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Tension, flexibility and self-criticism are more important than the model

Tension, flexibility and self-criticism

Organizations exploring PNAs often become fixated on the model they should use — often ignoring the more important considerations.

Mark Britnell

Global Chairman and Senior Partner

KPMG in the UK


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The model is important. However, most important is whether the model fits the context. For instance:

  • Does the model create sufficient tension for desirable change, such as quality improvement and appropriate service redistribution?
  • Is the model sufficiently flexible to avoid imprisonment through its funding sources, e.g. state payment systems based on hospital activity?
  • Is the model sufficiently self-critical in its governance (especially clinical governance) to understand and deliver on change requirements?

What this means for CEOs and Boards is that for PNAs to work, they need to think in ‘systems terms’.

The unit of analysis cannot simply be the institution. It has to take into consideration the wider ambitions and constraints of all players. This is often at odds with low-risk approaches to corporate governance driven by narrow performance parameters, such as short-term fi measures and operating process targets. So healthcare CEOs often face a tension between how their organizations are rewarded and the behaviors on which their sustained development depend.

For Aidan Kehoe, CEO of the Royal Liverpool and Broadgreen Hospitals in England, a number of conflicts threatened to block the development of a ‘health precinct’ around the largest of the organization’s existing hospitals.

Their plans aimed at securing long-term health and wealth creation for the city and beyond. It now comprises:

  • an ‘accelerator’ facility to house start-up life sciences companies
  • the relocation of a tertiary cancer hospital onto the campus
  • the assimilation of research and other activities into a ‘Knowledge Quarter’
  • furthering their relationship with the Northern Health Alliance — a regional collaboration of eight universities and eight university hospitals.

The complexity and tensions presented by these ambitious plans were significant, but for Kehoe the most important thing was to focus on the long-term goal of improving the health of the people of Liverpool.

The model, business case and multiple compliance requirements of regulators and other authorities could then all be developed around that strategic vision.

He lays strong emphasis on the skills needed of himself and his colleagues. “Most good teams can manage the day-to-day, but different skills are needed to stay with the big picture and to build the relationships necessary for all the collaborations and partnerships concerned.” This system lens through which organizations and their leaders must look for success was identified by Katz and Khan in the 1970s, Senge in the 1990s, and many commentators since.1,2,3 The challenge for leaders in the coming decades is to choose and stick to a sustainable path and protect it from the tyranny of the present.


  • Have you addressed the questions on context listed in this section?
  • Have you understood how your organization will be changed by PNA activity?
  • Have you clarified your internal capability to deliver PNA activity?


1Katz D and Khan Robert L. The Social Psychology of Organizations. New York. Wiley. 1966.

2Senge Peter M. The Fifth Discipline: the Art and Practice of the Learning Organization. New York. Doubleday. 1990.

3Hofstede Gerd. Cultures and Organizations : Software of the Mind. Administrative Science Quarterly 38. 1993.

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