Leadership for healthcare

Hartley, Jean, Benington, John

• Publisher: Policy Press
• Year: 2015
• ISBN:
  9781447329978
• Edition: 1
• Topic: Medicine
• Subtopic: Health Policy

It is vital for healthcare leaders to have a clear sense of which leadership ideas and practices are rooted in sound theory and convincing evidence, and which are more speculative. This book provides a coherent set of six lenses through which to scrutinise the leadership literature relevant to healthcare - leadership concepts, characteristics, contexts, challenges, capabilities and consequences. It offers a view of leadership beyond the traditional focus on the individual, and argues instead that leadership has to be understood and developed as a complex set of practices by many people within specific organisational and inter-organisational contexts and cultures.

CHAPTER 1

Introducing leadership

Writing, advice and training on leadership are growing at such a rate that the ‘field’ of leadership is better described as a tropical jungle. The plants (ideas, books, practices) are growing very vigorously, with more information being produced than could be read by a single person in a lifetime. Theories, concepts and ideas about leadership create such a thick undergrowth that it can be hard to hack your way through. It is not that any particular theory is difficult; it is just that there are so many of them, competing for the sunlight. A troupe of guru monkeys is chattering and screaming in the high canopy of the forest. You crane your neck up to catch sight of them, but they have just leapt on to the next tree. Exotic theory birds swoop past, with dazzling plumage, but they don’t stay put long enough to enable you to examine them closely. Down at your feet on the jungle floor, there are snakes that may appear innocuous but can be deadly. There is a lot of vegetation but it is hard to work out which is nutritious and which is poisonous.

Grint (2005a) notes that while we have a surfeit of information about leadership, there is much less in the way of understanding. Burns (1978) wrote that “leadership is one of the most observed and least understood phenomena on earth” (p 2). So, how does one survive and thrive in this jungle? This book aims to provide a compass, a map and a naturalist’s guide to help find a path through the undergrowth, and to enjoy the journey.

The compass is our attempt to provide strategic direction and clarity of purpose by offering concepts and theories that may help to make sense of the complexities of leadership talk and action. The map is the analytical framework, developed by the authors on the basis of the general leadership literature, and here applied to healthcare, to provide an orientation to the landscape, and to help to hack out a clear path through the jungle. The map is an analytical framework not a single theory, because the book covers a wide range of leadership phenomena (leaders, leadership, contexts, outcomes and so on) and in each of these areas particular theories may be relevant and useful. But the map provides an overview and a structure by which to analyse theory and practice. When you are feeling stuck – as a researcher in the literature or as a healthcare practitioner subjected to different exhortations or pressures about how to behave as a leader – then we hope that this map will help you, by being able to place theories in a framework, or conceptual structure.

This book will be of interest to all who exercise leadership in relation to healthcare. This includes those who have a formal leadership position in a healthcare organisation (for example, chief executive, clinical director, doctor, nurse manager) or those whose leadership is through influencing thinking and actions relevant to healthcare (for example, local government elected members and officers, patient groups).

At the strategic level this book will be of interest to board members, clinical directors, finance directors, senior managers and human resource (HR) professionals – and also health scrutiny members and officers in local government.

At the operational level, the book will be of interest to health professionals, such as doctors, nurses, pharmacists and other professions, in leading and influencing healthcare and improvements in healthcare.

The framework and the research evidence will also be of interest to policy-makers and policy advisors, and to health researchers, particularly those concerned with service delivery and organisation, with leadership and the evaluation of leadership development.

Finally, the map will be of generic interest to leadership researchers, whatever their field (jungle?) of study or the sector they are focused on. While the focus here is on healthcare, the book draws on insights, theories and evidence from the leadership field in general. The analytical framework is generic while the application (to healthcare) is specific.

We examine those aspects of the literature where there is an evidence base for ideas and practices about leadership and we aim to apply rigorous thinking to how such theories and ideas can be applied. ‘Evidence-based’ medicine has gained considerable ground over recent years, and there is a growing interest in evidence-based management as well (Walshe and Rundall, 2001; Tranfield et al, 2003; Rousseau, 2006). The fact that leadership studies are multidisciplinary and located in the social sciences and humanities rather than medical science means that the evidence base for leadership will always be different from, and more open to, value-laden debate than would occur in subjects covered in medical science. Evidence in this field is sometimes more like evidence in a court of law than in a laboratory – subject to dialogue, challenge and refutation. This discursive debate is part of the process of evaluation of the evidence (Morgan, 1997; Flyberg, 2001; Marsh and Stoker, 2002; Moses and Knutsen, 2007). Having a clear sense of which leadership ideas and practices are rooted in theory and evidence, and which are more speculative or normative, can be very helpful for leaders surrounded by conflicting advice, or being urged to behave in particular ways because it is fashionable. Having a clear compass and map of the terrain of leadership will help to avoid at least some of the pitfalls, fallacies and fantasies about leadership.

The literature used for this enquiry into the evidence base for public leadership, and specifically leadership in healthcare, came from several sources. First, we carried out an examination of the recent academic literature on leadership in healthcare organisations and networks. Second, we asked for key recommendations for articles, books and reports from 43 academic experts in the field of leadership and/or healthcare. Third, the authors drew on their wider knowledge of the leadership literature to introduce theories and ideas that are currently absent from the healthcare field but which have been established in other areas of leadership enquiry, and which have potential for the healthcare field. Fourth, we regularly tested and checked both our ideas and our writing with a range of healthcare practitioners, from a range of roles and disciplines, so that we could ensure that the ideas and the writing are accessible, practical and useful.

New look leadership – the height of fashion?

Leadership is currently a trendy topic (Storey, 2004; Grint, 2005a; Burke and Cooper, 2006; Jackson and Parry, 2008), with literally hundreds of new books and articles being published by the day. Google records 122 million references to leadership and 35.6 million to public leadership. ‘Leadership’ has replaced ‘management’ in some quarters as the fashionable language of business. The interest in leadership is particularly evident in the public sector (Hartley, 2010a). There has been a series of government policy papers asserting the importance of leadership in public service improvement, stemming from the influential Performance and Innovation Unit report of 2001 (Cabinet Office, 2001) and reflected in the titles of a number of White Papers. Dedicated leadership centres and programmes have been set up for particular public service sectors including central government, local government, schools, health, fire service, further education, higher education, police and the voluntary sector among others – and a Public Service Leadership Alliance (PSLA) set up to coordinate their efforts (Benington and Hartley, 2009).

Health is no exception to this trend, and ‘better leadership’ is seen as central to improving the quality of healthcare and the improvement of organisational processes. The NHS plan (DH, 2000) argued for more attention to be paid to leadership and the development of leaders and led to the establishment of the NHS Institute for Innovation and Improvement, which has a key stream of work on leadership development as well as improvement and innovation. More recently and very prominently, the Darzi report Next stage review (DH, 2008) places considerable emphasis on healthcare leadership, especially but not exclusively by clinicians, as the NHS tackles new challenges to improve health quality and care. From the opposite end of the argument, some of the high-profile media cases of lapses in professional care in the UK have, in part, been attributed to problems of leadership, as in the Bristol Royal Infirmary case, and in the Victoria Climbié case (although weakness in leadership is clearly not the whole story).

Although leadership is currently highlighted as one of the fashionable solutions to the complex challenges in healthcare (including the current financial crisis and threat of severe cutbacks in public expenditure), we think there are several reasons why leadership needs to be taken seriously as part of longer-term strategies for public service improvement and innovation. The profound restructuring of the ecological, political, economic, social and technological context is posing major new systemic challenges for governments and communities, and requires a Copernican revolution in mindsets as well as new patterns of action. Many of these issues (for example, climate change; care for an ageing population; crime and the fear of crime) are both complex and contested – there is no clear agreement about either the causes or the solutions to the problems. There are no ready-made technical solutions to these ‘wicked’ or ‘adaptive’ problems, and they often cannot be solved by a single profession or a single public service alone but require exploratory effort from a range of people, organisations and sectors.

There are therefore several reasons why leadership – both within the organisation and between organisations and across networks – needs to be taken seriously:

• There are many new challenges in healthcare, including changes in the kinds of illnesses to be confronted. For example, the major post-war curable diseases, such as measles and diphtheria, are largely conquered but instead chronic and multiple diseases associated with a larger elderly population, and chronic diseases due to lifestyle choices (such as obesity and smoking), are becoming more important. How can leadership be used to anticipate rather than just react to changes in demographic and disease profiles?

• There are new health goals. Partly because of the changing pattern of illness and also because of the longer-term pressures on budgets, ‘predict and prevent’ have become more important goals alongside ‘treatment’. Health promotion not just sickness alleviation is now of more concern. Healthcare in the community, not just in hospitals and clinics, is increasingly important. Public health may be moving back to the centre of health policy. Working with partner organisations becomes increasingly important. How can leadership be deployed to help shape these new goals, and to ensure that ideas are translated into more effective practices at the front-line of the NHS organisation, and between different partners?

• The expectations of patients, carers and communities are increasing with more widespread knowledge about health available via the internet, less deference towards professional and medical authority, and higher expectations of personalised and flexible care. What are the implications for healthcare organisations and their staff and how can leadership be used to ensure that these changes are seized as opportunities to innovate and improve the quality of healthcare?

• The new techniques and technologies emerging in healthcare require new ways of working both within and across teams, and with patients. Who can lead such changes and how might they be carried out?

• New approaches to self-sustaining continuous improvement, which rely as much on mobilising and motivating staff as on the techniques themselves, are being introduced. How can leaders support staff to make and sustain local problem-solving efforts in order to improve the service to the patient?

• The increasing emphasis on step-change innovation, and not just on continuous improvement, aims to improve safety, quality and efficiency in healthcare. How can leaders create the conditions for creative problem-solving and the taking of reasonable risks through innovation?

• The organisations of healthcare are changing – with not only new structures, such as Foundation Trusts, but also new cultures and ways of working. How might such changes be led?

These are just some of the reasons why leadership is important in healthcare. New paradigm thinking is helping to shift the emphasis away from a ‘one best way’ model of leadership towards thinking about a repertoire of different approaches and methods to be deployed according to the flow of change and the movement of the action. The arts of public leadership now have to include skills, for example, in deciding when to use hierarchies, markets or networks, and when to use exit, voice or loyalty, as part of the leadership repertoire (Benington, 2006).

The Warwick 6 C framework for thinking about leadership

Leadership research has a narrow focus, and there has been little integration of findings from different approaches. (Yukl, 2006, p 445)

Much writing on leadership is very descriptive and anecdotal. For example, leadership manuals and books often begin with a set of prescriptive behaviours, competencies or qualities required of individual leaders, and some assertions about the impact that leadership can have on team or organisational performance. A lot of books and articles on leadership consist of lists of ideal traits or inspirational behaviours, divorced from both theory and context. Some may provide guidance principles of the ‘do this, don’t do that’ kind. These tend, therefore, to be aspirational and prescriptive about the good qualities of leadership or the skills and behaviours that are shown by effective leaders. This has been described as the ‘heroic’ approach to leadership. Indeed, the illustrations of leadership qualities and behaviours are often derived from heroic personalities and heroic situations – arctic explorers, political leaders in war or crises, business leaders turning around major companies on the brink of bankruptcy. Such approaches may be particularly appealing in the health service, where the heroic consultant or doctor (and their sibling the heroic manager) have been applauded for their successes. In such narratives the focus is generally on the leader’s characteristics as an individual, rather than on the context or the other actors and partners in the process.

This simplistic individualistic perspective in much leadership writing means that there are relatively few conceptual frameworks to help analyse leadership as a dynamic and contested process within a complex adaptive ‘whole system’. Such frameworks are few and far between, but they are very important if leaders and potential leaders are to take an overview of the field and to have a compass and map for their own practices and reflections.

Storey (2004, p 341), to take one helpful example, presents a leadership framework based on an interlocking set of factors – the impact of both the industry or organisational context, and the ideological context, on leadership, the perceived need for leadership, the behavioural requirements of the leader and leadership development methods. His framework also includes a consideration of outcomes in terms of unit performance, and evaluations by a range of stakeholders.

Yukl (2006) is another writer who proposes an ‘integrating conceptual framework’, but one based on predicting the behaviour of the individual leader from their traits, behaviours and power resources, and from those of ‘followers’. This is a view of leadership based in individual and small group influence processes and is valuable as far as it goes but it provides little sense of an organisational or institutional context to understanding leadership or of how leadership frames meanings and purposes. Heifetz’s (1994) theory of leadership includes a number of features that constitute an integrative framework, although he does not himself make this claim. We return to the work of Heifetz at several points in this book.

The lack of satisfactory integrating theories of leadership has led the authors to develop the Warwick Six C Leadership Framework, which provides a lens through which to scrutinise the leadership literature and to provide an overview that takes into account key elements affecting leadership processes a...