Seeing the unseen: a pragmatic response to a public health emergency

Introduction: The National Health Service (NHS) organisations in England have a statutory duty to respond to an emergency. Hence, in responding to the COVID-19 pandemic, NHS organisations across all seven regions in England set up a protocolised ‘command and control’ hierarchical governance process. Its purpose was to provide strategic direction for responding to the emergency and support recovery. This study relates to one of the regions in NHS England and provides a network practitioner's perspective on the phenomenon of strategic decision-making governance. Due to the ongoing COVID -19 public inquiry, I have had to refrain from disclosing details of the region where this study was conducted.

Methodology: In response to the pandemic, my practice was rapidly evolving, and therefore, to intentionally study this I applied a pragmatic approach. This allowed me to embrace the transdisciplinary nature of my work as I started to view reality from different perspectives. To deeply study the dynamic phenomenon and my practice within it, I have applied my skills as a bricoleur and engaged with a variety of theoretical concepts. This approach is reflective of my practice in complex operational systems. As a result, this thesis is the product of the application of reflexivity and bricolage from which emerged my own theory of facilitative factors that supported decision-making. I have applied an autoethnography lens to present my findings.

Results: The findings of the enquiry contribute to the debates about the strength of distributed leadership and how it can support bureaucratic structures in managing emergency situations in complex systems. The findings also acknowledge that despite the complexity of the multiple layers and related power dynamics of the microsystems of health services, networks offer a platform for collaboration and facilitating decision-making. In this multilayered ecosystem, the findings highlight the strength of network coordination to facilitate cooperative relationship building between networks and bureaucratic structures.

Discussion: My unique contribution through this study is threefold, firstly in unravelling the function of network coordination and coordinator in managing relationships between bureaucratic structures and semi-autonomous agents when dealing with situations in complex environments. Through this, I have added to existing knowledge about the importance of network coordination in complex systems in providing a bridge across statutory and autonomous bodies. Secondly, I have contributed towards the role of public health specialists in providing leadership for complex issues. Finally, I offer a multidimensional framework of factors that influence strategic decision-making in emergencies. Although I studied the phenomenon during an emergency, I posit that the identified factors can equally be applied in non-emergency situations.

Conclusion: This thesis presents the dynamic yet symbiotic relationship between multiple factors that facilitated decision-making governance during the COVID-19 pandemic emergency. Equally importantly, this has also been a journey of self-discovery through which I, as a practitioner-researcher, have gained new knowledge and continuously improved my practice. It is my privilege that, through this process, I have added new perspectives to the existing pool of knowledge.

Implications for practice: This enquiry contributes to the evidence base for transdisciplinary work-based doctoral studies by strengthening the case for applying pragmatic approaches to study complex systems. Despite its limitations of being a contextual study, it offers principles for system leadership for managing situations in complex ecosystems.