Towards a New Model of Leadership for the NHS

ContentsForeword ......................................................................................................................................................................... 3Preface ............................................................................................................................................................................... 4Executive Summary .................................................................................................................................................. 6The Questions .............................................................................................................................................................. 7Elements for a new Leadership Model ...................................................................................................... 81 Provide and justify a clear sense of purpose and contribution ................................ 82 Motivate teams and individuals to work effectively ........................................................ 83 Focus on improving system performance ................................................................................. 8The case for these elements .............................................................................................................................. 91 Communicate a clear sense of purpose and contribution ............................................ 102 Motivate teams and individuals to work effectively ........................................................ 133 Focus on improving system performance ................................................................................. 19Conclusions ..................................................................................................................................................................... 22Appendix 1: Outcomes associated with Staff Engagement ...................................................... 23Appendix 2: Summary of the main theories of Leadership ....................................................... 26References ....................................................................................................................................................................... 292 Towards a New Model of Leadership for the NHS

ForewordI am delighted to introducethis paper which shares thebeginning of the evidencebase underpinning our newleadership model. The NHShas and continues to bereally well served by leadersfrom all professions.Although change in theNHS is often preceded byenquiries into failures of care we tend to be lessquick to learn from success and what has gonewell.The NHS’ Leadership Framework (LF) has for overa decade described what good leadership lookslike and supported those entering their careeras well as those well established, to think moredeeply about what they know and what they cando as a leader. The LF has been an example ofhow learning from what works well can inspire,encourage and improve our leaders.But times are changing and what we need fromour leaders is changing too. As described wellin this paper our leadership community need tocontinue to learn, develop and flex their styleand behaviours. A relentless focus on improvingleadership improves the climate and conditionsfor staff, which improves the care and treatmentof our patients and communities. Technicalcompetence, professional skills, managerialexcellence all contribute to good leadership butthe real test of what separates those peoplein an organisation such as the NHS is the care,compassion and genuine investment in staffthat great leaders recognise as being the keydifference between adequate technical clinicalcare and great healthcare service.Karen LynasDeputy Managing Director andHead of Programmes and Practice TeamNHS Leadership Academywww.leadershipacademy.nhs.uk 3

PrefaceThis paper was commissioned by the NHSLeadership Academy as a contribution to thinkingabout the future development of leadershipin and around the NHS. It was prepared incollaboration with the Hay Group.The backdrop and one of the triggers wasthe launch of a new suite of professionaldevelopment programmes sponsored andorganised by the NHS Leadership Academy.The programmes are:‘The first set of nationalprogrammes to combinesuccessful leadership strategiesfrom international healthcare,private sector organisationsand academic expert content.The difference is not just inthe reach, these are availablefor everyone in health andNHS funded care, but in scale,quality and approach. For thefirst time we are taking a single,national approach to leadershipdevelopment looking to supportour next generation of leaders.There are five programmes,designed to develop outstandingleaders for every tier across thehealthcare system.’www.leadershipacademy.nhs.ukThe NHS is facing a whole array of unprecedentedchanges and challenges. There are resourceconstraints, new demands, new institutions,and high expectations from patients and thepublic that service and care will be deliveredefficiently, effectively and with compassion.To meet such an array of needs it is recognisedthat appropriate leadership is vital. Over thepast decade, leadership frameworks for the NHShave been developed, including the currentLeadership Framework (LF), which has done muchto organise thinking about what good leadershipbehaviour should constitute. These have fed intoleadership development, selection, appraisal andreward.However, given the scale of contemporary changeand challenge it is timely to review the leadershipbehaviours deemed appropriate for current andfuture circumstances. The new suite of leadershipdevelopment programmes at all levels in the NHSneed to be properly informed and supported bya common vision of behaviours based on researchevidence. Prioritisation of the required behaviourshas begun to shift. There are concerns aboutleadership in the NHS as a whole. It is timely andnecessary to revisit the research evidence abouteffective healthcare behaviours and the role ofleadership in creating the right climate for theseto flourish and be sustained. The purpose of thispaper is to review the body of evidence whichcould contribute to a new Leadership Model forthe NHS fit for current and future purpose.In the immediately forthcoming period, the NHSwill need to accentuate different, or at leastnewly-prioritised, staff behaviours. This, in turn,means there will be a requirement for differentpriorities in leadership behaviours. Compassion,respect and humanity from frontline staff willevidently need to be better supported andengendered by a leadership community thatholds these qualities as central to the core missionand purpose of the NHS.4 Towards a New Model of Leadership for the NHS

In professional service organisations such as theNHS there is an understandable leaning towardsshared forms of leadership. But confusion hasarisen about ‘distributed’, ‘dispersed’ and ‘sharedleadership’ as counterpoints to top-down, ‘heroic’leadership. While shared leadership has beenproductive, the idea has unfortunately also ledto a lack of clear thinking about the role to beplayed by those persons occupying leadershippositions.In recent years a command and control cultureand matching set of mechanisms and styleshas been seen to be prevalent. This has runalongside the Leadership Qualities Framework(LQF) and other frameworks which extolother more collaborative or participativeapproaches. This tells us that there can bedissonance between expressed values, hardwiredregulatory mechanisms and everydayroutine practices. Ideally, an effective LeadershipModel would address both kinds of priorities.The currently desired shift in emphasis towardsautonomy, responsibility and accountabilitywith a strong orientation towards patientcare and compassion - as well as timely andeffective clinical interventions and practice -represents a contemporary modification in thedesired Leadership Model for the NHS. Theseemerging high priorities need to be reflectedin a leadership model suitable for the time.However the model also needs to allow space forother more directive aspects of leadership thatmay be crucial for particular circumstances, andwhich may also need to be present more broadly.Leadership can be seen as a process whichinvolves finding temporary resolutions betweenopposing principles, meeting the need to mobilisehuman motivation, whilst also regulating it andmaking it dependable and predictable.‘The currently desired shift inemphasis towards autonomy,responsibility and accountabilitywith a strong orientation towardspatient care and compassion - aswell as timely and effective clinicalinterventions and practice -represents a contemporarymodification in the desiredLeadership Model for the NHS.’www.leadershipacademy.nhs.uk 5

Executive SummaryThis paper stems from a request from the NHSLeadership Academy and from Hay Group fora re-examination of the relevant literature onleadership. This request was in turn triggered bythe launch of a new national suite of leadershipdevelopment programmes and deep anxietyabout the nature and adequacy of leadershipin the NHS following the scandals in MidStaffordshire and elsewhere. While extensivework had been done over a decade and moreon leadership competences in healthcare,there was a concern that more of the same wasquestionable for the forthcoming period ofincreased investment in leadership developmentacross the NHS at all levels. It was suggested thatit was timely to take a fresh look at the issue.We undertook an extensive review of theliterature on leadership in healthcare andrelated services industries in order to identifycritical attributes. 1 On the basis of this review,we propose the following elements for a newLeadership Model for the NHS organised underthree main headings. Each heading relatesto a category which in turn contains a set ofbehaviours. The approach is intended to helpdeal with the duality of shared leadership formswhile also clarifying the behaviours expected ofthose occupying leadership positions in the NHS.The first category is ‘Provide and justify aclear sense of purpose and contribution’. Thisembraces behaviours and skills which enable anexplicit focus on the needs and experiences ofservice users, continually reinforcing an inspiringvision of the mission and social contribution ofthe organisation or unit, couched in terms ofservice quality. It also includes behaviours whichfoster attention to and interpretations of thewider environment, including policy frameworks,systems of accountability and evidence oneffective health care.The second category refers to behavioursand skills related to ‘the motivation of teamsand individuals to work effectively’. This alsoconcerns the wider ability to work in closercollaboration with other organisations oroccupations. It also entails defining clear andchallenging goals with teams and individuals.It includes building team commitment andconstructing a positive emotional tone orclimate. This also requires a demonstration ofthe belief that both staff and service users arevalued. Effective leaders encourage high staffinvolvement and engagement by allowingautonomy within a framework of values andgoals focussed on meeting user needs. They alsoprovide and operate meaningful designs fororganisations, sub-units and individual jobs whichare underpinned by HRM systems that providerelevant staff development and reward. Suchleaders manage and improve performance ratherthan merely report it. They utilise a variety ofperspectives to manage performance includingthe use of ‘soft’ intelligence, rather thanfocussing only on a narrow range of hierarchicallyimposed targets or indicators. They also listento staff and respond to their voice; they validateand engage positively with difficult or negativeemotions evoked by the experience of deliveringcare rather than seeking to suppress or denythem.The third category refers to a ‘focus onimproving system performance’. This meansenacting and encouraging the practice of serviceimprovement, constructing compelling casesfor change and carefully constructing plans forchange based on a variety of kinds of evidence.It also means addressing system problems andpursuing innovation, initiating new structuresand processes, and finding ways to interveneinformally in patterns of thinking and acting.Finally, it means modelling the learning of newbehaviours. This in turn requires the forming ofaccurate assessments of their own and their unit’seffectiveness, identify new ways of workingappropriate to changing circumstances whiledemonstrating a willingness to reveal some selfdoubtand acknowledge mistakes.Each of the elements and the sub-elements aregrounded in the research literature.1We wish to acknowledge the invaluable advice provided by Professor MichaelWest of Lancaster University, and by David Barnard, Sharon Crabtree andLubna Haq from the Hay Group.6 Towards a New Model of Leadership for the NHS

The QuestionsThe overall goal of this paper is to offer a viewon the emerging consensus as to what ‘goodleadership in healthcare’ looks like. It draws onexisting leadership frameworks in health care,academic theory and analysis about the nature ofleadership currently required in healthcare, andrigorous empirical research about the outcomesof leadership. It will seek to answer two mainquestions:• What should be the core elements in a newLeadership Model fit for the NHS of the future?• What evidence is there, in health care or anyother relevant sector, of a link between theseleadership elements and service outcomes?It is important to draw not only upon researchconducted within the NHS and indeed withinhealth care but also to consider insights gainedin other sectors and other countries. Significantresearch has taken place on the role of leadershipin fostering high levels of customer service inretail and other competitive settings. Likewise,important research on safety has taken placein airlines, oil drilling rigs and nuclear fuelgeneration. Other work has revealed theways in which service-focused enterprises inretail, hospitality and other service-orientedorganisations have used leadership as a means todrive customer satisfaction and customer loyalty.www.leadershipacademy.nhs.uk 7

Elements for a newLeadership ModelWe propose the following elements for a new Leadership Modelfor the NHS as organised within three main categories.1. Provide and justify a clear sense ofpurpose and contribution1.1 Focus explicitly on the needs andexperiences of service users, continuallyreinforcing an inspiring vision of the missionand social contribution of the organisationor unit, couched in terms of service quality1.2 Interpret the wider environment, forexample policy frameworks, systems ofaccountability and evidence on effectivehealth care; making sense of what theserequire of the organisation and staff,including the need to work in closercollaboration with other organisations oroccupations.2. Motivate teams and individuals towork effectively2.1 Define clear and challenging goals withteams and individuals2.2 Build team commitment and a positiveemotional tone or climate, articulating thatboth staff and service users are valued, andattending to staff well-being2.3 Encourage high staff involvement andengagement, allowing autonomy within aframework of values and goals focussed onmeeting user needs2.4 Provide and operate meaningful designfor organisations, sub-units and individualjobs, with underpinning Human ResourceManagement (HRM) systems that providerelevant staff development and reward2.5 Manage and improve performance ratherthan merely reporting it, with openness toa variety of perspectives on performanceincluding ‘soft’ intelligence, rather thanfocussing on a narrow range of hierarchicallyimposed targets or indicators2.6 Listen to staff and respond to their voice,validate and engage with difficult ornegative emotions evoked by the experienceof delivering care, rather than suppress ordeny them3. Focus on improving systemperformance3.1 Enact and encourage the practice of serviceimprovement, with compelling cases forchange and carefully constructed plansfor change based on a variety of kinds ofevidence3.2 Address system problems and pursueinnovation, initiate new structures andprocesses; find ways to intervene informallyin patterns of thinking and acting3.3 Model learning of new behaviours: formaccurate assessments of own and uniteffectiveness, and identify new ways ofworking appropriate for new and changingcircumstances, coupled with a willingnessto show some self-doubt and acknowledgemistakes.8 Towards a New Model of Leadership for the NHS

The Case for these ElementsIn what follows, we now summarise undereach main heading and individual elementthe underlying thinking and research evidenceas drawn from a variety of sources includingacademic papers, existing competency modelsand recent NHS policy documents that have ledus to proposal this model of leadership fit forcontemporary circumstances and challenges.We have been mindful of the healthcare - andindeed more specifically the NHS - context. Thus,the selection of proposed categories and subcategoriesis influenced by healthcare challenges.Accordingly, these categories are somewhatmore focused than the four category taxonomyproposed by Gary Yukl directed at multiplesettings and diverse industries (Yukl 2012).1 Provide and justify a clear senseof purpose and contribution2 Motivate teams and individualsto work effectively3 Focus on improvingsystem performancewww.leadershipacademy.nhs.uk 9

1. Communicate a clear sense of purpose and contributionThe idea of defining the direction fororganisations or subunits is a central componentof almost all conceptions of leadership andleadership frameworks. It is represented in theLeadership Framework (LF), within the domainsof Setting Direction, applicable at all levels, andCreating the Vision, applicable at senior levels.In the current context, following the FrancisReport (2013) there is arguably a need to bringmore to the foreground the social purpose andmeaningful contribution of NHS and NHS-fundedorganisations. Providing overall direction includesneeds to encompass strengthening a sense of theresponsibility and contribution to society thatorganisations, teams and individuals are chargedwith, in accord with NHS values. This gives rise tothe following two elements.1.1 Focus explicitly on the needs andexperiences of service users, continuallyreinforcing an inspiring vision of the missionand social contribution of the organisationor unit, couched in terms of service qualityThe needs to focus on patient safety and tounderstand the needs of users in shaping thedevelopment of health services are present inthe LF. They are a central theme in Liberating theNHS (2011), the White Paper underlying currenthealth service reforms. The Francis Report (2013)emphasises the role of leadership in prioritisingpatient safety and in listening to and learningfrom patients. The significance of this strategicfocus on patients and users is supported bya growing body of recent research on serviceeffectiveness in health care as well as in otherkinds of services.One of the more influential frameworks is the‘customer service profit chain’ concept (Heskett,Jones et al. 1994; Heskett, Sasser et al. 1997). Theservice-profit chain framework seeks to showrelationships between profitability, customerloyalty, and employee satisfaction, employeeloyalty, and productivity. The proposition is that,in a service industry, profit and growth derivefrom customer loyalty. This in turn is a directresult of customer satisfaction, and satisfactionis largely influenced by the value of servicesprovided to customers by employees. Hence,value is created by satisfied, loyal, and productiveemployees. Employee satisfaction stems primarilyfrom high-quality support services and policiesthat enable employees to deliver results tocustomers. The service-profit chain, summarizedin the diagram below, is defined by a mode ofleadership that emphasizes the importance ofeach employee and customer. The work wasillustrated in the United States in the case ofthe retailer Sears amongst others (Heskett et al.1997).Leadership that emphasises employees and customers + Quality support services and policiesSatisfied, loyal, and productive employeesValued services provided by staffCustomer satisfactionOrganisational success, growth (and profit)10 Towards a New Model of Leadership for the NHS

The specific role of the leader within the serviceprofitchain framework has been explored. Suchleaders develop and maintain a culture that isfocused on service to customers and employees.They are effective listeners with both theability and willingness to listen. These are highengagement leaders that spend time with theiremployees and customers, test their servicedelivery processes, and actively seek employeesuggestions for improvement. In addition, theydemonstrate real care and concern for employeesas demonstrated by how they select them,tracking and guide their development, andproactively recognize them (Reichheld and Sasser1990).This work has been built on by Hong et al.(2013) who focus strongly on the mediatingrole of ‘service climate’ as the ‘missing link’between HR practices and leadership behavioursas antecedents and outcomes of various kindsincluding employee attitudes and behavioursand customer outcomes. This work would seemto have direct relevance to leadership andmanagement in the NHS. The authors argue thatthe role and work of leadership is to constructa positive service climate. Their meta-analysis of58 studies provides convincing statistical supportfor a strong association between this linkage andthe subsequent linkages to employee outcomesand in turn customer outcomes (satisfaction andloyalty).The studies suggest that effective leadershiptherefore has twin components: general highperformanceorientation supplanted by a specialservice-orientation. Transformational leaders whoexcel in service settings engage in behaviourssuch as:‘Articulating a compelling vision of customerservice, inspiring enthusiasm and optimism aboutwinning customers loyalty, serving as employee’scharismatic role model in service, encouragingnew ways of serving customers, and recognisingemployees’ individual needs and contributions.’Liao and Chuang, 20071.2 Interpret the wider environment, forexample policy frameworks, systems ofaccountability and evidence on effectivehealth care; making sense of what theserequire of the organisation and staff,including the need to work in closercollaboration with other organisations oroccupations.This element is again already representedwithin the LF within the Setting Direction andCreating the Vision domains. These emphasisethe importance of understanding stakeholdersand the range of requirements they place onan organisation or a unit, as well as the need toassimilate relevant evidence on new or improvedways of organising or providing care. Suchpriorities also widely present within other recentanalyses of health care leadership. For examplethe Health Foundation (Hardacre 2011) identifiedkey leadership behaviours including:• Explains the need for change and inspirescommitment to the process• Unites staff around an inspiring vision andaligns staff capabilities with planned activities• Takes a helicopter view of the system tooversee short and long term issuesGiven the complexity and continual change insystems of NHS organisation and accountability,there are strong arguments that making senseof what is required of organisations and teamswill become increasingly important (Storey etal 2010). The need to recognise the importanceof collaboration and effective working acrossorganisational boundaries is widely recognisedin a wider range of policy documents concerningthe desirability of improving integration betweenprimary and acute health services, and betweenhealth and social care (National Associationfor Primary Care, NHS Confederation and NHSAlliance 2013).www.leadershipacademy.nhs.uk 11

The significance of this element is well groundedin recent academic debates and research. (Hartleyand Bennington 2011) emphasise both politicalastuteness and the importance of making casesfor change based on evidence and argument.Numerous surveys reveal that large numbersof respondents identify leadership as a processinvolving the display of vision, strategic sense, anability to communicate that vision and strategy,and an ability to inspire and motivate (Council forExcellence in Management & Leadership 2001;Storey 2011).Recent years have witnessed increased use oftargets. But findings from a three-year researchproject by Tamkin and colleagues from The WorkFoundation (Tamkin et al 2010), suggests that‘outstanding leadership’ is a subtle process. It is,they conclude, more effective when it is peopleorientedin the sense of being able to elicitunderstanding of goals and commitment frompeople than it is when based on cruder forms oftarget-setting and measurement.One recent stream of theorising focuses on themeaning-making behaviour of leaders (Polodny.et al. 2010). Here, ‘leaders’ are those whointerpret the complexities of the given unit withinthe environment on behalf of the followers.Leaders thus make sense of the plight of thecollective - weighing up threats and opportunitiesin the environment, and evaluating thestrengths and weaknesses of the unit within thatenvironment. The capabilities required are thosefrequently described in recent transformativeliterature: clarity of vision; environment scanningand interpretation, ability to condense complexdata into simple compelling summations; andability to communicate clear messages.‘Big picture sense-making’ includes the abilityto scan and interpret the environment; todifferentiate threats to, and opportunities for,the organisation; to assess the organisations’strengths and weaknesses; and to constructa sensible vision, mission and strategy. As isconstantly emphasised in the literature and inthe dominant mode of thinking over the pastcouple of decades, the result of this big picturework may entail a transformative agenda for thefocal organisation. Indeed, the distinct impressionis easily gained that in modern perception,leadership work is of this nature almost bydefinition. Steady-state maintenance, it oftenappears, is not so much one variant of leadershipas one might logically suppose, but rather is afunction of that ‘other’ subordinate position,namely, management. What this expresses ofcourse is that leadership is closely identified withchange-making. The crucial capability here then isto correctly discern the direction of change.The importance of explaining the need foreffective working across established service andorganisational boundaries has been identified by(Fisher and Sharp 1998) who explain ‘how to leadwhen you are not in charge’. A further capabilityconcerns inter-organisational representationand the ambassadorial role. While this is a vitalcapability for a chief executive in a private sectorcompany it is one which has reached specialprominence in the public sector as a result of theincreasing requirement for inter-agency working.Indeed, the cluster of capabilities required to‘lead’ in a network context is one of the keycurrent themes in the leadership debate. Skillssuch as coalition building, understanding others’perspectives, persuasion, and assessing clientneeds in a holistic rather than a single agencymanner become the premium requirements.‘Numerous surveys reveal thatlarge numbers of respondentsidentify leadership as a processinvolving the display of vision,strategic sense, an ability tocommunicate that vision andstrategy, and an ability to inspireand motivate.’12 Towards a New Model of Leadership for the NHS

2. Motivate teams and individuals towork effectivelyWorking with teams to deliver and indeedimprove services features prominently in theLF and several other frameworks for describinggood leadership in health. This is borne out by anumber of academic studies which conceptualisegood leadership as that which encourages andinculcates a set of behaviours which are positivelyoriented to the service quality experienceof the end-user (Alimo-Metcalf and Alban-Metcalf 2012; King’s Fund 2012; Hong, Liao etal. 2013). These studies make the case that inservice organisations such as the NHS an optimalapproach to leadership is one which has andcommunicates clear objectives, and which focuseson creating a supportive and positive climatewhich encourages staff to give their best. Thisleadership approach also seeks to create anappropriate emotional environment that is intune with a caring and personal service such ashealthcare.There are two levels to this overall capability.The first level includes team or group leadership -or as it is sometimes termed, ‘near leadership’.At this level inter-personal skills are at a premium.The second level is termed ‘distant leadership’and it refers to those situations where theleader is not in direct personal contact withthe followers - perhaps because of their largenumber - and so has to lead through the multipletiers using means other than inter-personal skills.Different kinds of leadership capabilities areneeded for the accomplishment of these differentroles. It is also worth noting that there may bemisalignment of the perceptions between distantand near group followers (Waldman 1999).2.1 Define clear and challenging goals withteams and individualsA classic conceptualisation underpinning muchrecent work on leadership behaviour stemsfrom the Ohio State University studies of the1940s which distinguished between two broadleadership orientations: consideration versusinitiating structure (Stogdill 1950; Stogdill 1974).Consideration is a leadership behaviour showinga concern and respect for followers; initiatingstructure are those behaviours accentuating goalattainment. A meta-analysis conducted by Judgeet al found that both consideration and initiatingstructure had moderately strong relations withleadership outcomes (Judge, Piccolo et al. 2004).As expected, consideration was more stronglyassociated with follower satisfaction whileinitiating structure was more strongly associatedwith group-organisation performance. Judgeet al conclude that while there had been somerelative neglect of these two constructs in recentyears, the results of the meta-analysis were strongenough to merit a revived attention to theirimportance. Much contemporary work whetherexplicitly referencing these two dimensions or notowes a good deal to them.The perceived over-emphasis in the NHS onstructure, task and targets and the suggestedre-balancing towards a staff support orientationechoes the consideration theme. In the newNHS it will be important for leaders to payclose attention to setting the tone, having andcommunicating clear objectives and attendingclosely to culture and behaviour. Leaders mustseek and encourage far more than complianceseekingbehaviours and box-ticking.We now summarise the academic and researchbasis for a numbers of elements identified underthis heading.www.leadershipacademy.nhs.uk 13

2.2 Build team commitment and a positiveemotional tone or climate, articulating thatboth staff and service users are valued, andattending to staff well-beingThe proposition for the importance of aleadership mode which sets the appropriateemotional climate and which in turn can lead topositive ‘emotional contagion’ is that throughwhich these processes employee attitudes willinfluence customer attitudes (Pugh 2001).Employee behaviours underpinned by aservice climate will create a pleasant customerexperience and induce a higher perceived servicequality, customer loyalty retention, and higherexpenditure (Gracia, Cifre et al. 2010). And as aresult, the service profit chain theory suggeststhat customer satisfaction of this kind will alsoresult in superior financial performance for thoseorganisations and units able to induce suchsatisfactions (Schneider and Ehrhart 2005).The core purpose of constructing a service climateis to link leadership with the customer and beyondthat with the ultimate purpose of the organisationwhether that be profit or public service impact.That relationship is achieved via a series of chainlinkages built around desirable behaviours amongemployees. Hence, service-oriented leadershipmeans consciously attending to this above andbeyond the baseline of more general highperformanceor good practice HR.‘The finding that ‘service-oriented leadershipcontributed to service climate more strongly thangeneral leadership suggests that training andperformance assessment programmes can bedeveloped to specifically improve leaders’ serviceorientation. Having a precise understanding ofthe relative strengths of service oriented HR andleadership over general HR and leadership willfurnish useful guidance for managers balancingsuch trade-offs in allocating resources’Hong, Liao et al. 2013: 253In similar vein, a study of service levels in USrestaurants (Liao and Chuang 2004) used amultilevel approach to study 257 employees,44 managers, and 1,993 customers from 25restaurants. This demonstrated that bothindividual- and store-level factors weresignificantly associated with employee serviceperformance. In particular, conscientiousnessand extraversion explained within-store variancewhereas service climate and employee involvementexplained between-store variance. Additionally,employee service performance aggregated to thestore level explained between-store variance incustomer satisfaction and loyalty (2004).The implication of many of the studies cited so faris that leaders need to shape the conditions whichallow positive emotions and orientations to thriveand negative ones to be subdued or minimised.In turn this points to a need to attend to leaderbehaviour because employee behaviour is in largepart shaped by what leaders do.Leaders who occupy immediate supervisory roleshave been identified by some researchers asespecially critical (Kozlowski and Doherty 1989;Salvaggio, Schneider et al. 2007). Hence, even ifhigher-level leadership has sought to promulgatethe service message, there will be a problematicfilter unless the immediate supervisor alsoreinforces the employee’s climate perceptions.Such research is part of a wider trend whichemphasise the role of leadership in creating theemotional environment of work. This builds onextensive work in the area of ‘organizationalcitizenship behaviour’ (OCB). This refers toindividual behaviour which is ‘discretionary, notdirectly or explicitly recognized by the formalreward system, and that in the aggregatepromotes the effective functioning of theorganisation’ (Organ 1988). OCB has been a veryinfluential construct for two decades though it isnot without controversy. It is a multi-dimensionalconstruct which includes, for example, notions ofaltruism, compliance and the exercise of discretion.Field studies in the areas of service work haveexplored these non-contractual aspects such ascourtesy, smiling, and related customer-friendlybehaviours. This work is of clear relevance tohealthcare work and seems especially relevant tocurrent concerns about compassion and caring andof their neglect and/or presence. Related work ofrelevance concerns concepts such as ‘emotionalcontagion’ (Pugh 2001). This refers to the tendencyfor people to be influenced by the emotions feltby others in a social group.14 Towards a New Model of Leadership for the NHS

A contagion of negative emotions would not beproductive for most organisations - and certainlynot service organisations in particular.A further highly relevant body of research inorganisational psychology and in organisationalsociology is devoted to the nature of ‘emotionallabour’ (Hochschild 1983). This deals with themanagement of emotions so that they areconsistent with organisational and occupationalexpectations. Workers in service industries suchas healthcare, retail and hospitality are oftenexpected to smile at customers and to displayother outward sides of positive emotions. Forexample, clinical empathy during the patientclinicianencounter can be considered asemotional labour (Larson and Yao 2005). Suchemotional displays may, or may not, be discrepantwith internal feelings. Emotions can be sharedand individuals - including leaders - can influencethe emotions of others. A relevant theme hereis the idea of ‘emotional contagion’ (Hatfield,Cacioppo et al. 1993). This may work in a negativedirection - that is, a set of negative feelings andbehaviours can become normalised. This caninclude cynicism, pessimism, fear, anger, anxiety,distrust, frustration and discontent. Conversely,emotional contagion can work in a positive wayso that constructive feelings become normalised.Where surface acting develops into deep acting,emotional contagion is the by-product ofintentional affective impression management(Kelly and Barsade 2001). The crucial pointconcerning leadership in healthcare settings isthat leaders should seek to help create a climatewhich discourages the negative sets of emotionssuch as indifference and cynicism and encouragespositive emotional sets such as compassion,commitment, empathy and optimism.2.3 Encourage high staff involvement andengagement, allowing autonomy within aframework of values and goals focussed onmeeting user needsThe constructs of service orientation andpositive attitudes have in recent times also beenapproached through the notion of ‘employeeengagement.’ In the case of the NHS this is seenstrongly in the work of the King’s Fund whichin recent reports has linked leadership andengagement (King’s Fund 2012). This accords withthe idea of ‘Engaging Leadership’ (Alimo-Metcalfand Alban-Metcalf 2012).Practitioners tend to use the term engagementas associated with involvement in managerialdecision making. And they quote the NHSConstitution which pledges ‘to engage staff indecisions that affect them and the services theyprovide, individually through representativeorganisations and through local partnershipworking arrangements. All staff will beempowered to put forward ways to deliver betterand safer services for patients and their families’(Department of Health 2009). Thus, from thisperspective engagement is about involvementand participation. The implication for leadershipis that opportunities for involvement should beprovided and staff encouraged to participate,and to be involved. While taking such stepsnaturally cannot guarantee the state ofpsychological engagement, such measures can beseen as logical steps in that direction.Empirical support for the link betweenengagement and performance can be found ina number of studies. A study in the Netherlandsused data from a survey of 2115 residentphysicians and found that doctors who scoredmore highly on engagement were less likely tomake mistakes (Prins, Hockstra-Weebers et al.2010). A study of more than 8,000 nurses foundhigher work engagement was associated withsafer patient outcomes (Laschinger and Leiter2006).www.leadershipacademy.nhs.uk 15

The King’s Fund has recently stressed theimportance of moving from the pace-setting,command and control and target-drivenapproach. This is seen as having deliveredachievement of some targets but at a cost. Theycite the Commission on Dignity in Care for OlderPeople which identified the top-down culture asa cause of poor care: ‘If senior managers imposeas command and control culture that demoralisesstaff and robs them of authority to makedecisions poor care will follow’ (cited in King’sFund 2012).In the report on the Commission on Leadershipsubtitled No More Heroes (King’s Fund 2011)there was a call for the NHS to shift from theold ‘heroic’ model of leadership by individualstypified by the ‘turnaround chief executive’ tomake way for a more inclusive form of leadership.A year later a further report amplified that caseand elaborated the characteristic features ofan engaged form of leadership (King’s Fund2012). This made the case for engaging staff,patients, the board and other stakeholders. Sixdifferent styles of leadership were sketched bya consultant from Hay Group (Santry 2011). Ofthis repertoire NHS managers were said to be tooreliant on ‘pace-setting’ - that is an over-relianceon demanding targets, leading from the front,and a reluctance to delegate. It has been arguedthat an over-reliance on pace-setting leadershipreflected the priority to move the NHS from alow base. It now needs to be complementedmore often with other styles of leadership tomeet new circumstances. The damage caused byover-dominant chief executive on Trust Boardswas demonstrated by research conducted acrossall NHS Trust, Foundation Trusts and Primary CareTrusts (Storey et al 2010).The Kings Fund find some signs of optimism inthe expressed intent of the NHS CommissioningBoard (now NHS England) in its publicationDeveloping the NHS Commissioning Board thatit will not seek to micro-manage the clinicalcommissioning groups (CCGs) but will seek tocoach and develop them (Department of Health2011).The antecedents of engagement in healthcarecan be varied. A study of 409 Finnish healthworkers found that job control was the bestpredictor of the level of work engagement. Thiswas followed by management, self-esteem andjob security (Mauno, Kinnunen et al. 2007). Thisindicates that if leaders and managers want topromote staff engagement in healthcare theymay need to attend to factors ranging fromjob design to resource availability as well as thepromotion of self-esteem and the creation of apositive climate.This research and others like it have emphasizedthe crucial need to engage clinicians and otherstaff in owning the joint enterprise to improveand sustain care. This different approachto leadership emphasises building sharedvisions across a range of staff and a range ofstakeholders.16 Towards a New Model of Leadership for the NHS

These findings are given further support by theanalyses of the NHS staff attitude surveys (West2012). Drawing on data from the annual NHSStaff Survey and other sources, the report ‘showshow good management of NHS staff leads tohigher quality of care, more satisfied patients andlower patient mortality’ (2012: 2).‘By giving staff clear direction, good support andtreating them fairly and supportively, leaderscreate cultures of engagement, where dedicatedNHS staff in turn can give of their best in caringfor patients. The analysis of the data shows thiscan be achieved by focusing on the quality ofpatient care; ensuring that all staff and theirteams have clear objectives; supporting staffvia enlightened Human Resource Managementpractices such as effective appraisal and highquality training; creating positive work climates;building trust and ensuring team working iseffective.’West 2012The authors say that these elements together canlead to high quality patient care and effectivefinancial performance. Employee engagementis shown to be especially important. This inturn is seen as fostered by effective leadershipand management. A number of correlationswere revealed with staff engagement ‘havingsignificant associations with patient satisfaction,patient mortality, infection rates, Annual HealthCheck scores, as well as staff absenteeism andturnover. The more engaged staff members are,the better the outcomes for patients and theorganisation generally’ (West 2012).These correlations are shown in more detail inAppendix 1. The results reported were derivedfrom a variety of methods, data sets and years.2.4 Provide and operate meaningful designfor organisations, sub-units and individualjobs, with underpinning HRM systems thatprovide relevant staff development andrewardThe analysis of the results of the staff surveysjust referred to shows that good leadership isnot just about generally supportive orientation.It is also associated with having effective humanresource management systems in place. Theseinclude ensuring well-structured appraisals aredesigned and used, including the setting of clearobjectives, and making sure that the appraisal isrelevant and helpful in improving how to do thejob, and that the employee is left feeling valuedby their employer. Another associated factor isworking in a well-structured team environmentwhere teams have clear shared objectives, workinterdependently and meet regularly to discusstheir effectiveness. Another factor is havinggood job design. This means having meaningful,clear tasks for both individuals and teams, sothat it is possible for individuals and groupsto feel responsibility for managing their ownperformance, with some opportunity to beinvolved in appropriate decision making. Theseare also ‘linked to employee health, which is alsoimportant for engagement: high levels of workpressure and stress can lead to disaffection anddisengagement’ (West 2012: 2).Similarly the model developed by Hong et al(2013) includes ‘general HR practices’ as wellas ‘service-oriented HR practices’ as part ofthe package. In other words, they are notsuggesting that leadership alone can produceand sustain a positive service climate, ratherleadership and management systems need to bemutually supportive and mutually reinforcing.So, for example, service-oriented HR systemsneed to be in place to underpin the requiredbehaviours. Selection and training should targetservice-related skills and behaviours. Evaluationsand rewards are also made relevant to serviceperformance. In other words, high performanceHR systems are further enhanced with a specificservice orientation. Leadership behaviours thenneed to support these with appropriate signalsand guidance.www.leadershipacademy.nhs.uk 17

2.5 Manage and improve performance ratherthan merely reporting it, with openness toa variety of perspectives on performanceincluding ‘soft’ intelligence, rather thanfocussing on a narrow range of hierarchicallyimposed targets or indicatorsThe LF emphasises measuring and improvingservice performance, drawing on a wide rangeof data and perspectives. This broad based viewof performance and performance managementis found in several other reports on the natureof health care leadership, notably Hartley andBennington (2011). The Health Foundation(Hardacre et al 2011) emphasises the needto combine recognition, praise and indeedcelebration of success with constructive feedbackto staff that can be used to improve performance.2.6 Listen to staff and respond to their voice,validate and engage with difficult ornegative emotions evoked by the experienceof delivering care, rather than suppress ordeny themA considerable amount of academic analysishas now been devoted to understanding theincidences of absence of compassion in someinstances of care, and even apparent cruelty topatients and carers, documented in distressingdetail by Francis (2013). One compelling line ofanalysis is developed by Ballat and Campling(2011) and Dartington (2010).They argue that involvement in front linecare often evokes strong emotions, throughcontact with pain and vulnerability. Whileindividual members of staff may have a normallycompassionate and caring outlook, there is alsoan innate and usually unconscious need to limitone’s exposure to vulnerability and distress inorder to protect oneself from fears of one’s ownvulnerability and of being inadequate to helpthose in great need. This can give rise to dynamicsof displacement, projection, rationalisation,reaction formation and sublimation within careteams.No matter how hard a leader may work toestablish a positive emotional climate, the taskof care tends to evoke strong emotions thatare difficult to bear, which can result in theprojection of hostile feelings on to patients orindifference to recognising their humanity. Theimplication is that leaders need to acknowledgethe existence of such complex and difficultemotions, and provide forums for them to beexpressed and worked with. The real dangercomes from denying the reality of these difficultemotional aspects of care, which can leadto intensification and social legitimation ofdangerous defence mechanisms, such as denialand projection. These may too easily result in adistancing from the experience of patients andeven discounting or disrespecting patients andtheir experiences.18 Towards a New Model of Leadership for the NHS

information. It may also come from data onbreaches of patient safety, or from patient stories(Bate and Robert 2006), from staff suggestionsand reports, or from new perspectives offered byhealthcare ‘social movements’ (Bate, Robert et al.2004). Hartley and Bennington (2011) bring outthe importance of recognising multiple forms ofevidence and approaches to change, bearing inmind the preferences and priorities of differentconstituencies: ‘influencing and persuading basedon evidence and argument, analysing opposingviewpoints, negotiating, finding common ground,building networks’.3.2 Address system problems and pursueinnovation, initiate new structures andprocesses, or find ways to interveneinformally in patterns of thinking and actingThis element focuses attention on the role ofleadership in bringing about innovation, inthe sense of ways of working that break withestablished ways of operating in order to improveperformance. In the current NHS context atleast three kinds of innovations are crucial. Thefirst concern service redesigns that streamlinecare, breaking down barriers between primaryand acute services or between health and socialcare, in order better to meet the needs of users.Such redesigns are also widely seen as offeringsignificant cost savings, through eliminatingunnecessary hand-offs, overlapping assessmentsand redundant administrative processes. Thesecond kind of innovation involves supportingpatients or service users in managing their owncare, often through use of some form of remotemonitoring or condition reporting technology.The third kind involves changing ingrainedpatterns of behaving within staff groups in thedirection of becoming more patient-centred.Studies of health service innovations reveal aneed for an effective alliance between cliniciansand administrative managers in thinking througha range of administrative and informationtechnology related aspects of the new service,as well as new clinical protocols and divisionsof labour, and new criteria for judging serviceperformance (Storey and Holti 2013).Leadership for successful innovation involvesthe exercise of political astuteness, developingalignment and sometimes coalitions acrossdifferent interests implicated by the innovation,in both formal and informal alliances. It alsoinvolves an ability to mobilise a variety ofresources (Hartley and Fletcher 2008; AlfordJ, Hartley et al. 2013). Informal relationshipsbetween clinicians and managers can mobilisefunding and gain legitimacy stemming fromnational strategies targeting new service modelsin particular clinical areas (Storey and Holti 2013).So, leadership for innovation involves mobilisingexisting relationships, and developing new ones,to encompass the range of practices involved ininnovation, as well as seeking out backing andfunding from centres of power in the healthservice.Complex service innovations, such as theestablishment of region-wide network ofcancer services, seem to require a multi-leveland multidisciplinary array of clinical andadministrative leadership roles, sometimesreferred to as a ‘leadership constellation’ (Touati,Roberge et al. 2006: 120; Fitzgerald, Ferlie et al.2007). Similarly, Fitzgerald et al (2007) concludedthat, even for these more limited serviceimprovements, ‘distributed change leadership’ isneeded, comprising united senior level supportfrom both formal clinical leaders and seniormanagers, credible opinion leaders at the levelof senior clinicians in the services concerned, and‘willing workers’, front line clinicians preparedto embrace the new way of working. Serviceinnovations were more likely to progress ifgrounded in good established relationshipsbetween clinicians and managers (Humphrey2002; Fitzgerald, Ferlie et al. 2007; Greenhalgh,Humphrey et al. 2009). The argument here isthat trusting and well-established relationshipsprovide a basis for problem solving andresilient adaption of innovative ideas to localcircumstances, and this has been found in othersettings (Rashman et al. 2005).20 Towards a New Model of Leadership for the NHS

Similarly, staff with high levels of engagementwere less likely to be absent from work; thosewith low levels of engagement were more likelyto be absent. The broad results are shown inFigure 2 below.Figure 2: Absenteeism by engagement54.84.6Absenteeism Rate (%)4.44.243.83.63.43.23OverallMotivation Involvement AdvocacyengagementLowMediumHighSource: (West 2012:12)24 Towards a New Model of Leadership for the NHS

Staff engagement scores were also correlatedwith overall organisational performancemeasures as indicated by the Annual HealthCheck as used by the Care Quality Commission(CQC). The Health Check is based on two mainindicators one for quality of service and onefor financial management. Both indicators arepositively associated with staff engagement.Figure 3: Overall engagement by AHC performance54.84.6Absenteeism Rate (%)4.44.243.83.63.43.23OverallMotivation Involvement AdvocacyengagementLowMediumHighSource: (West 2012:13)Other factors associated with higher scores in theHealth Check were well-designed appraisals, higherlevels of training and flexible working.www.leadershipacademy.nhs.uk 25

Appendix 2Summary of the main theories of LeadershipFor many years, the focus of leadership studiesderived from a concern in organisationalpsychology to understand the impact of leaderstyle on small group behaviour and outcomes.Moreover, the focus as we saw above whendiscussing consideration and initiating structure,was further directed to just two main dimensions‘task focus’ versus ‘people orientation’ and therewere various re-workings of this theme (Blakeand Moulton 1964; Vroom and Yetton 1988).In the 1980s, attention shifted dramatically tothe elaboration and promotion of the conceptof transformational, charismatic, visionary andinspirational leadership. This school was labelledthe ‘New Leadership’ theories (Bryman 1992).‘The essence of the debatehowever is switching to thekey task requirements and thecontribution of leaders/managers.This more practice-orientedagenda is itself evolving.’This has shifted attention to leadership of entireorganizations rather than the leadership ofsmall groups. With the work of Alimo-Metcalfand others there are some important currentattempts to pull the agenda back to distributedleadership and teams. While on the face ofthings, much of the debate over the past twodecades appears to have been about ‘styles ofleadership’ in reality, the sub-text was mainlyabout a propounded dichotomy between‘leadership’ versus ‘management’. This messagewas extolled graphically and influentially in aHarvard Business Review article by AbrahamZaleznick (Zaleznik 1992) - originally published inHBR 1977.This article argued that ‘It takes neither geniusnor heroism to be a manager, but ratherpersistence, tough-mindedness, hard work,intelligence, analytical ability and perhapsmost important, tolerance and goodwill’ (1992:127). Leaders, it is said, ‘think about goals, theyare active rather than reactive, shaping ideasabout ideas rather than responding to them’.Managers, on the other hand, aim to ‘shiftbalances of power towards solutions acceptableas compromises, managers act to limit choices,leaders develop fresh approaches’ (1992: 128).Evidently, the controversy about the essentialdifferences between leadership and managementwill continue for some time. The essence of thedebate however is switching to the key taskrequirements and the contribution of leaders/managers. This more practice-oriented agenda isitself evolving.In order to gain broad oversight of this and othermain trends in leadership theory it is useful toview the summary of leadership theories shownin Table 1. Reviews of the journey through thesequence of theories can be found in Yukl (2009)and Storey (2011).26 Towards a New Model of Leadership for the NHS

Table 1: Summary of the Main Theories of LeadershipTrait theory; innate qualities; 'great mantheories'Behavioural theories: task related andrelationship related; style theory (e.g. autocraticvs. democratic)Situational and contingency theory; repertoireof styles; expectancy theoryExchange and path-goal models (relationshipbetween leader and led as a series of trades)'New Leadership'; charismatic and visionaryleadership; transformational leadershipCarlyle (1841); Bernard (1926); Hong, Liao et al.(2013)Ohio State University studies; University ofMichigan, Katz and Kahn (1951) Likert (1961);Blake, (1964); Lewin (1939)Fiedler (1967) Vroom and Yetton (1973) Yukl(2009); Hersey and Blanchard (1969); Thompsonand Vecchio (2009)Graen and Uhl-Bien (1995); House (1996)Burns (1978); Bryman (1992) Conger and Kanuungo(1988); Bass (1985); Tichy and Devanna(1986); Kouzes and Posner (1997)Leadership as performance Mangham (1986); Peck (2009)Constitutive, constructivist theory Grint (2000)Leadership within Learning Organizations:leadership as a creative and collective process;distributed leadershipPost charismatic and post-transformationalleadership theory; spiritual leadership; authenticleadership; leadership with compassionSenge (1990)Khurana (2002); Maccoby (2000); Fullan (2001a);Fullan (2001b); Boyatzis and McKee (2005); Tamkinet al (2010); Avolio and Luthans (2005)www.leadershipacademy.nhs.uk 27

The ‘shadow side of charisma’ has been noted bya number of writers (Conger and Kanungo 1998;Howell and Avolio 1992; Sankowsky 1995). Thedangers of narcissism and the associated misuse,and even abuse, of power were thus knownabout even at the height of the period whencharismatic and transformational leadershipwere being celebrated. There were even specificcase analyses where malign effects had beenexperienced in corporations such as PeoplesExpress, Polaroid-Kodak and Disney (Garrett1986; Berg 1976; Sankowsky 1995).Sankowsky explored the problems of exploitationof dependency among the followers ofcharismatic, narcissistic leaders. And the highlyregarded Manfred Kets de Vries has beenespecially notable for his clinical reflections onsome of the dysfunctional aspects of leadership(De Vries 1994; De Vries 2000).But these isolated warning signs have beenbrought together in a far more developedway in recent times to such a degree that thecharismatic- transformational model itself is nowbeing questioned. The research has also becomemore systematic and critical. For example,following a study of CEO successions in the US,Khurana (2002) found that the widespreadfaith in the power of charismatic leaders hadresulted in a number of problems. There wasan exaggerated belief in the impact of CEOs oncompanies because recruiters were pursuing thechimera of a special ‘type’ of individual. Therewas a further tendency for companies to neglectsuitable candidates while entertaining unsuitableones. Finally, appointed charismatic leaders wereproblematic because it was found they ‘candestabilise organisations in dangerous ways’(2002: 4).A common trait in the charismatic leadersstudied was their willingness to deliberatelyfracture their organisations as a means to effectchange. The destructive impact of a charismaticleader is exemplified by the case of Enron. ItsCEO Jeff Skilling, ‘induced blind obediencein his followers’, and while his abilities as a‘new economy strategist were overrated’ (heinstigated the shift to an asset-light positionfor the company), what he excelled at was‘motivating subordinates to take risks to thinkoutside the box - in short to do whatever pleasedhim’ (Khurana 2002: 7). The case illustrates thedangerous downside of charismatic leadership -the dismissal of normal checks and balances andthe impatience with, if not complete disregardof, convention and rule. These are of course thequalities which prompted their appointment andwhich helped shape their remit in the first place.As Khurana observes (2002: 8) the recent displayof ‘extraordinary trust in the power of charismaticCEO resembles less a mature faith than it does abelief in magic.’28 Towards a New Model of Leadership for the NHS

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