Effective Leadership

A Cure for the NHS?

Denise Chaffer

• Publisher: CRC Press
• Year: 2016
• ISBN:
  9780429586552
• Edition: 1
• Topic: Business
• Subtopic: Industria dei servizi
• Index: Business

While the investigations and reports which have followed recent health care scandals in the UK have highlighted the very important issue of addressing organizational culture and the need for more effective leadership at every level, patients and their families have struggled to comprehend how such things can occur in a health service that is suppos

CHAPTER 1

Theories on the common features of good and bad leadership

LEADERSHIP THEORIES

The subject of leadership theory is complex, and includes a variety of definitions and characteristics. It appears to be an area that has been widely studied but little understood (Bennis & Nanus, 1985). The quality of leadership is frequently commented on in the media these days and the public appear to show less tolerance for leaders’ mistakes and foibles (Yankelovich, 1991).

Prior to the 20th century leadership was often described in terms of ‘great man theories’, in which individuals such as Napoleon Bonaparte, George Washington and even Adolph Hitler are viewed as men who displayed great leadership and shaped history (Van Wart, 2003). Later these theories included ‘trait theories’ in the belief that these leaders shared a list of psychological characteristics. Debate among theorists such as Argyris (1957) and McMurry (1958) appear to take opposing positions, McMurry perceiving humans to be lazy by nature and needing leading, whereas Argyris argues that people will move naturally towards growth and development, and need to be nurtured and motivated. It would appear that leadership theories can be viewed from two perspectives, one of focusing on directing specific work-related tasks and goals, or alternatively focusing on creating the optimum psychological and social environments in which work can take place.

Understanding the difference between followers and leaders adds a further dimension to explore. Kean and Haycock (2011) suggest the literature on leadership ignores the significant contribution followers make and the important judgements that staff make as to whether to follow a leader or not. Whitlock (2013) believes that effective leaders set direction and enable culture for others to thrive and that ‘good’ followership is being recognised increasingly as important.

Despite the lack of empirical research to help construct an evidence base for leadership effectiveness (Willcocks, 2012), there is a growing interest in the concept of ‘effective leadership’ and a number of books have been written on the subject. These provide managers and leaders with advice on how to improve their leadership effectiveness. In addition there is a range of leadership courses, such as provided by the NHS Leadership Academy, which attempt to utilise a variety of theories to underpin their training on what makes an effective leader. It is difficult to determine which theories or research studies underpin these ‘self-help books’ and this is compounded by limitations on how effectiveness has been studied and measured. The measurements of leadership effectiveness appear to be primarily based on the concept of staff feedback utilising tools such as 360 degree feedback, assessment centres, staff surveys and other methods of feedback. Another approach to measurement of leadership effectiveness can be seen in relation to organisational outcomes, but they may vary in focus depending on the type of industry. For example, for some the measurement may be in terms of profit, or productivity, and this may include customer satisfaction and market share. Some companies, such as Toyota (Liker, 2004) have a major focus on the quality of their product as their key priority and centre their organisation on this goal. Collins (2001) in his research describes successful organisations as those that make a distinctive impact and deliver superior performance over a period of time.

He believes this applies equally to public sector organisations, stating that the key to success is one that is most relative to the organisation’s mission and not necessarily focused on just its financial results.

Disillusionment with these models has led to a growth in support for the concept of a distributed model of leadership which views leadership as a more collective social process (Bolden, Wood & Gosling, 2006). Distributed leadership is one where rather than the focus being on one leader, there is a group of leaders that work and lead together rather than through the actions of individuals (Bennett et al., 2003). One of the key features for those advocating the benefits of distributed leadership is one of enhanced engagement with staff (Spillane, 2006; Gronn, 2008). One benefit (MacBeath, 2005) includes selecting the best people and bringing them together to meet a particular leadership need; this can engender greater engagement and collaborative behaviours of staff (Spillane, 2006). Critics such as Young (2009) state that while leadership may be distributed, often the power is not, and is therefore potentially subject to abuse by senior management who while aiming to encourage engagement and inclusivity don’t relinquish their power. This can give an illusion of distributed leadership, marketed as wide engagement, which may not be real.

EXPLORING KEY ELEMENTS OF SUCCESSFUL ORGANISATIONS

Internationally there appears to have been a significant shift away from what are perceived as outdated models of leadership of ‘top down’ hierarchies and imposition of performance targets, performance frameworks and leadership by fear, towards one of greater collaboration, engagement of the workforce and alignment of common purpose (King’s Fund, 2011).

Despite the lack of measurable leadership effectiveness theories, some views on the characteristics of successful organisations are fairly consistent, concluding the job of the ‘executives’ is no longer to command and control, but to ‘cultivate and coordinate the actions of others at all levels of the organisation’ (Ancona et al., 2007). New models of leadership see ‘leaders drive values, values drive behaviours and behaviours drive performance of an organisation. The collective behaviours of an organisation define its culture’ (Frankel, Leonard & Denham, 2006).

THE CONTEXT OF THE CURRENT NHS SYSTEM LEADERSHIP

The NHS system is publicly funded and arguably subject to more central control with accountability to a range of stakeholders. There appear to be some common themes on what takes companies from ‘good to great’ (Collins, 2001) that are relevant to the leadership of the NHS. Debates about whether the features of leadership which apply in the private sector can be applied to the public sector (Parry & Proctor-Thomson, 2003) tend to focus on perceived differences in relation to business’s focus on profit, competition and productivity, and views held that organisations funded by the taxpayer are very different. The NHS in particular has been resistant to the application of the business model, and to the ideological swings of various governments around the need to introduce a market model. For example, there was the Sainsbury style of business seen in the 1980s introduced by the Thatcher Government. The Labour Government, although often perceived as against a business model for running the NHS, introduced during their last term the concept of ‘any willing provider’, which allowed the contracting out of NHS services to the private sector. The NHS chief executive since 2014 was previously the chief executive of a large US private healthcare organisation and a key author of the NHS plan for Alan Milburn (Secretary of State for Health 1999–2003), which was introduced when the previous Labour Government came into power. It would seem the arguments have become somewhat less polarised regarding the use of the market and competition to drive up quality, and both of the main parties continue to adhere to the overarching principle of healthcare in UK being free at the point of delivery.

One common theme emerging in relation to the public sector is the need for greater adaptability and flexibility, and openness to change. Valle (1999) argues that for the public sector to survive it must be able to mitigate ‘perceived stress, decreased personal satisfaction, increase absenteeism and turnover’. The evidence in relation to health appears to suggest good leadership needs to be about engagement and relationship building, devolved and decentralised (Bohmer, 2012).

Collins (2001) in his book Good to Great, believes the keys to success are those things most relative to the organisation’s mission, and not its financial results.

Successful health organisations share many of these necessary features and while it could be argued these theories don’t necessarily apply to the public sector (King’s Fund, 2011), there are others that dispute this and fully support the need to embrace these newer theories of leadership.

NHS executive team members commonly hold Master’s degrees including MBAs or similar level qualifications in management in the UK, and they are familiar with much of the management theory which defines components of successful management and effective leadership. However, accounts by staff of bullying cultures across some of the leadership of the NHS begs the question of why more leaders don’t use the theories they have learnt, instead of focusing more on the ‘just get it done mentality’. Many of the media reports on the events at Mid Staff ordshire Hospital describe a leadership culture of fear driven by achievement of government targets at all costs, an approach far removed from that recommended by the various theories on effective leadership.

The theory–practice gap is a concept familiar to clinical health professionals, particularly when applied to the clinical setting. Many have adjusted their practice over time to something considerably different to that taught in the classroom. How much of this learning is applied to the practice of leadership poses an interesting question. The application of theory to the selection and monitoring of executive leaders appears to be a less researched area. There have been many attempts to address the performance of executive leadership and these include: executive development determined by Monitor for aspiring foundation trusts; King’s Fund programmes; the NHS Leadership Academy leadership and talent management programmes; the NHS Institute; and the National Patient Safety Agency, to name but a few. All were designed to support health professionals in leadership and promote greater understanding of improvement systems and principles of learning organisations. There have been many programmes run over the years to support clinical leadership, such as Leading Empowered Organisations (LEO), Clinical Leaders Network, and the British Association of Medical Managers (BAMM), which appear more recently to have lost momentum, and in the case of BAMM is no longer operating.

The NHS has identified a number of leadership competencies for its top leaders and while setting the standard is a good first step, experience suggests that considerable variation of standards exists across NHS hospitals. The King’s Fund commissioned work on the state of NHS leadership and concluded there was a need for a more consistent approach (King’s Fund, 2011). They stopped short of recommending a regulatory framework for NHS executives, instead suggesting that NHS leadership culture be subject to greater scrutiny by the existing regulatory bodies such as the Care Quality Commission (CQC) and Monitor. The King’s Fund also concluded that the NHS had more in common with the private sector than is often recognised.

Greater attention needs to be given to the selection and monitoring of top teams, and the development of top leaders needs to be mindful of the new models which have a culture of shared leadership. The NHS Leadership Academy was established to deliver a number of programmes, but Bolden et al. (2006) argue that future learning needs to be far more work-and team-based for it to achieve effective leadership at all levels.

KEY CHARACTERISTICS OF SUCCESSFUL HEALTHCARE PROVIDERS

Top performing hospitals in the United States show those that made the biggest leaps in terms of healthcare value, safety, quality and customer value had a number of common features. A sample of the top four hospitals studied showed achievements of top scores in quality of care while keeping use of resources low. The most common feature was that hospital leaders had set clear goals for the organisations and aligned daily practice to these objectives. Frankel, Leonard and Denham (2006) showed that leadership by an organisation’s trustees, chief executives and physician leaders was seen as the single most important success factor in reducing barriers and making performance improvement and transformation. Senior leaders in most of the well-respected organisations had been in their posts for many years, and when they did leave they were often replaced by long-serving leaders from within the organisations, unlike the NHS where chief executives’ tenure is often limited to under 18 months (Santry, 2007, citing Bohmer, 2012). Other interesting aspects of successful top teams is the inclusion of a higher percentage of women on boards; in many examples this has significantly enhanced overall performance of the organisations studied (King’s Fund, 2011).

The commonality between the successful health organisations includes pursuing quality and access, and shows that cost reduction is a consequence not the primary goal of their efforts. They all reinforced goals by addressing organisational culture and implementing a culture of continuous quality improvement.

The Institute for Healthcare Improvement (IHI), which has wide international membership, defined their core mission (described as the triple aim) as to:

• improve the health of the nation

• enhance the patient experience of care, including quality, access and reliability

• reduce, or at least control, the per capita cost of care.

The triple aim is included in hospitals across the United States, where the strategy has been widely embraced and a renewed focus by hospital boards is driving quality to reduce costs, with a specific focus on reduction of waste.

One impressive output of this initiative was seen at the Auckland IHI conference in 2012, which had a high level of attendance from senior clinicians. Many of them gave keynote addresses and ran workshops about clinicians taking the lead and accepting accountability for the quality of the care delivered. An interesting aspect of the conference was the collaboration between clinicians and chief executives, with shared vision for their organisations committed to the triple aim.

There is some evidence which links high staff satisfaction in NHS hospitals with higher patient satisfaction and also with feeling valued by management; there are also links to meaningful appraisals and feeling involved (King’s Fund, 2011). The variables that currently exist in drawing conclusions from national patient and staff surveys are complex, together with the sample size, and there is potential for bias in motivation for staff and patients to return questionnaires. The Care Quality Commission collects data known as the ‘intelligent monitoring tool’ from each trust, bringing together a number of measures and scoring systems which are publicly available. It is difficult to draw meaningful conclusions from much of this data. However, many of these quality measures, which have been used by hospitals in England for some time, should have highlighted the ‘red flags’ which were present in detecting the many failings on the scale seen in the Mid Staff ordshire Hospital. The trust had high mortality rates, and there was local public concern in the form of complaints and media stories. What is unclear is why the board failed to act, and an understanding of the extent to which they were aware of how much an outlier this trust actually was. This poses the question of whether there is a better and more evidence-based way of predicting potential failure which takes a more integrated approach to an organisation and sits at the heart of the functioning of the executive team.

KEY CHARACTERISTICS OF FAILING ORGANISATIONS

There have been a number of highly publicised failings of health organisations leading to increased patient mortality, such as Maidstone and Tunbridge Wells NHS Trust (Mid Staff ordshire Hospital), and poor care delivery. What is common to these failings is a tendency to seek blame (and shame) sometimes aimed at a particular profession, in particular nursing. Often a scatter gun approach is taken to identify the cause, concluding it must be the training, or the selection, as to why we have such poor nurses. Sometimes the blame is aimed at a particular chief executive and as a knee-jerk action they may be removed in a very public way. While executives should be held accountable, as they and their boards are responsible for the governance of their organisation, there is a need for greater understanding of the difference between blame and accountability. This is critical to achieving effective leadership and changing organisational culture. Frequently action plans are rapidly developed in response to a large number of external bodies’ view of what may be the organisation’s problems. There needs to be a full, comprehensive diagnosis and analysis of the true root cause and context of the failings to ensure that action plans explicitly relate to the areas they are seeking to address. The outputs from failing organisations are fairly obvious. In the non-public sector this relates to falling profits, financial loss, and rapid turnover of staff, failure to attract and recruit good people, and poor quality products that are not demanded. In the NHS, organisations are measured across a number of key performance indicators, usually including financial, access targets, compliance to regulatory standards, and a range of safety and quality outcomes. Commonly NHS trusts are ranked from best to worst across a number of these benchmarks, and variations between hospitals are publicly available. The limitation of this approach is that in every measure using comparisons there will be a best, a worst and a number in the middle. This is best illustrated in the national patient survey results, where a trust can be labelled as either the best or worst in the country. This in turn attracts much ‘brow beat...