Influence without authority

How do you get stuff done when you're not the one who can make the decision?

Most NHS organisations have a medic and a nurse on the executive. Given the increasing pressure on headcount at all levels, including executives and boards, very few will make room for a pharmacist.

Although there are historical reasons for that, I don't think history is enough to explain it. If pharmacy wants to be in a position to influence differently the next time the NHS decides to redraw the map, the question is not simply whether that feels fair, or even whether medicines matter enough to justify it (they do, obviously, and they always did, but with the UK-US trade deal that is now not even up for debate). The question is what do we do now to exert influence on the system. Both individually and as a profession.

It's worth reflecting on what the pharmacy profession has taught the system to expect from it, because executive authority and a seat at the top table doesn't appear out of thin air. It formalises what people already see. Pharmacy has taught the system to expect operational excellence, technical and clinical expertise, and safe management of medicines, but not broader organisational leadership and judgement in complexity.

I've written before about whether we as a profession are ready and/or willing to take on that type of authority, but it is important to understand that authority and influence are not the same thing. The research on power has made that point for years.

Formal position is only one source of power.

Expertise matters, of course, and we have that in spades, but so do credibility, informational power, and the trust that comes from people repeatedly finding your opinion and judgement useful when something difficult has to be worked through.

In other words, people and professions are often treated as authoritative before the structure catches up, which means that if pharmacy wants to be seen differently at the inevitable next reorganisation, it can't wait for the box on the org chart to magically appear. It has to look like a profession that is capable of operating at that level.

Part of the problem, I think, is that pharmacy has too often been framed as an operational service. Too often we are associated with dispensing, medicines reconciliation, meds management, and governance; how the medicines are prescribed, stored and supplied, and what rules govern their use.

Much less often are we seen owning the bigger strategic case for medicines themselves as one of the organisation’s most important resources, shaping patient journey, patient experience, flow, risk, productivity, outcome, and cost. If that is how the system experiences pharmacy, then we will continue to be valued, but too narrowly, and professions that are valued too narrowly are brought in for specific purposes as opposed to being at the heart of strategic authority.

That, to me, is the real issue. It's not that medicines are peripheral. They are not. It is that pharmacy is too often experienced as peripheral to the wider strategic conversation about them. A seat at the top executive table is created for professions that the organisation experiences as central to its hardest choices, most notable and intractable risks, trade-offs, and strategic direction.

That is why looking at organisational literature is worth doing. It gives us direction on how we can have more influence even when we're not sat at the top table, whether we have aspirations of operating at an that level or whether we just want to be more effective at executing the day job (whatever that is).

The last article was about communication clarity. That was the starting point, because if people can't follow your thinking, very little else matters. But clarity is not the same thing as influence. Plenty of pharmacy professionals are clear, accurate, thoughtful and well informed, and still find that nothing much changes. This is the next step. Communication clarity is how people follow your thinking, and influence is how your thinking starts to change what happens.

That is why influence without authority matters so much, and also why it is too often misunderstood. I do not mean it in the shallow sense of being more political, or in the embarrassing sense of becoming better at self-promotion. I mean it in the much more practical sense of being able to impact understanding, movement, and decisions when nobody is obliged to do what you say.

For most people reading this, the immediate question is less about the next reorganisation and more about tomorrow morning. If you don't currently have the title, the budget, or the hierarchy, what does influence without authority actually require? And how can you build it?

In practice, it's usually a handful of things:

• You need to be an expert.

  • That's the easy one.

• You need to understand the organisation intimately.

  • Find out how it works and how things get done. The processes and rules that are written down and, more importantly, the unwritten ones.

• You need to build trust before the day you need to cash it in.

  • Find out who else has influence in the organisation and understand their pressures, goals, and needs

  • Actively help others solve their problems. Being a resource builds a "reputation capital" that encourages them to support you in return.

None of that is fake and none of it requires you to become someone else.

But this is where a lot of professionals get stuck, particularly those of a clinical background. They assume that if they are right enough, clear enough, and patient enough, the system will eventually do the right thing. Sometimes it does. But you can't rely on it.

We've all seen people in organisations far less capable than ourselves but far more influential, and we've all thought 'why are people listening to them and not me'?

The evidence on influence helps here because it strips away some of the mythology. The most effective tactics are usually not the most theatrical ones. Studies of influence behaviour have found that rational persuasion and consultation are both common and effective, while pressure, coalition, and legitimating tactics tend to perform worse when it comes to commitment and perceived effectiveness.

Basically, people are more likely to do what you want when you help them understand the case and involve them early than when you try to push them, gang up on them, or tell on them.

And that brings up the important point about escalation in the context of influence. If the default response to a difficult situation is escalate to someone who does have authority, as it so often is, then we may get the result we want in the short term but we are still borrowing somebody else’s authority rather than building our own.

So if pharmacy wants to be seen differently in the next big reorganisation, I do not think the answer is to spend the next few years talking to ourselves in a bubble about why we deserves it. And equally it's not to complain about the fact that nobody is listening.

I think the answer is to spend them becoming increasingly difficult to leave out, and that means becoming more visible not just as the profession that runs pharmacy services, manages medicines, and governs their use, but as the profession that can explain what medicines mean to the organisation’s real objectives and help leaders act accordingly. That is a more demanding standard than competence, and a more interesting one too, because it asks not just whether pharmacy is good at its own work, but whether it can improve the organisation’s understanding of one of its most important resources.

The next article in this series is about judgement and decision making, because professional effectiveness is not limited to being able to communicate and influence, in also includes whether we can make good decisions and live with them in uncertainty.

I hope this article is useful and I'd love to hear your thoughts on it.