From a leadership perspective, I love the months leading up to Christmas. It’s not just the anticipation of the festive season or the especial frisson you get from a bright wintery morning with sun on frost or snow. In recent years, it’s been because this is also seasonal flu immunisation time, and that means leadership!
For over a decade, international and national experts have recommended that health care workers are vaccinated annually against seasonal flu. Historically, the NHS failed to engage with these recommendations but in recent years there has been increasing effort to promote immunisation, to measure uptake and provide benchmarking data for those interested, and even to bandy the “target” word around. All of this without there being any kind of legal, or to my knowledge organisational, mandate to enforce vaccine uptake anywhere within the NHS.
This is very different to some organisations in the USA and Europe that have embraced the evidence (imperfect as it is) and the recommendations, and have developed increasingly rigorous frameworks and sanctions around flu immunisation. These have included forcing staff who refuse the vaccine to sign a document acknowledging that their refusal to engage in a recommended patient safety activity may cause harm (this reduces the number of refusals); forcing staff who decline the vaccine to wear a face mask during the flu season when caring for patients; and making annual vaccination a contractual requirement (once organisations get to this stage, uptake rates are generally extremely high anyway, many habitual refusers change their minds, and only a handful of intransigent staff are dismissed).
The NHS approach to staff vaccination against flu is also very different to that taken within the NHS over other issues seen as important for patient safety, such as hand hygiene, aseptic non-touch technique, VTE risk assessment and prophylaxis compliance, and immunisation against Hepatitis B. All of these requirements are mandated in organisational policy, and staff have no choice but to comply. As a consequence, none of these areas really allows for transformational leadership or for staff to engage and put in their discretionary effort. These safety programmes become tasks for project and performance management; deliver, track uptake, deal with those who refuse.
It’s this difference that makes, for now, the annual flu immunisation campaign a real test of leadership. There are, of course, some major operational challenges to be met; how to deliver vaccine in sufficient capacity, at locations and at times and with enough vaccinators, to meet the need? But far greater than these challenges are those in the leadership domain; how to persuade hundreds, often thousands, of clinicians to comply with an initiative that numerous bodies endorse, but which is not compulsory, and about which their behaviour may manifest as enthusiastic, receptive, indifferent, uneasy or resistant?
It strikes me that although this is a bit confusing (as one doctor said to me to my great surprise, “If this was important it would be compulsory….so until it is, I won’t have the vaccine!”), if we want to build up what Steve Radcliffe calls our “leadership muscles”, the discretionary nature of the flu campaign offers a serious workout. In his language, we need to set out a compelling Future (of the benefits of high staff vaccine uptake); we need to Engage with both a distributed leadership through the organisation to reinforce that message, and through them with the whole organisation; and we need to Deliver high vaccine uptake through lots of availability, communication, and possibly challenge (of just the right sort) to individuals.
Students of organisational change can map the vaccine effort onto their favourite models of influencing, implementing or leading change, now even onto the NHS Change Model. Fans of influencing as a leadership attribute can think about the diverse different staff and departmental groups and sub-cultures to be reached and separately convinced. Aficionados of the impact of leadership on organisational culture and staff engagement can reflect on the meaning of differing levels of uptake between sites or departments in the same organisation. (As an aside, my sense that this was an issue was confirmed when a colleague in leadership fed back a verbatim comment from a "refuser", namely "This is the only chance I get to say 'no' to the Trust"). And pace-setters can encourage the collection of vaccine uptake data and use it to stimulate healthy competition, but on a strictly voluntary basis! In the final analysis, even the kind of campaign that is run will be a function of organisational leadership and capability from the very top down, and of organisational culture and staff engagement from the very bottom up.
Maybe mandation of annual vaccination is where we are heading if uptake levels continue to remain low in many organisations. Oddly, the "free choice" that those individuals who refuse the vaccine often cite could, in that event, have been precisely what leads to the removal of choice. We removed choice for those other important actions, and will no doubt remove choice for many others in the future. But it will be a sad day for our leadership, because in some way, it will be an admission that we just could not find the time or the energy or the language or the connectedness to build, on this issue or others for which this one becomes iconic, the conversations and relationships that make all our colleagues clear about their roles as "NHS citizens" and the behaviours we should all expect of each other as a result. We would have to remind ourselves that when large numbers of the colleagues we purport to lead "don't get it", there may be a problem about how we are going about communicating "it".
So get involved, unless your organisation has already stopped immunising! The flu campaign is entertaining and stretching. It offers opportunities to connect more with other leaders and more with all grades of staff across the whole organisation, and to develop your own leadership and the leadership capability of others. And it’s all in a good cause. To rephrase a quote from Peter Lees, what is leadership for, if not for purpose? And to misquote Hillel, “If not now, when? If not you, flu!”.
