Towards a New Model of Leadership for the NHS
Towards a New Model of Leadership for the NHS
Towards a New Model of Leadership for the NHS
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ContentsForeword ......................................................................................................................................................................... 3Preface ............................................................................................................................................................................... 4Executive Summary .................................................................................................................................................. 6The Questions .............................................................................................................................................................. 7Elements <strong>for</strong> a new <strong>Leadership</strong> <strong>Model</strong> ...................................................................................................... 81 Provide and justify a clear sense <strong>of</strong> purpose and contribution ................................ 82 Motivate teams and individuals to work effectively ........................................................ 83 Focus on improving system per<strong>for</strong>mance ................................................................................. 8The case <strong>for</strong> <strong>the</strong>se elements .............................................................................................................................. 91 Communicate a clear sense <strong>of</strong> purpose and contribution ............................................ 102 Motivate teams and individuals to work effectively ........................................................ 133 Focus on improving system per<strong>for</strong>mance ................................................................................. 19Conclusions ..................................................................................................................................................................... 22Appendix 1: Outcomes associated with Staff Engagement ...................................................... 23Appendix 2: Summary <strong>of</strong> <strong>the</strong> main <strong>the</strong>ories <strong>of</strong> <strong>Leadership</strong> ....................................................... 26References ....................................................................................................................................................................... 292 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
ForewordI am delighted to introducethis paper which shares <strong>the</strong>beginning <strong>of</strong> <strong>the</strong> evidencebase underpinning our newleadership model. The <strong>NHS</strong>has and continues to bereally well served by leadersfrom all pr<strong>of</strong>essions.Although change in <strong>the</strong><strong>NHS</strong> is <strong>of</strong>ten preceded byenquiries into failures <strong>of</strong> care we tend to be lessquick to learn from success and what has gonewell.The <strong>NHS</strong>’ <strong>Leadership</strong> Framework (LF) has <strong>for</strong> overa decade described what good leadership lookslike and supported those entering <strong>the</strong>ir careeras well as those well established, to think moredeeply about what <strong>the</strong>y know and what <strong>the</strong>y cando as a leader. The LF has been an example <strong>of</strong>how 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 <strong>the</strong>ir styleand behaviours. A relentless focus on improvingleadership improves <strong>the</strong> climate and conditions<strong>for</strong> staff, which improves <strong>the</strong> care and treatment<strong>of</strong> our patients and communities. Technicalcompetence, pr<strong>of</strong>essional skills, managerialexcellence all contribute to good leadership but<strong>the</strong> real test <strong>of</strong> what separates those peoplein an organisation such as <strong>the</strong> <strong>NHS</strong> is <strong>the</strong> care,compassion and genuine investment in staffthat great leaders recognise as being <strong>the</strong> keydifference between adequate technical clinicalcare and great healthcare service.Karen LynasDeputy Managing Director andHead <strong>of</strong> Programmes and Practice Team<strong>NHS</strong> <strong>Leadership</strong> Academywww.leadershipacademy.nhs.uk 3
PrefaceThis paper was commissioned by <strong>the</strong> <strong>NHS</strong><strong>Leadership</strong> Academy as a contribution to thinkingabout <strong>the</strong> future development <strong>of</strong> leadershipin and around <strong>the</strong> <strong>NHS</strong>. It was prepared incollaboration with <strong>the</strong> Hay Group.The backdrop and one <strong>of</strong> <strong>the</strong> triggers was<strong>the</strong> launch <strong>of</strong> a new suite <strong>of</strong> pr<strong>of</strong>essionaldevelopment programmes sponsored andorganised by <strong>the</strong> <strong>NHS</strong> <strong>Leadership</strong> Academy.The programmes are:‘The first set <strong>of</strong> nationalprogrammes to combinesuccessful leadership strategiesfrom international healthcare,private sector organisationsand academic expert content.The difference is not just in<strong>the</strong> reach, <strong>the</strong>se are available<strong>for</strong> everyone in health and<strong>NHS</strong> funded care, but in scale,quality and approach. For <strong>the</strong>first time we are taking a single,national approach to leadershipdevelopment looking to supportour next generation <strong>of</strong> leaders.There are five programmes,designed to develop outstandingleaders <strong>for</strong> every tier across <strong>the</strong>healthcare system.’www.leadershipacademy.nhs.ukThe <strong>NHS</strong> is facing a whole array <strong>of</strong> unprecedentedchanges and challenges. There are resourceconstraints, new demands, new institutions,and high expectations from patients and <strong>the</strong>public that service and care will be deliveredefficiently, effectively and with compassion.To meet such an array <strong>of</strong> needs it is recognisedthat appropriate leadership is vital. Over <strong>the</strong>past decade, leadership frameworks <strong>for</strong> <strong>the</strong> <strong>NHS</strong>have been developed, including <strong>the</strong> current<strong>Leadership</strong> Framework (LF), which has done muchto organise thinking about what good leadershipbehaviour should constitute. These have fed intoleadership development, selection, appraisal andreward.However, given <strong>the</strong> scale <strong>of</strong> contemporary changeand challenge it is timely to review <strong>the</strong> leadershipbehaviours deemed appropriate <strong>for</strong> current andfuture circumstances. The new suite <strong>of</strong> leadershipdevelopment programmes at all levels in <strong>the</strong> <strong>NHS</strong>need to be properly in<strong>for</strong>med and supported bya common vision <strong>of</strong> behaviours based on researchevidence. Prioritisation <strong>of</strong> <strong>the</strong> required behaviourshas begun to shift. There are concerns aboutleadership in <strong>the</strong> <strong>NHS</strong> as a whole. It is timely andnecessary to revisit <strong>the</strong> research evidence abouteffective healthcare behaviours and <strong>the</strong> role <strong>of</strong>leadership in creating <strong>the</strong> right climate <strong>for</strong> <strong>the</strong>seto flourish and be sustained. The purpose <strong>of</strong> thispaper is to review <strong>the</strong> body <strong>of</strong> evidence whichcould contribute to a new <strong>Leadership</strong> <strong>Model</strong> <strong>for</strong><strong>the</strong> <strong>NHS</strong> fit <strong>for</strong> current and future purpose.In <strong>the</strong> immediately <strong>for</strong>thcoming period, <strong>the</strong> <strong>NHS</strong>will need to accentuate different, or at leastnewly-prioritised, staff behaviours. This, in turn,means <strong>the</strong>re will be a requirement <strong>for</strong> differentpriorities in leadership behaviours. Compassion,respect and humanity from frontline staff willevidently need to be better supported andengendered by a leadership community thatholds <strong>the</strong>se qualities as central to <strong>the</strong> core missionand purpose <strong>of</strong> <strong>the</strong> <strong>NHS</strong>.4 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
In pr<strong>of</strong>essional service organisations such as <strong>the</strong><strong>NHS</strong> <strong>the</strong>re is an understandable leaning towardsshared <strong>for</strong>ms <strong>of</strong> leadership. But confusion hasarisen about ‘distributed’, ‘dispersed’ and ‘sharedleadership’ as counterpoints to top-down, ‘heroic’leadership. While shared leadership has beenproductive, <strong>the</strong> idea has un<strong>for</strong>tunately also ledto a lack <strong>of</strong> clear thinking about <strong>the</strong> role to beplayed by those persons occupying leadershippositions.In recent years a command and control cultureand matching set <strong>of</strong> mechanisms and styleshas been seen to be prevalent. This has runalongside <strong>the</strong> <strong>Leadership</strong> Qualities Framework(LQF) and o<strong>the</strong>r frameworks which extolo<strong>the</strong>r more collaborative or participativeapproaches. This tells us that <strong>the</strong>re can bedissonance between expressed values, hardwiredregulatory mechanisms and everydayroutine practices. Ideally, an effective <strong>Leadership</strong><strong>Model</strong> would address both kinds <strong>of</strong> 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 <strong>the</strong>desired <strong>Leadership</strong> <strong>Model</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>. Theseemerging high priorities need to be reflectedin a leadership model suitable <strong>for</strong> <strong>the</strong> time.However <strong>the</strong> model also needs to allow space <strong>for</strong>o<strong>the</strong>r more directive aspects <strong>of</strong> leadership thatmay be crucial <strong>for</strong> particular circumstances, andwhich may also need to be present more broadly.<strong>Leadership</strong> can be seen as a process whichinvolves finding temporary resolutions betweenopposing principles, meeting <strong>the</strong> 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 <strong>the</strong> desired<strong>Leadership</strong> <strong>Model</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>.’www.leadershipacademy.nhs.uk 5
Executive SummaryThis paper stems from a request from <strong>the</strong> <strong>NHS</strong><strong>Leadership</strong> Academy and from Hay Group <strong>for</strong>a re-examination <strong>of</strong> <strong>the</strong> relevant literature onleadership. This request was in turn triggered by<strong>the</strong> launch <strong>of</strong> a new national suite <strong>of</strong> leadershipdevelopment programmes and deep anxietyabout <strong>the</strong> nature and adequacy <strong>of</strong> leadershipin <strong>the</strong> <strong>NHS</strong> following <strong>the</strong> scandals in MidStaf<strong>for</strong>dshire and elsewhere. While extensivework had been done over a decade and moreon leadership competences in healthcare,<strong>the</strong>re was a concern that more <strong>of</strong> <strong>the</strong> same wasquestionable <strong>for</strong> <strong>the</strong> <strong>for</strong>thcoming period <strong>of</strong>increased investment in leadership developmentacross <strong>the</strong> <strong>NHS</strong> at all levels. It was suggested thatit was timely to take a fresh look at <strong>the</strong> issue.We undertook an extensive review <strong>of</strong> <strong>the</strong>literature on leadership in healthcare andrelated services industries in order to identifycritical attributes. 1 On <strong>the</strong> basis <strong>of</strong> this review,we propose <strong>the</strong> following elements <strong>for</strong> a new<strong>Leadership</strong> <strong>Model</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong> organised underthree main headings. Each heading relatesto a category which in turn contains a set <strong>of</strong>behaviours. The approach is intended to helpdeal with <strong>the</strong> duality <strong>of</strong> shared leadership <strong>for</strong>mswhile also clarifying <strong>the</strong> behaviours expected <strong>of</strong>those occupying leadership positions in <strong>the</strong> <strong>NHS</strong>.The first category is ‘Provide and justify aclear sense <strong>of</strong> purpose and contribution’. Thisembraces behaviours and skills which enable anexplicit focus on <strong>the</strong> needs and experiences <strong>of</strong>service users, continually rein<strong>for</strong>cing an inspiringvision <strong>of</strong> <strong>the</strong> mission and social contribution <strong>of</strong><strong>the</strong> organisation or unit, couched in terms <strong>of</strong>service quality. It also includes behaviours whichfoster attention to and interpretations <strong>of</strong> <strong>the</strong>wider environment, including policy frameworks,systems <strong>of</strong> accountability and evidence oneffective health care.The second category refers to behavioursand skills related to ‘<strong>the</strong> motivation <strong>of</strong> teamsand individuals to work effectively’. This alsoconcerns <strong>the</strong> wider ability to work in closercollaboration with o<strong>the</strong>r 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 <strong>of</strong><strong>the</strong> belief that both staff and service users arevalued. Effective leaders encourage high staffinvolvement and engagement by allowingautonomy within a framework <strong>of</strong> values andgoals focussed on meeting user needs. They alsoprovide and operate meaningful designs <strong>for</strong>organisations, sub-units and individual jobs whichare underpinned by HRM systems that providerelevant staff development and reward. Suchleaders manage and improve per<strong>for</strong>mance ra<strong>the</strong>rthan merely report it. They utilise a variety <strong>of</strong>perspectives to manage per<strong>for</strong>mance including<strong>the</strong> use <strong>of</strong> ‘s<strong>of</strong>t’ intelligence, ra<strong>the</strong>r thanfocussing only on a narrow range <strong>of</strong> hierarchicallyimposed targets or indicators. They also listento staff and respond to <strong>the</strong>ir voice; <strong>the</strong>y validateand engage positively with difficult or negativeemotions evoked by <strong>the</strong> experience <strong>of</strong> deliveringcare ra<strong>the</strong>r than seeking to suppress or deny<strong>the</strong>m.The third category refers to a ‘focus onimproving system per<strong>for</strong>mance’. This meansenacting and encouraging <strong>the</strong> practice <strong>of</strong> serviceimprovement, constructing compelling cases<strong>for</strong> change and carefully constructing plans <strong>for</strong>change based on a variety <strong>of</strong> kinds <strong>of</strong> evidence.It also means addressing system problems andpursuing innovation, initiating new structuresand processes, and finding ways to intervenein<strong>for</strong>mally in patterns <strong>of</strong> thinking and acting.Finally, it means modelling <strong>the</strong> learning <strong>of</strong> newbehaviours. This in turn requires <strong>the</strong> <strong>for</strong>ming <strong>of</strong>accurate assessments <strong>of</strong> <strong>the</strong>ir own and <strong>the</strong>ir unit’seffectiveness, identify new ways <strong>of</strong> workingappropriate to changing circumstances whiledemonstrating a willingness to reveal some selfdoubtand acknowledge mistakes.Each <strong>of</strong> <strong>the</strong> elements and <strong>the</strong> sub-elements aregrounded in <strong>the</strong> research literature.1We wish to acknowledge <strong>the</strong> invaluable advice provided by Pr<strong>of</strong>essor MichaelWest <strong>of</strong> Lancaster University, and by David Barnard, Sharon Crabtree andLubna Haq from <strong>the</strong> Hay Group.6 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
The QuestionsThe overall goal <strong>of</strong> this paper is to <strong>of</strong>fer a viewon <strong>the</strong> emerging consensus as to what ‘goodleadership in healthcare’ looks like. It draws onexisting leadership frameworks in health care,academic <strong>the</strong>ory and analysis about <strong>the</strong> nature <strong>of</strong>leadership currently required in healthcare, andrigorous empirical research about <strong>the</strong> outcomes<strong>of</strong> leadership. It will seek to answer two mainquestions:• What should be <strong>the</strong> core elements in a new<strong>Leadership</strong> <strong>Model</strong> fit <strong>for</strong> <strong>the</strong> <strong>NHS</strong> <strong>of</strong> <strong>the</strong> future?• What evidence is <strong>the</strong>re, in health care or anyo<strong>the</strong>r relevant sector, <strong>of</strong> a link between <strong>the</strong>seleadership elements and service outcomes?It is important to draw not only upon researchconducted within <strong>the</strong> <strong>NHS</strong> and indeed withinhealth care but also to consider insights gainedin o<strong>the</strong>r sectors and o<strong>the</strong>r countries. Significantresearch has taken place on <strong>the</strong> role <strong>of</strong> leadershipin fostering high levels <strong>of</strong> customer service inretail and o<strong>the</strong>r competitive settings. Likewise,important research on safety has taken placein airlines, oil drilling rigs and nuclear fuelgeneration. O<strong>the</strong>r work has revealed <strong>the</strong>ways in which service-focused enterprises inretail, hospitality and o<strong>the</strong>r service-orientedorganisations have used leadership as a means todrive customer satisfaction and customer loyalty.www.leadershipacademy.nhs.uk 7
Elements <strong>for</strong> a new<strong>Leadership</strong> <strong>Model</strong>We propose <strong>the</strong> following elements <strong>for</strong> a new <strong>Leadership</strong> <strong>Model</strong><strong>for</strong> <strong>the</strong> <strong>NHS</strong> as organised within three main categories.1. Provide and justify a clear sense <strong>of</strong>purpose and contribution1.1 Focus explicitly on <strong>the</strong> needs andexperiences <strong>of</strong> service users, continuallyrein<strong>for</strong>cing an inspiring vision <strong>of</strong> <strong>the</strong> missionand social contribution <strong>of</strong> <strong>the</strong> organisationor unit, couched in terms <strong>of</strong> service quality1.2 Interpret <strong>the</strong> wider environment, <strong>for</strong>example policy frameworks, systems <strong>of</strong>accountability and evidence on effectivehealth care; making sense <strong>of</strong> what <strong>the</strong>serequire <strong>of</strong> <strong>the</strong> organisation and staff,including <strong>the</strong> need to work in closercollaboration with o<strong>the</strong>r 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 <strong>of</strong> values and goals focussed onmeeting user needs2.4 Provide and operate meaningful design<strong>for</strong> organisations, sub-units and individualjobs, with underpinning Human ResourceManagement (HRM) systems that providerelevant staff development and reward2.5 Manage and improve per<strong>for</strong>mance ra<strong>the</strong>rthan merely reporting it, with openness toa variety <strong>of</strong> perspectives on per<strong>for</strong>manceincluding ‘s<strong>of</strong>t’ intelligence, ra<strong>the</strong>r thanfocussing on a narrow range <strong>of</strong> hierarchicallyimposed targets or indicators2.6 Listen to staff and respond to <strong>the</strong>ir voice,validate and engage with difficult ornegative emotions evoked by <strong>the</strong> experience<strong>of</strong> delivering care, ra<strong>the</strong>r than suppress ordeny <strong>the</strong>m3. Focus on improving systemper<strong>for</strong>mance3.1 Enact and encourage <strong>the</strong> practice <strong>of</strong> serviceimprovement, with compelling cases <strong>for</strong>change and carefully constructed plans<strong>for</strong> change based on a variety <strong>of</strong> kinds <strong>of</strong>evidence3.2 Address system problems and pursueinnovation, initiate new structures andprocesses; find ways to intervene in<strong>for</strong>mallyin patterns <strong>of</strong> thinking and acting3.3 <strong>Model</strong> learning <strong>of</strong> new behaviours: <strong>for</strong>maccurate assessments <strong>of</strong> own and uniteffectiveness, and identify new ways <strong>of</strong>working appropriate <strong>for</strong> new and changingcircumstances, coupled with a willingnessto show some self-doubt and acknowledgemistakes.8 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
The Case <strong>for</strong> <strong>the</strong>se ElementsIn what follows, we now summarise undereach main heading and individual element<strong>the</strong> underlying thinking and research evidenceas drawn from a variety <strong>of</strong> sources includingacademic papers, existing competency modelsand recent <strong>NHS</strong> policy documents that have ledus to proposal this model <strong>of</strong> leadership fit <strong>for</strong>contemporary circumstances and challenges.We have been mindful <strong>of</strong> <strong>the</strong> healthcare - andindeed more specifically <strong>the</strong> <strong>NHS</strong> - context. Thus,<strong>the</strong> selection <strong>of</strong> proposed categories and subcategoriesis influenced by healthcare challenges.Accordingly, <strong>the</strong>se categories are somewhatmore focused than <strong>the</strong> four category taxonomyproposed by Gary Yukl directed at multiplesettings and diverse industries (Yukl 2012).1 Provide and justify a clear sense<strong>of</strong> purpose and contribution2 Motivate teams and individualsto work effectively3 Focus on improvingsystem per<strong>for</strong>mancewww.leadershipacademy.nhs.uk 9
1. Communicate a clear sense <strong>of</strong> purpose and contributionThe idea <strong>of</strong> defining <strong>the</strong> direction <strong>for</strong>organisations or subunits is a central component<strong>of</strong> almost all conceptions <strong>of</strong> leadership andleadership frameworks. It is represented in <strong>the</strong><strong>Leadership</strong> Framework (LF), within <strong>the</strong> domains<strong>of</strong> Setting Direction, applicable at all levels, andCreating <strong>the</strong> Vision, applicable at senior levels.In <strong>the</strong> current context, following <strong>the</strong> FrancisReport (2013) <strong>the</strong>re is arguably a need to bringmore to <strong>the</strong> <strong>for</strong>eground <strong>the</strong> social purpose andmeaningful contribution <strong>of</strong> <strong>NHS</strong> and <strong>NHS</strong>-fundedorganisations. Providing overall direction includesneeds to encompass streng<strong>the</strong>ning a sense <strong>of</strong> <strong>the</strong>responsibility and contribution to society thatorganisations, teams and individuals are chargedwith, in accord with <strong>NHS</strong> values. This gives rise to<strong>the</strong> following two elements.1.1 Focus explicitly on <strong>the</strong> needs andexperiences <strong>of</strong> service users, continuallyrein<strong>for</strong>cing an inspiring vision <strong>of</strong> <strong>the</strong> missionand social contribution <strong>of</strong> <strong>the</strong> organisationor unit, couched in terms <strong>of</strong> service qualityThe needs to focus on patient safety and tounderstand <strong>the</strong> needs <strong>of</strong> users in shaping <strong>the</strong>development <strong>of</strong> health services are present in<strong>the</strong> LF. They are a central <strong>the</strong>me in Liberating <strong>the</strong><strong>NHS</strong> (2011), <strong>the</strong> White Paper underlying curren<strong>the</strong>alth service re<strong>for</strong>ms. The Francis Report (2013)emphasises <strong>the</strong> role <strong>of</strong> leadership in prioritisingpatient safety and in listening to and learningfrom patients. The significance <strong>of</strong> this strategicfocus on patients and users is supported bya growing body <strong>of</strong> recent research on serviceeffectiveness in health care as well as in o<strong>the</strong>rkinds <strong>of</strong> services.One <strong>of</strong> <strong>the</strong> more influential frameworks is <strong>the</strong>‘customer service pr<strong>of</strong>it chain’ concept (Heskett,Jones et al. 1994; Heskett, Sasser et al. 1997). Theservice-pr<strong>of</strong>it chain framework seeks to showrelationships between pr<strong>of</strong>itability, customerloyalty, and employee satisfaction, employeeloyalty, and productivity. The proposition is that,in a service industry, pr<strong>of</strong>it and growth derivefrom customer loyalty. This in turn is a directresult <strong>of</strong> customer satisfaction, and satisfactionis largely influenced by <strong>the</strong> value <strong>of</strong> 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-pr<strong>of</strong>it chain, summarizedin <strong>the</strong> diagram below, is defined by a mode <strong>of</strong>leadership that emphasizes <strong>the</strong> importance <strong>of</strong>each employee and customer. The work wasillustrated in <strong>the</strong> United States in <strong>the</strong> case <strong>of</strong><strong>the</strong> retailer Sears amongst o<strong>the</strong>rs (Heskett et al.1997).<strong>Leadership</strong> that emphasises employees and customers + Quality support services and policiesSatisfied, loyal, and productive employeesValued services provided by staffCustomer satisfactionOrganisational success, growth (and pr<strong>of</strong>it)10 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
The specific role <strong>of</strong> <strong>the</strong> leader within <strong>the</strong> servicepr<strong>of</strong>itchain framework has been explored. Suchleaders develop and maintain a culture that isfocused on service to customers and employees.They are effective listeners with both <strong>the</strong>ability and willingness to listen. These are highengagement leaders that spend time with <strong>the</strong>iremployees and customers, test <strong>the</strong>ir servicedelivery processes, and actively seek employeesuggestions <strong>for</strong> improvement. In addition, <strong>the</strong>ydemonstrate real care and concern <strong>for</strong> employeesas demonstrated by how <strong>the</strong>y select <strong>the</strong>m,tracking and guide <strong>the</strong>ir development, andproactively recognize <strong>the</strong>m (Reichheld and Sasser1990).This work has been built on by Hong et al.(2013) who focus strongly on <strong>the</strong> mediatingrole <strong>of</strong> ‘service climate’ as <strong>the</strong> ‘missing link’between HR practices and leadership behavioursas antecedents and outcomes <strong>of</strong> various kindsincluding employee attitudes and behavioursand customer outcomes. This work would seemto have direct relevance to leadership andmanagement in <strong>the</strong> <strong>NHS</strong>. The authors argue that<strong>the</strong> role and work <strong>of</strong> leadership is to constructa positive service climate. Their meta-analysis <strong>of</strong>58 studies provides convincing statistical support<strong>for</strong> a strong association between this linkage and<strong>the</strong> subsequent linkages to employee outcomesand in turn customer outcomes (satisfaction andloyalty).The studies suggest that effective leadership<strong>the</strong>re<strong>for</strong>e has twin components: general highper<strong>for</strong>manceorientation supplanted by a specialservice-orientation. Trans<strong>for</strong>mational leaders whoexcel in service settings engage in behaviourssuch as:‘Articulating a compelling vision <strong>of</strong> customerservice, inspiring enthusiasm and optimism aboutwinning customers loyalty, serving as employee’scharismatic role model in service, encouragingnew ways <strong>of</strong> serving customers, and recognisingemployees’ individual needs and contributions.’Liao and Chuang, 20071.2 Interpret <strong>the</strong> wider environment, <strong>for</strong>example policy frameworks, systems <strong>of</strong>accountability and evidence on effectivehealth care; making sense <strong>of</strong> what <strong>the</strong>serequire <strong>of</strong> <strong>the</strong> organisation and staff,including <strong>the</strong> need to work in closercollaboration with o<strong>the</strong>r organisations oroccupations.This element is again already representedwithin <strong>the</strong> LF within <strong>the</strong> Setting Direction andCreating <strong>the</strong> Vision domains. These emphasise<strong>the</strong> importance <strong>of</strong> understanding stakeholdersand <strong>the</strong> range <strong>of</strong> requirements <strong>the</strong>y place onan organisation or a unit, as well as <strong>the</strong> need toassimilate relevant evidence on new or improvedways <strong>of</strong> organising or providing care. Suchpriorities also widely present within o<strong>the</strong>r recentanalyses <strong>of</strong> health care leadership. For example<strong>the</strong> Health Foundation (Hardacre 2011) identifiedkey leadership behaviours including:• Explains <strong>the</strong> need <strong>for</strong> change and inspirescommitment to <strong>the</strong> process• Unites staff around an inspiring vision andaligns staff capabilities with planned activities• Takes a helicopter view <strong>of</strong> <strong>the</strong> system tooversee short and long term issuesGiven <strong>the</strong> complexity and continual change insystems <strong>of</strong> <strong>NHS</strong> organisation and accountability,<strong>the</strong>re are strong arguments that making sense<strong>of</strong> what is required <strong>of</strong> organisations and teamswill become increasingly important (Storey etal 2010). The need to recognise <strong>the</strong> importance<strong>of</strong> collaboration and effective working acrossorganisational boundaries is widely recognisedin a wider range <strong>of</strong> policy documents concerning<strong>the</strong> desirability <strong>of</strong> improving integration betweenprimary and acute health services, and betweenhealth and social care (National Association<strong>for</strong> Primary Care, <strong>NHS</strong> Confederation and <strong>NHS</strong>Alliance 2013).www.leadershipacademy.nhs.uk 11
The significance <strong>of</strong> this element is well groundedin recent academic debates and research. (Hartleyand Bennington 2011) emphasise both politicalastuteness and <strong>the</strong> importance <strong>of</strong> making cases<strong>for</strong> change based on evidence and argument.Numerous surveys reveal that large numbers<strong>of</strong> respondents identify leadership as a processinvolving <strong>the</strong> display <strong>of</strong> vision, strategic sense, anability to communicate that vision and strategy,and an ability to inspire and motivate (Council <strong>for</strong>Excellence in Management & <strong>Leadership</strong> 2001;Storey 2011).Recent years have witnessed increased use <strong>of</strong>targets. 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,<strong>the</strong>y conclude, more effective when it is peopleorientedin <strong>the</strong> sense <strong>of</strong> being able to elicitunderstanding <strong>of</strong> goals and commitment frompeople than it is when based on cruder <strong>for</strong>ms <strong>of</strong>target-setting and measurement.One recent stream <strong>of</strong> <strong>the</strong>orising focuses on <strong>the</strong>meaning-making behaviour <strong>of</strong> leaders (Polodny.et al. 2010). Here, ‘leaders’ are those whointerpret <strong>the</strong> complexities <strong>of</strong> <strong>the</strong> given unit within<strong>the</strong> environment on behalf <strong>of</strong> <strong>the</strong> followers.Leaders thus make sense <strong>of</strong> <strong>the</strong> plight <strong>of</strong> <strong>the</strong>collective - weighing up threats and opportunitiesin <strong>the</strong> environment, and evaluating <strong>the</strong>strengths and weaknesses <strong>of</strong> <strong>the</strong> unit within thatenvironment. The capabilities required are thosefrequently described in recent trans<strong>for</strong>mativeliterature: clarity <strong>of</strong> vision; environment scanningand interpretation, ability to condense complexdata into simple compelling summations; andability to communicate clear messages.‘Big picture sense-making’ includes <strong>the</strong> abilityto scan and interpret <strong>the</strong> environment; todifferentiate threats to, and opportunities <strong>for</strong>,<strong>the</strong> organisation; to assess <strong>the</strong> organisations’strengths and weaknesses; and to constructa sensible vision, mission and strategy. As isconstantly emphasised in <strong>the</strong> literature and in<strong>the</strong> dominant mode <strong>of</strong> thinking over <strong>the</strong> pastcouple <strong>of</strong> decades, <strong>the</strong> result <strong>of</strong> this big picturework may entail a trans<strong>for</strong>mative agenda <strong>for</strong> <strong>the</strong>focal organisation. Indeed, <strong>the</strong> distinct impressionis easily gained that in modern perception,leadership work is <strong>of</strong> this nature almost bydefinition. Steady-state maintenance, it <strong>of</strong>tenappears, is not so much one variant <strong>of</strong> leadershipas one might logically suppose, but ra<strong>the</strong>r is afunction <strong>of</strong> that ‘o<strong>the</strong>r’ subordinate position,namely, management. What this expresses <strong>of</strong>course is that leadership is closely identified withchange-making. The crucial capability here <strong>the</strong>n isto correctly discern <strong>the</strong> direction <strong>of</strong> change.The importance <strong>of</strong> explaining <strong>the</strong> need <strong>for</strong>effective 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 fur<strong>the</strong>r capabilityconcerns inter-organisational representationand <strong>the</strong> ambassadorial role. While this is a vitalcapability <strong>for</strong> a chief executive in a private sectorcompany it is one which has reached specialprominence in <strong>the</strong> public sector as a result <strong>of</strong> <strong>the</strong>increasing requirement <strong>for</strong> inter-agency working.Indeed, <strong>the</strong> cluster <strong>of</strong> capabilities required to‘lead’ in a network context is one <strong>of</strong> <strong>the</strong> keycurrent <strong>the</strong>mes in <strong>the</strong> leadership debate. Skillssuch as coalition building, understanding o<strong>the</strong>rs’perspectives, persuasion, and assessing clientneeds in a holistic ra<strong>the</strong>r than a single agencymanner become <strong>the</strong> premium requirements.‘Numerous surveys reveal thatlarge numbers <strong>of</strong> respondentsidentify leadership as a processinvolving <strong>the</strong> display <strong>of</strong> vision,strategic sense, an ability tocommunicate that vision andstrategy, and an ability to inspireand motivate.’12 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
2. Motivate teams and individuals towork effectivelyWorking with teams to deliver and indeedimprove services features prominently in <strong>the</strong>LF and several o<strong>the</strong>r frameworks <strong>for</strong> describinggood leadership in health. This is borne out by anumber <strong>of</strong> academic studies which conceptualisegood leadership as that which encourages andinculcates a set <strong>of</strong> behaviours which are positivelyoriented to <strong>the</strong> service quality experience<strong>of</strong> <strong>the</strong> end-user (Alimo-Metcalf and Alban-Metcalf 2012; King’s Fund 2012; Hong, Liao etal. 2013). These studies make <strong>the</strong> case that inservice organisations such as <strong>the</strong> <strong>NHS</strong> an optimalapproach to leadership is one which has andcommunicates clear objectives, and which focuseson creating a supportive and positive climatewhich encourages staff to give <strong>the</strong>ir 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 <strong>the</strong>leader is not in direct personal contact with<strong>the</strong> followers - perhaps because <strong>of</strong> <strong>the</strong>ir largenumber - and so has to lead through <strong>the</strong> multipletiers using means o<strong>the</strong>r than inter-personal skills.Different kinds <strong>of</strong> leadership capabilities areneeded <strong>for</strong> <strong>the</strong> accomplishment <strong>of</strong> <strong>the</strong>se differentroles. It is also worth noting that <strong>the</strong>re may bemisalignment <strong>of</strong> <strong>the</strong> 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 <strong>the</strong> Ohio State University studies <strong>of</strong> <strong>the</strong>1940s which distinguished between two broadleadership orientations: consideration versusinitiating structure (Stogdill 1950; Stogdill 1974).Consideration is a leadership behaviour showinga concern and respect <strong>for</strong> 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 per<strong>for</strong>mance. Judgeet al conclude that while <strong>the</strong>re had been somerelative neglect <strong>of</strong> <strong>the</strong>se two constructs in recentyears, <strong>the</strong> results <strong>of</strong> <strong>the</strong> meta-analysis were strongenough to merit a revived attention to <strong>the</strong>irimportance. Much contemporary work whe<strong>the</strong>rexplicitly referencing <strong>the</strong>se two dimensions or notowes a good deal to <strong>the</strong>m.The perceived over-emphasis in <strong>the</strong> <strong>NHS</strong> onstructure, task and targets and <strong>the</strong> suggestedre-balancing towards a staff support orientationechoes <strong>the</strong> consideration <strong>the</strong>me. In <strong>the</strong> new<strong>NHS</strong> it will be important <strong>for</strong> leaders to payclose attention to setting <strong>the</strong> 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 <strong>the</strong> academic and researchbasis <strong>for</strong> a numbers <strong>of</strong> 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 <strong>for</strong> <strong>the</strong> importance <strong>of</strong> aleadership mode which sets <strong>the</strong> appropriateemotional climate and which in turn can lead topositive ‘emotional contagion’ is that throughwhich <strong>the</strong>se 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, <strong>the</strong> service pr<strong>of</strong>it chain <strong>the</strong>ory suggeststhat customer satisfaction <strong>of</strong> this kind will alsoresult in superior financial per<strong>for</strong>mance <strong>for</strong> thoseorganisations and units able to induce suchsatisfactions (Schneider and Ehrhart 2005).The core purpose <strong>of</strong> constructing a service climateis to link leadership with <strong>the</strong> customer and beyondthat with <strong>the</strong> ultimate purpose <strong>of</strong> <strong>the</strong> organisationwhe<strong>the</strong>r that be pr<strong>of</strong>it or public service impact.That relationship is achieved via a series <strong>of</strong> chainlinkages built around desirable behaviours amongemployees. Hence, service-oriented leadershipmeans consciously attending to this above andbeyond <strong>the</strong> baseline <strong>of</strong> more general highper<strong>for</strong>manceor good practice HR.‘The finding that ‘service-oriented leadershipcontributed to service climate more strongly thangeneral leadership suggests that training andper<strong>for</strong>mance assessment programmes can bedeveloped to specifically improve leaders’ serviceorientation. Having a precise understanding <strong>of</strong><strong>the</strong> relative strengths <strong>of</strong> service oriented HR andleadership over general HR and leadership willfurnish useful guidance <strong>for</strong> managers balancingsuch trade-<strong>of</strong>fs in allocating resources’Hong, Liao et al. 2013: 253In similar vein, a study <strong>of</strong> 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 serviceper<strong>for</strong>mance. In particular, conscientiousnessand extraversion explained within-store variancewhereas service climate and employee involvementexplained between-store variance. Additionally,employee service per<strong>for</strong>mance aggregated to <strong>the</strong>store level explained between-store variance incustomer satisfaction and loyalty (2004).The implication <strong>of</strong> many <strong>of</strong> <strong>the</strong> studies cited so faris that leaders need to shape <strong>the</strong> 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 promulgate<strong>the</strong> service message, <strong>the</strong>re will be a problematicfilter unless <strong>the</strong> immediate supervisor alsorein<strong>for</strong>ces <strong>the</strong> employee’s climate perceptions.Such research is part <strong>of</strong> a wider trend whichemphasise <strong>the</strong> role <strong>of</strong> leadership in creating <strong>the</strong>emotional environment <strong>of</strong> work. This builds onextensive work in <strong>the</strong> area <strong>of</strong> ‘organizationalcitizenship behaviour’ (OCB). This refers toindividual behaviour which is ‘discretionary, notdirectly or explicitly recognized by <strong>the</strong> <strong>for</strong>malreward system, and that in <strong>the</strong> aggregatepromotes <strong>the</strong> effective functioning <strong>of</strong> <strong>the</strong>organisation’ (Organ 1988). OCB has been a veryinfluential construct <strong>for</strong> two decades though it isnot without controversy. It is a multi-dimensionalconstruct which includes, <strong>for</strong> example, notions <strong>of</strong>altruism, compliance and <strong>the</strong> exercise <strong>of</strong> discretion.Field studies in <strong>the</strong> areas <strong>of</strong> service work haveexplored <strong>the</strong>se non-contractual aspects such ascourtesy, smiling, and related customer-friendlybehaviours. This work is <strong>of</strong> clear relevance tohealthcare work and seems especially relevant tocurrent concerns about compassion and caring and<strong>of</strong> <strong>the</strong>ir neglect and/or presence. Related work <strong>of</strong>relevance concerns concepts such as ‘emotionalcontagion’ (Pugh 2001). This refers to <strong>the</strong> tendency<strong>for</strong> people to be influenced by <strong>the</strong> emotions feltby o<strong>the</strong>rs in a social group.14 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
A contagion <strong>of</strong> negative emotions would not beproductive <strong>for</strong> most organisations - and certainlynot service organisations in particular.A fur<strong>the</strong>r highly relevant body <strong>of</strong> research inorganisational psychology and in organisationalsociology is devoted to <strong>the</strong> nature <strong>of</strong> ‘emotionallabour’ (Hochschild 1983). This deals with <strong>the</strong>management <strong>of</strong> emotions so that <strong>the</strong>y areconsistent with organisational and occupationalexpectations. Workers in service industries suchas healthcare, retail and hospitality are <strong>of</strong>tenexpected to smile at customers and to displayo<strong>the</strong>r outward sides <strong>of</strong> positive emotions. Forexample, clinical empathy during <strong>the</strong> 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 influence<strong>the</strong> emotions <strong>of</strong> o<strong>the</strong>rs. A relevant <strong>the</strong>me hereis <strong>the</strong> idea <strong>of</strong> ‘emotional contagion’ (Hatfield,Cacioppo et al. 1993). This may work in a negativedirection - that is, a set <strong>of</strong> 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 <strong>the</strong> by-product <strong>of</strong>intentional affective impression management(Kelly and Barsade 2001). The crucial pointconcerning leadership in healthcare settings isthat leaders should seek to help create a climatewhich discourages <strong>the</strong> negative sets <strong>of</strong> 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 <strong>of</strong> values and goals focussed onmeeting user needsThe constructs <strong>of</strong> service orientation andpositive attitudes have in recent times also beenapproached through <strong>the</strong> notion <strong>of</strong> ‘employeeengagement.’ In <strong>the</strong> case <strong>of</strong> <strong>the</strong> <strong>NHS</strong> this is seenstrongly in <strong>the</strong> work <strong>of</strong> <strong>the</strong> King’s Fund whichin recent reports has linked leadership andengagement (King’s Fund 2012). This accords with<strong>the</strong> idea <strong>of</strong> ‘Engaging <strong>Leadership</strong>’ (Alimo-Metcalfand Alban-Metcalf 2012).Practitioners tend to use <strong>the</strong> term engagementas associated with involvement in managerialdecision making. And <strong>the</strong>y quote <strong>the</strong> <strong>NHS</strong>Constitution which pledges ‘to engage staff indecisions that affect <strong>the</strong>m and <strong>the</strong> services <strong>the</strong>yprovide, individually through representativeorganisations and through local partnershipworking arrangements. All staff will beempowered to put <strong>for</strong>ward ways to deliver betterand safer services <strong>for</strong> patients and <strong>the</strong>ir families’(Department <strong>of</strong> Health 2009). Thus, from thisperspective engagement is about involvementand participation. The implication <strong>for</strong> leadershipis that opportunities <strong>for</strong> involvement should beprovided and staff encouraged to participate,and to be involved. While taking such stepsnaturally cannot guarantee <strong>the</strong> state <strong>of</strong>psychological engagement, such measures can beseen as logical steps in that direction.Empirical support <strong>for</strong> <strong>the</strong> link betweenengagement and per<strong>for</strong>mance can be found ina number <strong>of</strong> studies. A study in <strong>the</strong> Ne<strong>the</strong>rlandsused data from a survey <strong>of</strong> 2115 residentphysicians and found that doctors who scoredmore highly on engagement were less likely tomake mistakes (Prins, Hockstra-Weebers et al.2010). A study <strong>of</strong> 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 <strong>the</strong>importance <strong>of</strong> moving from <strong>the</strong> pace-setting,command and control and target-drivenapproach. This is seen as having deliveredachievement <strong>of</strong> some targets but at a cost. Theycite <strong>the</strong> Commission on Dignity in Care <strong>for</strong> OlderPeople which identified <strong>the</strong> top-down culture asa cause <strong>of</strong> poor care: ‘If senior managers imposeas command and control culture that demoralisesstaff and robs <strong>the</strong>m <strong>of</strong> authority to makedecisions poor care will follow’ (cited in King’sFund 2012).In <strong>the</strong> report on <strong>the</strong> Commission on <strong>Leadership</strong>subtitled No More Heroes (King’s Fund 2011)<strong>the</strong>re was a call <strong>for</strong> <strong>the</strong> <strong>NHS</strong> to shift from <strong>the</strong>old ‘heroic’ model <strong>of</strong> leadership by individualstypified by <strong>the</strong> ‘turnaround chief executive’ tomake way <strong>for</strong> a more inclusive <strong>for</strong>m <strong>of</strong> leadership.A year later a fur<strong>the</strong>r report amplified that caseand elaborated <strong>the</strong> characteristic features <strong>of</strong>an engaged <strong>for</strong>m <strong>of</strong> leadership (King’s Fund2012). This made <strong>the</strong> case <strong>for</strong> engaging staff,patients, <strong>the</strong> board and o<strong>the</strong>r stakeholders. Sixdifferent styles <strong>of</strong> leadership were sketched bya consultant from Hay Group (Santry 2011). Ofthis repertoire <strong>NHS</strong> managers were said to be tooreliant on ‘pace-setting’ - that is an over-relianceon demanding targets, leading from <strong>the</strong> front,and a reluctance to delegate. It has been arguedthat an over-reliance on pace-setting leadershipreflected <strong>the</strong> priority to move <strong>the</strong> <strong>NHS</strong> from alow base. It now needs to be complementedmore <strong>of</strong>ten with o<strong>the</strong>r styles <strong>of</strong> leadership tomeet new circumstances. The damage caused byover-dominant chief executive on Trust Boardswas demonstrated by research conducted acrossall <strong>NHS</strong> Trust, Foundation Trusts and Primary CareTrusts (Storey et al 2010).The Kings Fund find some signs <strong>of</strong> optimism in<strong>the</strong> expressed intent <strong>of</strong> <strong>the</strong> <strong>NHS</strong> CommissioningBoard (now <strong>NHS</strong> England) in its publicationDeveloping <strong>the</strong> <strong>NHS</strong> Commissioning Board thatit will not seek to micro-manage <strong>the</strong> clinicalcommissioning groups (CCGs) but will seek tocoach and develop <strong>the</strong>m (Department <strong>of</strong> Health2011).The antecedents <strong>of</strong> engagement in healthcarecan be varied. A study <strong>of</strong> 409 Finnish healthworkers found that job control was <strong>the</strong> bestpredictor <strong>of</strong> <strong>the</strong> level <strong>of</strong> 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 <strong>the</strong>ymay need to attend to factors ranging fromjob design to resource availability as well as <strong>the</strong>promotion <strong>of</strong> self-esteem and <strong>the</strong> creation <strong>of</strong> apositive climate.This research and o<strong>the</strong>rs like it have emphasized<strong>the</strong> crucial need to engage clinicians and o<strong>the</strong>rstaff in owning <strong>the</strong> joint enterprise to improveand sustain care. This different approachto leadership emphasises building sharedvisions across a range <strong>of</strong> staff and a range <strong>of</strong>stakeholders.16 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
These findings are given fur<strong>the</strong>r support by <strong>the</strong>analyses <strong>of</strong> <strong>the</strong> <strong>NHS</strong> staff attitude surveys (West2012). Drawing on data from <strong>the</strong> annual <strong>NHS</strong>Staff Survey and o<strong>the</strong>r sources, <strong>the</strong> report ‘showshow good management <strong>of</strong> <strong>NHS</strong> staff leads tohigher quality <strong>of</strong> care, more satisfied patients andlower patient mortality’ (2012: 2).‘By giving staff clear direction, good support andtreating <strong>the</strong>m fairly and supportively, leaderscreate cultures <strong>of</strong> engagement, where dedicated<strong>NHS</strong> staff in turn can give <strong>of</strong> <strong>the</strong>ir best in caring<strong>for</strong> patients. The analysis <strong>of</strong> <strong>the</strong> data shows thiscan be achieved by focusing on <strong>the</strong> quality <strong>of</strong>patient care; ensuring that all staff and <strong>the</strong>irteams 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 <strong>the</strong>se elements toge<strong>the</strong>r canlead to high quality patient care and effectivefinancial per<strong>for</strong>mance. Employee engagementis shown to be especially important. This inturn is seen as fostered by effective leadershipand management. A number <strong>of</strong> 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,<strong>the</strong> better <strong>the</strong> outcomes <strong>for</strong> patients and <strong>the</strong>organisation generally’ (West 2012).These correlations are shown in more detail inAppendix 1. The results reported were derivedfrom a variety <strong>of</strong> methods, data sets and years.2.4 Provide and operate meaningful design<strong>for</strong> organisations, sub-units and individualjobs, with underpinning HRM systems thatprovide relevant staff development andrewardThe analysis <strong>of</strong> <strong>the</strong> results <strong>of</strong> <strong>the</strong> 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 <strong>the</strong> setting <strong>of</strong> clearobjectives, and making sure that <strong>the</strong> appraisal isrelevant and helpful in improving how to do <strong>the</strong>job, and that <strong>the</strong> employee is left feeling valuedby <strong>the</strong>ir employer. Ano<strong>the</strong>r associated factor isworking in a well-structured team environmentwhere teams have clear shared objectives, workinterdependently and meet regularly to discuss<strong>the</strong>ir effectiveness. Ano<strong>the</strong>r factor is havinggood job design. This means having meaningful,clear tasks <strong>for</strong> both individuals and teams, sothat it is possible <strong>for</strong> individuals and groupsto feel responsibility <strong>for</strong> managing <strong>the</strong>ir ownper<strong>for</strong>mance, with some opportunity to beinvolved in appropriate decision making. Theseare also ‘linked to employee health, which is alsoimportant <strong>for</strong> engagement: high levels <strong>of</strong> workpressure and stress can lead to disaffection anddisengagement’ (West 2012: 2).Similarly <strong>the</strong> model developed by Hong et al(2013) includes ‘general HR practices’ as wellas ‘service-oriented HR practices’ as part <strong>of</strong><strong>the</strong> package. In o<strong>the</strong>r words, <strong>the</strong>y are notsuggesting that leadership alone can produceand sustain a positive service climate, ra<strong>the</strong>rleadership and management systems need to bemutually supportive and mutually rein<strong>for</strong>cing.So, <strong>for</strong> example, service-oriented HR systemsneed to be in place to underpin <strong>the</strong> requiredbehaviours. Selection and training should targetservice-related skills and behaviours. Evaluationsand rewards are also made relevant to serviceper<strong>for</strong>mance. In o<strong>the</strong>r words, high per<strong>for</strong>manceHR systems are fur<strong>the</strong>r enhanced with a specificservice orientation. <strong>Leadership</strong> behaviours <strong>the</strong>nneed to support <strong>the</strong>se with appropriate signalsand guidance.www.leadershipacademy.nhs.uk 17
2.5 Manage and improve per<strong>for</strong>mance ra<strong>the</strong>rthan merely reporting it, with openness toa variety <strong>of</strong> perspectives on per<strong>for</strong>manceincluding ‘s<strong>of</strong>t’ intelligence, ra<strong>the</strong>r thanfocussing on a narrow range <strong>of</strong> hierarchicallyimposed targets or indicatorsThe LF emphasises measuring and improvingservice per<strong>for</strong>mance, drawing on a wide range<strong>of</strong> data and perspectives. This broad based view<strong>of</strong> per<strong>for</strong>mance and per<strong>for</strong>mance managementis found in several o<strong>the</strong>r reports on <strong>the</strong> nature<strong>of</strong> health care leadership, notably Hartley andBennington (2011). The Health Foundation(Hardacre et al 2011) emphasises <strong>the</strong> needto combine recognition, praise and indeedcelebration <strong>of</strong> success with constructive feedbackto staff that can be used to improve per<strong>for</strong>mance.2.6 Listen to staff and respond to <strong>the</strong>ir voice,validate and engage with difficult ornegative emotions evoked by <strong>the</strong> experience<strong>of</strong> delivering care, ra<strong>the</strong>r than suppress ordeny <strong>the</strong>mA considerable amount <strong>of</strong> academic analysishas now been devoted to understanding <strong>the</strong>incidences <strong>of</strong> absence <strong>of</strong> compassion in someinstances <strong>of</strong> care, and even apparent cruelty topatients and carers, documented in distressingdetail by Francis (2013). One compelling line <strong>of</strong>analysis is developed by Ballat and Campling(2011) and Dartington (2010).They argue that involvement in front linecare <strong>of</strong>ten evokes strong emotions, throughcontact with pain and vulnerability. Whileindividual members <strong>of</strong> staff may have a normallycompassionate and caring outlook, <strong>the</strong>re is alsoan innate and usually unconscious need to limitone’s exposure to vulnerability and distress inorder to protect oneself from fears <strong>of</strong> one’s ownvulnerability and <strong>of</strong> being inadequate to helpthose in great need. This can give rise to dynamics<strong>of</strong> displacement, projection, rationalisation,reaction <strong>for</strong>mation and sublimation within careteams.No matter how hard a leader may work toestablish a positive emotional climate, <strong>the</strong> task<strong>of</strong> care tends to evoke strong emotions thatare difficult to bear, which can result in <strong>the</strong>projection <strong>of</strong> hostile feelings on to patients orindifference to recognising <strong>the</strong>ir humanity. Theimplication is that leaders need to acknowledge<strong>the</strong> existence <strong>of</strong> such complex and difficultemotions, and provide <strong>for</strong>ums <strong>for</strong> <strong>the</strong>m to beexpressed and worked with. The real dangercomes from denying <strong>the</strong> reality <strong>of</strong> <strong>the</strong>se difficultemotional aspects <strong>of</strong> care, which can leadto intensification and social legitimation <strong>of</strong>dangerous defence mechanisms, such as denialand projection. These may too easily result in adistancing from <strong>the</strong> experience <strong>of</strong> patients andeven discounting or disrespecting patients and<strong>the</strong>ir experiences.18 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
in<strong>for</strong>mation. It may also come from data onbreaches <strong>of</strong> patient safety, or from patient stories(Bate and Robert 2006), from staff suggestionsand reports, or from new perspectives <strong>of</strong>fered byhealthcare ‘social movements’ (Bate, Robert et al.2004). Hartley and Bennington (2011) bring out<strong>the</strong> importance <strong>of</strong> recognising multiple <strong>for</strong>ms <strong>of</strong>evidence and approaches to change, bearing inmind <strong>the</strong> preferences and priorities <strong>of</strong> 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 intervenein<strong>for</strong>mally in patterns <strong>of</strong> thinking and actingThis element focuses attention on <strong>the</strong> role <strong>of</strong>leadership in bringing about innovation, in<strong>the</strong> sense <strong>of</strong> ways <strong>of</strong> working that break wi<strong>the</strong>stablished ways <strong>of</strong> operating in order to improveper<strong>for</strong>mance. In <strong>the</strong> current <strong>NHS</strong> context atleast three kinds <strong>of</strong> 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 <strong>the</strong> needs <strong>of</strong> users.Such redesigns are also widely seen as <strong>of</strong>feringsignificant cost savings, through eliminatingunnecessary hand-<strong>of</strong>fs, overlapping assessmentsand redundant administrative processes. Thesecond kind <strong>of</strong> innovation involves supportingpatients or service users in managing <strong>the</strong>ir owncare, <strong>of</strong>ten through use <strong>of</strong> some <strong>for</strong>m <strong>of</strong> remotemonitoring or condition reporting technology.The third kind involves changing ingrainedpatterns <strong>of</strong> behaving within staff groups in <strong>the</strong>direction <strong>of</strong> becoming more patient-centred.Studies <strong>of</strong> health service innovations reveal aneed <strong>for</strong> an effective alliance between cliniciansand administrative managers in thinking througha range <strong>of</strong> administrative and in<strong>for</strong>mationtechnology related aspects <strong>of</strong> <strong>the</strong> new service,as well as new clinical protocols and divisions<strong>of</strong> labour, and new criteria <strong>for</strong> judging serviceper<strong>for</strong>mance (Storey and Holti 2013).<strong>Leadership</strong> <strong>for</strong> successful innovation involves<strong>the</strong> exercise <strong>of</strong> political astuteness, developingalignment and sometimes coalitions acrossdifferent interests implicated by <strong>the</strong> innovation,in both <strong>for</strong>mal and in<strong>for</strong>mal alliances. It alsoinvolves an ability to mobilise a variety <strong>of</strong>resources (Hartley and Fletcher 2008; Al<strong>for</strong>dJ, Hartley et al. 2013). In<strong>for</strong>mal 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 <strong>for</strong> innovation involves mobilisingexisting relationships, and developing new ones,to encompass <strong>the</strong> range <strong>of</strong> practices involved ininnovation, as well as seeking out backing andfunding from centres <strong>of</strong> power in <strong>the</strong> healthservice.Complex service innovations, such as <strong>the</strong>establishment <strong>of</strong> region-wide network <strong>of</strong>cancer services, seem to require a multi-leveland multidisciplinary array <strong>of</strong> 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 <strong>for</strong> <strong>the</strong>se more limited serviceimprovements, ‘distributed change leadership’ isneeded, comprising united senior level supportfrom both <strong>for</strong>mal clinical leaders and seniormanagers, credible opinion leaders at <strong>the</strong> level<strong>of</strong> senior clinicians in <strong>the</strong> services concerned, and‘willing workers’, front line clinicians preparedto embrace <strong>the</strong> new way <strong>of</strong> 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 <strong>for</strong> problem solving andresilient adaption <strong>of</strong> innovative ideas to localcircumstances, and this has been found in o<strong>the</strong>rsettings (Rashman et al. 2005).20 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
Similarly, staff with high levels <strong>of</strong> engagementwere less likely to be absent from work; thosewith low levels <strong>of</strong> 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 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
Staff engagement scores were also correlatedwith overall organisational per<strong>for</strong>mancemeasures as indicated by <strong>the</strong> Annual HealthCheck as used by <strong>the</strong> Care Quality Commission(CQC). The Health Check is based on two mainindicators one <strong>for</strong> quality <strong>of</strong> service and one<strong>for</strong> financial management. Both indicators arepositively associated with staff engagement.Figure 3: Overall engagement by AHC per<strong>for</strong>mance54.84.6Absenteeism Rate (%)4.44.243.83.63.43.23OverallMotivation Involvement AdvocacyengagementLowMediumHighSource: (West 2012:13)O<strong>the</strong>r factors associated with higher scores in <strong>the</strong>Health Check were well-designed appraisals, higherlevels <strong>of</strong> training and flexible working.www.leadershipacademy.nhs.uk 25
Appendix 2Summary <strong>of</strong> <strong>the</strong> main <strong>the</strong>ories <strong>of</strong> <strong>Leadership</strong>For many years, <strong>the</strong> focus <strong>of</strong> leadership studiesderived from a concern in organisationalpsychology to understand <strong>the</strong> impact <strong>of</strong> leaderstyle on small group behaviour and outcomes.Moreover, <strong>the</strong> focus as we saw above whendiscussing consideration and initiating structure,was fur<strong>the</strong>r directed to just two main dimensions‘task focus’ versus ‘people orientation’ and <strong>the</strong>rewere various re-workings <strong>of</strong> this <strong>the</strong>me (Blakeand Moulton 1964; Vroom and Yetton 1988).In <strong>the</strong> 1980s, attention shifted dramatically to<strong>the</strong> elaboration and promotion <strong>of</strong> <strong>the</strong> concept<strong>of</strong> trans<strong>for</strong>mational, charismatic, visionary andinspirational leadership. This school was labelled<strong>the</strong> ‘<strong>New</strong> <strong>Leadership</strong>’ <strong>the</strong>ories (Bryman 1992).‘The essence <strong>of</strong> <strong>the</strong> debatehowever is switching to <strong>the</strong>key task requirements and <strong>the</strong>contribution <strong>of</strong> leaders/managers.This more practice-orientedagenda is itself evolving.’This has shifted attention to leadership <strong>of</strong> entireorganizations ra<strong>the</strong>r than <strong>the</strong> leadership <strong>of</strong>small groups. With <strong>the</strong> work <strong>of</strong> Alimo-Metcalfand o<strong>the</strong>rs <strong>the</strong>re are some important currentattempts to pull <strong>the</strong> agenda back to distributedleadership and teams. While on <strong>the</strong> face <strong>of</strong>things, much <strong>of</strong> <strong>the</strong> debate over <strong>the</strong> past twodecades appears to have been about ‘styles <strong>of</strong>leadership’ in reality, <strong>the</strong> 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 nei<strong>the</strong>r geniusnor heroism to be a manager, but ra<strong>the</strong>rpersistence, tough-mindedness, hard work,intelligence, analytical ability and perhapsmost important, tolerance and goodwill’ (1992:127). Leaders, it is said, ‘think about goals, <strong>the</strong>yare active ra<strong>the</strong>r than reactive, shaping ideasabout ideas ra<strong>the</strong>r than responding to <strong>the</strong>m’.Managers, on <strong>the</strong> o<strong>the</strong>r hand, aim to ‘shiftbalances <strong>of</strong> power towards solutions acceptableas compromises, managers act to limit choices,leaders develop fresh approaches’ (1992: 128).Evidently, <strong>the</strong> controversy about <strong>the</strong> essentialdifferences between leadership and managementwill continue <strong>for</strong> some time. The essence <strong>of</strong> <strong>the</strong>debate however is switching to <strong>the</strong> key taskrequirements and <strong>the</strong> contribution <strong>of</strong> leaders/managers. This more practice-oriented agenda isitself evolving.In order to gain broad oversight <strong>of</strong> this and o<strong>the</strong>rmain trends in leadership <strong>the</strong>ory it is useful toview <strong>the</strong> summary <strong>of</strong> leadership <strong>the</strong>ories shownin Table 1. Reviews <strong>of</strong> <strong>the</strong> journey through <strong>the</strong>sequence <strong>of</strong> <strong>the</strong>ories can be found in Yukl (2009)and Storey (2011).26 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
Table 1: Summary <strong>of</strong> <strong>the</strong> Main Theories <strong>of</strong> <strong>Leadership</strong>Trait <strong>the</strong>ory; innate qualities; 'great man<strong>the</strong>ories'Behavioural <strong>the</strong>ories: task related andrelationship related; style <strong>the</strong>ory (e.g. autocraticvs. democratic)Situational and contingency <strong>the</strong>ory; repertoire<strong>of</strong> styles; expectancy <strong>the</strong>oryExchange and path-goal models (relationshipbetween leader and led as a series <strong>of</strong> trades)'<strong>New</strong> <strong>Leadership</strong>'; charismatic and visionaryleadership; trans<strong>for</strong>mational leadershipCarlyle (1841); Bernard (1926); Hong, Liao et al.(2013)Ohio State University studies; University <strong>of</strong>Michigan, 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)<strong>Leadership</strong> as per<strong>for</strong>mance Mangham (1986); Peck (2009)Constitutive, constructivist <strong>the</strong>ory Grint (2000)<strong>Leadership</strong> within Learning Organizations:leadership as a creative and collective process;distributed leadershipPost charismatic and post-trans<strong>for</strong>mationalleadership <strong>the</strong>ory; spiritual leadership; au<strong>the</strong>nticleadership; 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 <strong>of</strong> charisma’ has been noted bya number <strong>of</strong> writers (Conger and Kanungo 1998;Howell and Avolio 1992; Sankowsky 1995). Thedangers <strong>of</strong> narcissism and <strong>the</strong> associated misuse,and even abuse, <strong>of</strong> power were thus knownabout even at <strong>the</strong> height <strong>of</strong> <strong>the</strong> period whencharismatic and trans<strong>for</strong>mational 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 <strong>the</strong> problems <strong>of</strong> exploitation<strong>of</strong> dependency among <strong>the</strong> followers <strong>of</strong>charismatic, narcissistic leaders. And <strong>the</strong> highlyregarded Manfred Kets de Vries has beenespecially notable <strong>for</strong> his clinical reflections onsome <strong>of</strong> <strong>the</strong> dysfunctional aspects <strong>of</strong> leadership(De Vries 1994; De Vries 2000).But <strong>the</strong>se isolated warning signs have beenbrought toge<strong>the</strong>r in a far more developedway in recent times to such a degree that <strong>the</strong>charismatic- trans<strong>for</strong>mational model itself is nowbeing questioned. The research has also becomemore systematic and critical. For example,following a study <strong>of</strong> CEO successions in <strong>the</strong> US,Khurana (2002) found that <strong>the</strong> widespreadfaith in <strong>the</strong> power <strong>of</strong> charismatic leaders hadresulted in a number <strong>of</strong> problems. There wasan exaggerated belief in <strong>the</strong> impact <strong>of</strong> CEOs oncompanies because recruiters were pursuing <strong>the</strong>chimera <strong>of</strong> a special ‘type’ <strong>of</strong> individual. Therewas a fur<strong>the</strong>r tendency <strong>for</strong> companies to neglectsuitable candidates while entertaining unsuitableones. Finally, appointed charismatic leaders wereproblematic because it was found <strong>the</strong>y ‘candestabilise organisations in dangerous ways’(2002: 4).A common trait in <strong>the</strong> charismatic leadersstudied was <strong>the</strong>ir willingness to deliberatelyfracture <strong>the</strong>ir organisations as a means to effectchange. The destructive impact <strong>of</strong> a charismaticleader is exemplified by <strong>the</strong> case <strong>of</strong> Enron. ItsCEO Jeff Skilling, ‘induced blind obediencein his followers’, and while his abilities as a‘new economy strategist were overrated’ (heinstigated <strong>the</strong> shift to an asset-light position<strong>for</strong> <strong>the</strong> company), what he excelled at was‘motivating subordinates to take risks to thinkoutside <strong>the</strong> box - in short to do whatever pleasedhim’ (Khurana 2002: 7). The case illustrates <strong>the</strong>dangerous downside <strong>of</strong> charismatic leadership -<strong>the</strong> dismissal <strong>of</strong> normal checks and balances and<strong>the</strong> impatience with, if not complete disregard<strong>of</strong>, convention and rule. These are <strong>of</strong> course <strong>the</strong>qualities which prompted <strong>the</strong>ir appointment andwhich helped shape <strong>the</strong>ir remit in <strong>the</strong> first place.As Khurana observes (2002: 8) <strong>the</strong> recent display<strong>of</strong> ‘extraordinary trust in <strong>the</strong> power <strong>of</strong> charismaticCEO resembles less a mature faith than it does abelief in magic.’28 <strong>Towards</strong> a <strong>New</strong> <strong>Model</strong> <strong>of</strong> <strong>Leadership</strong> <strong>for</strong> <strong>the</strong> <strong>NHS</strong>
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