedded to a methodology. Indeed, they seek to learn from others, from experience and through study.

Psychological Safety

Team members have strong psychological safety, they know that they have the support of their colleagues, their leader and that they are respected within the wider organisation and its stakeholders.

Diversity

High performance is boosted by diversity “The gains from diversity in the workplace are not just moral. Top quartile companies for diversity are more likely to financially outperform industry medians.”  Says Stephen Cappello, Senior Manager of Psychology, Thomas International drawing upon research by McKinsey (diversity and performance). The ability of teams to embrace diversity is indicative of their ability to supercharge their performance.

Leading

Leading high performance is highly rewarding but challenging. As a leader one must gain the confidence of the team, manage the organisational system in which the team is working to provide “air cover” and deliver resources. There is an art as to when to step up, for example in conversations with customers and when to allow empowered team members to manage situations. Leaders will generally coach, support, advocate and manage boundaries with the odd interjection to refocus or make a minor course adjustment. Above all leaders need to be credible, do their jobs exceptionally and deliver for the team. High performance leaders know their team as individuals and professionals and are supportive in both capacities. Feedback from high performing teams suggest that leaders need to be approachable, composed and value driven.

Coaching

There are 2 significant coaching contributions to high performing teams. Firstly, to support the leader as a gardener, nurturing the team and either building or sustaining its performance sometimes within an environment that it volatile, uncertain, complex, and ambiguous, often summarised as VUCA.

The second coaching intervention can be at team level, harnessing the team’s determination for constant never-ending improvement and the requirement for renewal and redesign to perform excellently within changing environments. Coaching sessions at a team level must be consensual with the external coach invited in to support the team in their quest for continued high performance. It cannot be imposed.

What are the symptoms?

Whilst it is likely that turnover within high performing teams will be low, new team members will be required at times to support the replacement of team members and to expand the team. New members will be welcomed, inducted, mentored, and supported as they become fully fledged team members.

The team will have confidence in their ability to deliver, stepping up to meet newly imposed deadlines or to address remedial issues within the organisation. Team members may be vociferous about the situation and clearly make their concerns known but will then “do the necessary”.

Within high performing teams, members will collaborate without direction to get work done to the required excellence.

Team members will present new ideas or study topics at meetings to ensure that the team continues to learn. What will their job look like in a year? In five years? With the fast-paced development of AI?

Fertile Organisations for High Performing Teams

Securing the soil to nurture and maintain high performance is partly the responsibility of the team leader. That said, there are wider responsibilities within the organisation and particularly its senior leadership. This is a key factor within high performance and was recognised by Tannenbaum as oneof the 7Cs of team effectiveness.[2] Teams and their outputs must be valued by the higher echelons of their organisation. This must be done explicitly. Ultimately high performance will flounder if the seed of that performance consistently fall on stony ground.

What I don’t agree with

Some literature strays into the territory of reporting structures and locations.

There is a suggestion that teams need to be co-located to achieve excellence. Whilst it is certainly true that a high performing football or basketball team need to play at the same stadium, I do not believe that this is a wider precondition for high performance. Having led global teams distributed across time zones, I do believe that high performance can be secured by dispersed teams. The ability of high performing teams to deliver is, at least in part, a function of their communication within the team whether this is face to face or virtual.

I also strongly believe that teams do not necessarily need common line reporting. Given the compelling vision and the correct leadership, a team can form focused on a project and deliver high performance.

So, What Next?

If you are interested in conversations about high performance, then Massive Heart Consulting may warrant your consideration. We are passionate about high performance and can give you, your leaders and your teams insights into both the theory and the practice. In the meantime, as you plant your cabbages, broccoli and cauliflowers[3] think about your role as a cultivator of high performance

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[1] Hanna David P Designing Organisations for High Performance Addison Wesley Series on organisational development ISBN0-201-12693-1

[2] Tannenbaum,S.I. & Salas, E. (2020). Teams that work : the seven drivers of team effectiveness. Oxford University Press.

[3] Royal Horticultural Society Jobs to do in March  Things to plant in March

Move Over Dr Finlay. The Future may be Dr FinlAI- or is it?

Remembering Dr Finlay

Whilst the famous Dr Finlay’s case book television programmes may be receding into the midst of time, the character has become a model for the “ideal GP”.

Invented by A J Cronin the initial TV series was screened between 1962 and 1971,

Dr Finlay is a general physician beginning his practice in the fictional Scottish town of Levenford. Initially his career would have been before the NHS was founded. In the stories he is charming and becomes well-acquainted with his patients over many years. It is thus his trademark to know them from birth to death and so provide a continuous relationship.

The main characters were Dr. Finlay, the junior partner in the practice, played by Bill Simpson, Dr. Cameron, the craggy senior partner, played by Andrew Cruickshank and Janet, their unflappable housekeeper and receptionist at Arden House, played by Barbara Mullen. The impact of the programme was such that it is reported that Cruickshank was invited to speak to the BMA’s annual dinner. Additionally, a song entitled Dr Finlay, sung by Andy Stewart enjoyed a position in the UK charts for 5 weeks!

Impact, Evidence and Concern

The series was set in the 1930s but it is noticeable that, even when it screened in the 1960s, GPs were expressing concern about it raising unrealistic expectations from patients. Its impact had considerable traction as, even in 2011, 30 years after the last episode was screened, the Daily Telegraph ran a headline reading ‘Farewell Dr Finlay: patients think GPs are rude and rich’, (The Telegraph, 5^th December 2011)!

Despite all the developments in medicine since the programme was set, the values of continuity of care and access to general practitioners still resonate with patients. They want to see a GP quickly when they perceive this is necessary but also to establish an ongoing relationship with a trusted GP. It is not just about the patient’s perceptions of care though. The Nuffield Trust’s publication from 2018[1]  sets out the benefits of continuity including outcomes, patient experience, and costs of care from continuity of care.

The Modern Dr Finlay

Delivery of the apparent nirvana where patients have instant access to “their doctor” is challenging. Let’s look at the “Dr Finlay comparators” to illustrate this:

• The average life expectancy has increased by around 20 years since Dr Finlay’s time in Levenford[2]
• Healthy life expectancy has also increased over time, but not as much as life expectancy, so more years are spent in poor health. Whilst Dr Finlay would have been focused on Scottish data, it is telling that, although a male in England could expect to live 79.4 years in 2018–20, his average healthy life expectancy was only 63.1 years – ie, he would have spent 16.3 of those years (20 per cent) in ‘not good’ health. In 2018–20 a female in England could expect to live 83.1 years, of which 19.3 years (23 per cent) would have been spent in ‘not good’ health.[3] And although females live an average of 3.7 years longer than males, most of that time (3 years) is spent in poor health. Dr Finlay is busy providing care to an expanded cohort of older patients with health challenges.
• The modern-day Dr Finlay will be providing many more preventative care interventions. These may include statin medications, anticoagulants, ACE inhibitors and betablockers. All of these have an evidence-based rationale for prevention but require monitoring with periodic blood tests, consultations and managing possible side effects or patient concerns about the latest newspaper headline.
• Whereas the original Dr Finlay would have seen a much higher proportion of his population smoking (82% of men and 41% of women in 1948)[4], modern Dr Finlay would see less smokers but much more significant obesity. Almost 75% of people aged 45–74 in the UK are living with overweight or obesity as well as over 20% of children before they leave primary school. There are also significant health inequalities in that those from lower income areas are significantly more likely to be living with obesity than those from more affluent areas.[5]
• Since the programme screened in the early 1960s, the number of GPs per 2000 head of populations has increased only slightly. Whilst the NHS has seen an increase in doctors from its inception in 1948 from 1.4 per 2,000 to 5.1 per 2,000, the GP numbers suggest that, since 1961 the number of GPs has only increased from one per 2000 to 1.6 per 2000 despite the increased workload.[6]
• In 2023, the current Dr Finlay is more likely to be a female, salaried GP working either within a portfolio career or working part time[7]. She may have strongly considered a career in hospital medicine before electing to pursue life as a GP.
• Her practice may well have GP vacancies[8], A Pulse survey in 2023 suggested that nearly one in five GP positions in the UK are unfilled according to a Pulse survey, the highest since the data has been collected.  Of the total number of GPs needed, 18.5% of positions were unfilled. Only one in 10 vacancies are currently being advertised, with GPs saying they had given up trying to recruit the remaining 8.5% of vacancies. Two thirds – 66% of practices – said they would hire at least one more GP if there were no problems in recruiting, while 32% said they would hire at least two more. [9]
• She faces increasing workload year on year[10]
• Whilst recognising that she needs a multi-disciplinary team and appropriate premises for modern general practice, she may have some challenges in securing resources for that[11]

The Finlay Manifesto

As a GP, I believe strongly that patients and the wider health systems needs an effective model of general practice. I think the evidence supports this. It cannot, however, be a “one size fits all” model as there are strong variations in practice populations and geographical locations.

The future of General Practice should be a priority. A resilient, effective general practice model will provide accessible, cost-effective care for patients with the potential to ameliorate the increases in demand upon hospital care.

Workforce is the single most important element of realising this approach and will require.

• System respect for clinicians working within primary care settings.
• Effective models of contracting for healthcare provision which secure high-quality services but which support those working within the service and the organisations responsible for delivering the services.
• Great training experiences which excite clinicians to pursue a career in primary care.
• New models of multidisciplinary care which provide safe, accessible, high quality of patient care whilst delivering sustainable services.
• Technology enabled clinicians and organisations using technical solutions that support effective care which is coordinated across practice teams and wider primary healthcare teams.
• A focus on developing continuity at a practice or organisation level which becomes part of patient’s “felt experience” of using services repeatedly. In most instances continuity as per the good Dr Finlay is not achievable.

We cannot have a single model for providing and commissioning services. When I first started practising, there was an initiative called Community Orientate Primary Care which advocated practices actively recognising local needs and developing services to respond to them. Health Visitors were seen as potential public health nurses who could drive some of the local need assessments and work as part of the primary healthcare team to develop appropriate service responses. Empowering primary care to develop services that meet local needs.

The Future Dr FinlAI

So how can technology support future models? My assertion is that this is through empowering clinicians rather than replacing or dictating care.

We must recognise the value of human interactions in securing holistic care that considers the physical, psychological, and social elements of a person’s condition and to effectively co-design care with our patients.

At present, primary care systems provide a range of alerts to clinicians, proposing potential interventions, providing alerts, identifying potential gaps in care, and suggesting opportunities to use more cost-effective medication. When in clinical practice, I find these computer interventions to be frequently ill timed within the workflow with the effect that I must cancel, check whether the alert is relevant and then restart, simmering with outrage. Alerting is also unsophisticated, raising a flag abut a drug whether it is relevant to that patient. In addition to poor calibration and timing, alerts are often frankly rude, documenting in the records that the awful Dr Lee had ignored the computer’s advice. All of this must improve as we move forward.

There is no doubt that Artificial Intelligence will have the ability to deliver more sophisticated assistance but must be developed and deployed to meet specific pain points. In a world, for example, where specialist services are increasingly demanding templated referrals rather than elegant “Dear Dr……… Kind Regards” approaches, systems could do a lot more to support GPs navigate the local system.

Decision support will also need to evolve to help GPs and other clinicians have the complex discussions required by patients with multimorbidity. I have previously blogged on this (multimorbidity). But effective technology support for these discussions and the ability to document the outcome of these discussions in a system wide care plan will, I believe, become essential.

Patient engagement in their care is also an important element of future general practice. How can we activate patients to become active in their care. Submitting their home readings directly into their records, adding to their care plans and reviewing their records? I am sure that this will substantially improve the safety of care and personalise the way in which care is delivered. There will, no doubt, be some technophobic objections but I am personally struck by the fact that nearly all telephone consultations are done to mobile numbers and digital confidence is clearly growing,

Healthcare data has the potential to move us towards better bespoke care for individual people, improved care for cohorts and better service planning at a system level. For people with complex needs, we can use interoperability and coordination to help provide a concierge service to navigate the healthcare system, potentially reducing admissions, improving care experiences, and improving outcomes.

I personally feel that the future of primary care will see significant technological developments which support better care. I feel that the future Dr FinlAI will still be a human who is technologically supported to provide and participated in excellent care but in turn will bring their very important interpersonal skills and “gut feelings” to brilliant care.

It may be that Dr Finlay of Levenford might thoroughly approve of the care delivered by Dr FinlAI.

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[1] https://www.nuffieldtrust.org.uk/sites/default/files/2018-11/improving-access-and-continuity-in-general-practice-summary-final.pdf

[2] https://www.statista.com/statistics/1040159/life-expectancy-united-kingdom-all-time/

[3] What Is Happening to Life Expectancy in England? | The King’s Fund 2022

[4] https://ash.org.uk/uploads/Smoking-Statistics-Fact-Sheet.pdf?v=1697728811

[5] https://www.rcplondon.ac.uk/news/world-obesity-day-let-s-talk-about-drugs

[6] https://www.nuffieldtrust.org.uk/resource/the-nhs-workforce-in-numbers#toc-header-6

[7] https://assets.publishing.service.gov.uk/media/5a7ff981ed915d74e33f7b37/CfWI_GP_in-depth_review.pdf

[8] https://assets.publishing.service.gov.uk/media/5a7ff981ed915d74e33f7b37/CfWI_GP_in-depth_review.pdf

[9] https://www.pulsetoday.co.uk/news/breaking-news/one-in-five-gp-positions-unfilled-as-vacancy-rates-reach-record-levels/

[10] https://www.rcgp.org.uk/getmedia/3613990d-2da8-458a-b812-ed2cf6d600a6/RCGP-Brief_GP-Shortages-in-England.pdf

[11] https://www.rcgp.org.uk/getmedia/3613990d-2da8-458a-b812-ed2cf6d600a6/RCGP-Brief_GP-Shortages-in-England.pdf