En gendering leadership

‘Your Money or Your Life’:
en-gendering leadership
Philip Boxer BSc MBA PhD
OPUS Conference 2018
November 15th
1. The Case
2. Symptoms of Maladaptation
3. The view from NHS England
4. The citizen-patient as boundary object
5. The relation to ‘lack’ aka incompleteness
6. In Conclusion – how hard can that be?
1
Commons Copyright © Philip Boxer 2018 – Attribution-ShareAlike

The Case
2

Context to the case
• A Clinical Commissioning Group (CCG) within the UK’s National Health Service
(NHS).
• My client had been employed by the CCG to focus on particular health
conditions with the goal of delivering improvements in quality, innovation,
productivity and prevention (QIPP).
• My client reported directly to the Deputy Director of Commissioning (DDoC),
who reported to the CCG’s General-Practitioner-led Board.
3
• To be effective, my client
• had to work in support of the Clinical Leads working on behalf of the Primary Care
GPs for the particular conditions being focused on by the CCG.
• also had to work within the constraints imposed by the CCG’s Head of Information
(HoI) who reported through a Chief Financial Officer to NHS England and who was
also Head of the Programme Management Office (PMO), which tracked delivery of
the CCG’s 5 year Strategic Plan.

The demand arising from patients
• The QIPP* goals for respiratory conditions had been set by comparing the
Clinical Commissioning Group’s (CCG’s) average performance with that of a
grouping of other CCGs with comparable catchment profiles.
• The goal was set by assuming that the CCG’s below-average performance could
be improved to the average.
4
• At his job interview, my client had described an approach to QIPP that involved
• stratifying patients’ conditions, ranging from simple to complex; and
• examining the interactions of the healthcare ecosystem with an individual patient
over time.
• The Deputy Director of Commissioning (DDoC) liked the approach.
* Delivering improvements in Quality, Innovation, Productivity and Prevention

The Challenge of the Case1
• Stratified Analysis of patients in terms of the complexity of their condition
• Showed that breathlessness could arise not only from respiratory conditions but
from other comorbidities such as coronary heart disease, chronic obstructive
pulmonary disease, cancer and neurological conditions.
• Showed the need to diagnose early, focus on breathlessness and manage differently
the patients identified as high users of the healthcare ecosystem.
5
• But the acute data was not organised around patient timelines, the data being
organised around treatments because of the acute system’s focus on the cost of
treatments.
• My client was able to extract data from the information systems and reorganise it by
patient timeline for the preliminary analysis.
• And the CCG’s information department, which reported to the Head of
Information (HoI), was not prepared to take responsibility for performing a
reorganisation of data in this way.

The Challenge of the Case2
• No data existed for examining the timelines of the interactions by patients with
complex conditions between the primary and acute care systems.
• each practice’s data being held in its own information silo.
6
• It was therefore proposed to do this analysis on a sample basis.
• It was proposed this be done on the outlier practice (top-right), which happened to
be the practice of the Clinical Lead for respiratory conditions.

Resistance aka conservation of identity
• At this point the Clinical Lead objected to the whole sampling approach,
• citing that GPs would be insulted by a study that sought to identify issues that they
were already aware of in their practices, and refused to sign off on the analysis.
• The Head of Information then added that the PMO would not recognise any
data analysis not done by them, having previously refused to take responsibility
for this type of analysis.
• The new Director of Commissioning (DoC), who had recently replaced the
previous DoC and who had been supportive of the sampling approach proposed
by my client, was now faced with pushback from both the PMO and the Clinical
Lead.
• She requested my client to revert to the approach that had been used prior to his
recruitment by the DDoC and complete the work in an impossibly short time.
7

The Ethical Crisis for my client
• It was as if his unconscious was demanding of his professional self: ‘are you
going to give me your money or your life?’
• Should he stay and get paid for serving his time doing an impossible task? Choosing
‘money’ would mean going along with what the CCG was demanding of him at the
cost of patients’ quality of life and devaluing his own.
• Should he try and fight with the larger system based on all the work he had done up
to that point? Choosing ‘life’ meant risking being fired by confronting the issues the
current organization was implicitly choosing not to face.
• Should he resign? Resigning meant giving up on what felt like an unequal struggle
with the powers-that-be – the resistance of the HoI/PMO and the Clinical Lead.
8
• It is possible to examine this case situation in terms of what my client might
have done ‘wrong’ in his role.
• This paper considers how my client was never going to succeed with the CCG’s
current approach to governance.
• The primary issue was not about how my client was taking up a role in the life of
the CCG, but rather how the CCG was taking up a role in the lives of the citizen-
patients for whom it had a duty of care.

Symptoms of Maladaptation
9

Maladaptation by an organization within
an ecosystem
• Monothematic dogmatism
• depth is captured once and for all. It is a superficial satisfaction of the need for
overriding values to guide behavior in turbulent environments.
• Hence, dogma becomes the normative base for distinguishing right from wrong, good
from bad, goals from noxiants.
• Polarisation
• in-group/out-group dynamics. The tendency at the group level is autonomy,
exemplified in each group's striving to become more distinct and independent from
others.
• The tendency at the individual level is a need to belong to a larger whole, satisfied through
the strong affiliation with an in-group.
• Stalemate
• the suffocation or frustration of progress, movement, growth, or development for
the whole system.
• It involves an inability to articulate, design, and, in particular, pursue sometimes even the
most mechanical ends of the whole system.
• There seems to be an obsessive concern with means at almost complete expense to
ends,
• so much so that stalemated social systems come as close to being purposeless as can be
expected from a social system
See Baburoglu, O. N. (1988). "The Vortical Environment: The Fifth in the Emery-
Trist Levels of Organizational Environments." Human Relations 41(3): 181-210. 10

The view from NHS England
11

The limitations of Primary Task
• The CCG’s primary task had been defined as being one of commissioning the
availability of a repertoire of possible services and treatments within the
healthcare ecosystem based on aggregated measures of healthcare demand
• in effect defining the catchment in terms of markets for different kinds of healthcare
treatment.
12
Clinical Commissioning Groups (CCGs) were created following the Health and Social
Care Act in 2012 and replaced Primary Care Trusts on 1 April 2013. They are clinically-
led statutory NHS bodies responsible for the planning and commissioning of health
care services for their local area.
NHS Clinical Commissioners. (2018). "About CCGs." NHS Confederation Retrieved 10/30/2018, 2018.
• Meanwhile, at the level of individual patients, the healthcare ecosystem
was needing to support many simultaneous care pathways aka networked
organisations,
• each of which needing to orchestrate and synchronise services and treatments
in different ways for different citizen-patients’ situations

The need to respond to citizen-clients
one-by-one
• The result was that the CCGs needed to respond to the nature of each person’s
condition and circumstances
• So that the CCGs could not rely on a stable definition of its primary task, but had to
continually adapt and respond to the demands and expectations being placed on
them,
13
“such as in 2014’s Leading local partnerships, […] driving new and innovative models of care by
putting the patient at the heart of the system, and improving the health and wellbeing of local
people […] in 2015 with Transforming healthcare in England’s core cities […] and in 2016 with
Delivering a healthier future […] showing how CCGs are addressing health inequalities, the
prevention agenda and striving for parity of esteem between mental and physical healthcare.”
NHS Clinical Commissioners. (2016). "The future of commissioning." Retrieved 10/30/2018, 2018.
• The resultant accelerating proliferation of primary tasks meant that in practice the
CCGs could not rely on its organisation as a whole being defined by the primary task
of commissioning for aggregated measures of healthcare demand aka healthcare
markets.
• It had to be able to commission in a way that enabled different citizen-patients
to be responded to differently through the life of their conditions one-by-one.

Source: Fig 2-1 on the Management Challenge: Systems Engineering
Guide for Systems of Systems, OSD, Version 1.0 August 2008.
A collaboration between actors aka a networked organisation
Supporting care platforms
Superposition of many
care pathways aka
networked organizations
Simultaneous
networked
organizations
Support
The CCG has to be able to
commission many different care
pathways at the same time
Responding to clients one-by-one:
each care pathway aka networked organisation defines a ‘quantum’ state of the
healthcare ecosystem*
• A networked organisation is a collaboration, the nature of which will be determined by the
way its actors understand what its patient wants, i.e. what is the patient’s demand.
• The actors participating in the networked organisation define the way they want their
collaboration to be supported by the platform.
• Its actors can be spread across multiple organizations within the healthcare ecosystem.
• For this to be possible, the supporting platforms have to be able to support multiple
simultaneous networked organisations aka ‘superposed’ collaborations.
14
* Boxer, P. J. (2014a). "Leading Organizations Without Boundaries: 'Quantum' Organization and
the Work of Making Meaning." Organizational and Social Dynamics 14(1): 130-153.

The challenge facing the CCG
• The challenge facing the CCG is thus between being an organization
• defined as a hierarchy; or
• defined by its support for many concurrent networked organizations.
15
* Boxer, P. J. (2014a). "Leading Organisations Without Boundaries: 'Quantum' Organisation and
the Work of Making Meaning." Organizational and Social Dynamics 14(1): 130-153.
“[…] traditional models of care need to change […] where some of the day-to-day
transactional elements of commissioning may transfer to what are becoming collectively
described as accountable care systems, taking direct responsibility for day-to-day care for a
defined population within an area […] in the future, […] it should be locally defined and
driven..” NHS Clinical Commissioners. (2016). "The future of commissioning." Retrieved 10/30/2018, 2018.
• This presents a challenge to leadership based on vertical accountability alone.
• This requires a move from unipolar to multipolar forms of governance,
• moving from a vertically-dominant form of governance defined by accountabilities to
a pre-existent model
• towards a horizontally-dominant form of governance defined by horizontal linkages
between networked organisations accountable to current local situations. e.

The citizen-patient as boundary object*
The patient’s condition constituted a boundary object because
while from the clinician’s side of the boundary, it represented a condition needing
treatment,
from the patient’s side, it was something s/he had to find ways of living with within the
context of his or her life.
16
*Akkerman, S. F. and A. Bakker (2011). "Boundary Crossing and Boundary Objects." Review of Educational Research 81(2):
132-169; Leigh-Star, S. and J. R. Griesemer (1989). "Institutional Ecology, 'Translations' and Boundary Objects: Amateurs
and Professionals in Berkeley's Museum of Vertebrate Zoology, 1907-39." Social Studies of Science 19: 387-420.
Hirschhorn, L. (2018). "Beyond BART (Boundaries, Authority, Role and Task): Creative Work and the Developmental
Project." Organisational & Social Dynamics 18(1): 41-61.
The patient as boundary object challenged the BART paradigm insofar as it took
the CCG beyond its definition of itself in terms of its primary task.

Distinguishing object-referenced from
subject-referenced meanings
• The Head of Information (HoI) was arguing that my client was using language
that had subject-referenced meanings not established by the CCG’s
accountability hierarchy, or at least not without following the forms of analysis
introduced by my client, on which they had been based.
17
meaning that can be established
independently of the speaker by
a community of listeners aka
inter-subjectively agreed
meaning that can only be
established by reference to
the speaker’s experience of
their experiencing aka vague
‘objective’ aka
independent of the
speaker because it is
as if ‘facts’ speak for
themselves
degrees of vagueness
Subject-referenced
characterising
Object-referenced
categorising invariably vague* aka
wholly dependent on
the relation to the
speaker because rooted
in the speaker’s
experiencing
* A characteristic of what is held to be acritically indubitable.
See Peirce, C. S. (1905). "Issues of Pragmaticism." The Monist XV(4): 481-499.
Boxer, P. J. (2019b). "Working with the 'irritation of doubt': the place of metaphor."
Socioanalysis submitted for publication.

Accountability hierarchy
dependent on establishing inter-subjectively agreed meanings for
signifiers
• The CCG’s accountability hierarchy (and the PMO in particular) described an
established inter-subjectively-agreed way of fixing meaning aka way of
‘organising’ signifiers with its way of referring to an object-referenced signified
18
↑
𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟
𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑
The direction of the arrow here
indicates that the signified is
subjected to the signifier*
𝐴𝑐𝑐𝑜𝑢𝑛𝑡𝑎𝑏𝑖𝑙𝑖𝑡𝑦 ℎ𝑖𝑒𝑟𝑎𝑟𝑐ℎ𝑦 𝑥 = ↓
𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔
↑
𝑤𝑎𝑦 𝑜𝑓 ′𝑟𝑒𝑎𝑑𝑖𝑛𝑔′ → 𝑡ℎ𝑒 ′𝑣𝑖𝑟𝑡𝑢𝑎𝑙′
′𝑟𝑒𝑎𝑙′ 𝑝𝑟𝑜𝑐𝑒𝑠𝑠𝑒𝑠 → 𝑡ℎ𝑒 ′𝑎𝑐𝑡𝑢𝑎𝑙′The way of ‘reading’ is
privileged
≡ ↓
↑
𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠
𝑎𝑛 𝑜𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑There has to be a
shared ‘actual’
*Based on a structuralist way of understanding the relation between signifier and signified,
see Miller, J.-A. (2011). "The Economics of Jouissance." Lacanian Ink 38 (Fall 2011): 6-63.

The presumption of an unconscious
‘below-the-surface’
with object-relations theory, the unconscious object-signifier is a way of
being in relation to a signified
• We speak of there being a fixing of libidinal investment in the sovereign ego’s
way of being in relation to a subject-referenced signified aka ‘a radically
unconscious’
19
↓
𝑎 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 ′𝑏𝑒𝑙𝑜𝑤 − 𝑡ℎ𝑒 − 𝑠𝑢𝑟𝑓𝑎𝑐𝑒′
The assumption
of an unconscious
↓
↑
𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑜𝑏𝑗𝑒𝑐𝑡 − 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠
𝑎 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑
The way of being
in relation to a
signified has an
organisation…
≡ ↓
↑
𝑠𝑜𝑣𝑒𝑟𝑒𝑖𝑔𝑛 𝑒𝑔𝑜
… which, as a
sovereign ego,
subjects the signified
Miller, J.-A. (2000). "Paradigms of Jouissance." Lacanian Ink 17: 8-47.

Unconscious valency
A ‘fit’ between the fixing of libidinal investment in the sovereign ego’s way
of being and the support provided by an accountability hierarchy
• My client was introducing a different way of ‘organising’ signifiers that had not
been inter-subjectively agreed with the HoI/PMO, albeit one that had formed
the basis of his having been recruited by the DDoC.
20
↓
𝑀𝑦 𝑐𝑙𝑖𝑒𝑛𝑡 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔
↑
𝑠𝑜𝑣𝑒𝑟𝑒𝑖𝑔𝑛 𝑒𝑔𝑜
𝑎 𝑟𝑎𝑑𝑖𝑐𝑎𝑙𝑙𝑦 𝑢𝑛𝑐𝑜𝑛𝑠𝑐𝑖𝑜𝑢𝑠
↓
Τ𝐻𝑜𝐼 𝑃𝑀𝑂 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔
↑
𝑤𝑎𝑦 𝑜𝑓 ′𝑟𝑒𝑎𝑑𝑖𝑛𝑔′ → 𝑡ℎ𝑒 ′ 𝑣𝑖𝑟𝑡𝑢𝑎𝑙′
′𝑟𝑒𝑎𝑙′ 𝑝𝑟𝑜𝑐𝑒𝑠𝑠𝑒𝑠 → 𝑡ℎ𝑒 ′𝑎𝑐𝑡𝑢𝑎𝑙′
≢
… did not fit with the
existing accountability
hierarchy as represented
by the HMI/PMO
↓
𝐷𝐷𝑜𝐶 𝑠𝑝𝑒𝑎𝑘𝑖𝑛𝑔
↑
𝑎𝑛 𝑜𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑
DDoC’s unconscious
valency
DDoC’s unconscious
valency…
Boxer, P. J. (2017a). "Working with defences against innovation: the forensic
challenge." Organizational and Social Dynamics 17(1): 89-110.
• This rendered my client’s meanings subject-referenced and was the means by
which the accountability hierarchy defended itself against innovation.

The relation to ‘lack’ aka
incompleteness
21

Need for more
clinical
research
Reinforcing
Consequence ‘impossible desire’
The impossibility around which these frames
oscillate… each frame’s relation to
incompleteness
2: Intervention should
be based on directly
experienced truths
Outcomes
in this case
clinical
consultation
A GP’s counter-
narrative Framing
Demand for
more
consultations
http://www.asymmetricleadership.com/2007/07/dilemmas-as-drivers-of-change/
Dilemmas and the relation to ‘impossible
desire’ aka incompleteness
22
So what in
clinical
practice?
Flipping
Consequence
So what
knowledge am
I missing?
The accountability hierarchy’s
dominant Framing
Framing
consistency
with its
a priori
assumption
Outcome
Process
1: Intervention
should be based on
scientifically
established truths
Knowledge
research

The relation to ‘lack’
The subject is ultimately subjected to a radically unconscious relation to
‘lack’, with the effect of reversing the direction of the arrow
• En-gendering leadership is defined as leadership that works explicitly with this
non-rapport between consistency and incompleteness,
• non-rapport because any taking up of a way of being consistent will always be limited
by its incompleteness – by an ‘irritation of doubt’.
23
‘lack’
↓
↓
𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠 → 𝑎
a 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑 → 
Being subjected to
the relation to ‘lack’
Consistency
All of the CCG’s behaviors are
subject to the CCG’s
accountability hierarchy
Incompleteness
Only some behaviors in the citizen-
patient’s situation may be subject to
the CCG’s accountability hierarchy
↓
↑
Sovereign
ego
Boundary
object
Boxer, P. J. (2019b). "Working with the 'irritation of doubt': the place of metaphor." Socioanalysis submitted for publication.

Working with the ‘irritation of doubt’
any taking up of a way of being consistent will always be limited by its
incompleteness
• My client, in working with the gaps in the way the ecosystem was relating to its
clients was opening up a demand on the CCG for en-gendering leadership
• Leadership in which leadership’s way of ‘reading’ needed to be open to an
‘irritation of doubt’ about its current efficacy,
• making it possible for there to be learning about the ‘actual’ gaps in the way patients
were being treated
24
↓
↓
𝑤𝑎𝑦 𝑜𝑓 ′𝑟𝑒𝑎𝑑𝑖𝑛𝑔′ → 𝑡ℎ𝑒 ′𝑣𝑖𝑟𝑡𝑢𝑎𝑙′ → 𝑑𝑜𝑢𝑏𝑡
′𝑟𝑒𝑎𝑙′ 𝑝𝑟𝑜𝑐𝑒𝑠𝑠𝑒𝑠→ ′𝑎𝑐𝑡𝑢𝑎𝑙′ 𝑔𝑎𝑝𝑠
… means being subjected
to the ‘irritation of doubt’
triggered by encountering
‘actual’ gaps
↓
↓
𝑤𝑎𝑦 𝑜𝑓 ′𝑜𝑟𝑔𝑎𝑛𝑖𝑠𝑖𝑛𝑔′ → 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑟𝑠 → 𝑎
a 𝑠𝑢𝑏𝑗𝑒𝑐𝑡 − 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒𝑑 𝑠𝑖𝑔𝑛𝑖𝑓𝑖𝑒𝑑 → Being subjected to
the relation to lack…
‘lack’
Boundary
object

primary
task
primary
risk
domain of
relevance
Horizontal linkages to
particular multi-sided situations
Incompleteness made present
by a patient situation
The CCG’s Consistency defined
by a prior relation to the
domain of relevance
Vertical
accountability to
one-sided model
En-gendering leadership
Maladaptation arises from the conservation of an existing form of
consistency and a refusal to take up a relation to its incompleteness
• In order to address the inherent non-rapport between the consistency of the
accountability hierarchy and the life of the citizen-patient, the incompleteness
presented by the particular situation of the patient must be addressed.
• En-gendering leadership requires that the patient as boundary object brings a
particular collaboration into being, aka a networked organization, relating the
current consistencies of suppliers’ offerings to the incompleteness that the
patient situation makes present.

In Conclusion – how hard can that be?
The en-gendering of the relation to boundary objects allows us to understand the
radical difference between hierarchy and networked organisation in terms of their
different relation to incompleteness,
which goes further than just recognising the incompleteness of existing forms of
consistency.
It involves taking up a relation to the incompleteness per se made present by each
‘other’ client encountered one-by-one at the edges of an organisation,
in such a way as to drive the learning and adaptation of the ecosystem within which it is
working.
26

En gendering leadership

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