There’s been a lot written about leadership this week, particularly with the publication of the HSJ top 50 most inspirational women for 2014 (see the list at http://www.hsj.co.uk/news/-hsjs-most-inspirational-women-in-healthcare-2014-revealed/5072644.article#.U8LD-nlOVjo).
Culture and leadership are paramount to the future success of the NHS and right now we haven’t got it quite right. The old command and control culture that previously pervaded may have got us this far but it won’t be able to take us any further and so we need a new type of leader- and fast.
Monitor estimates that by 2020 the NHS will require £30bn worth of savings (Closing the Gap). which will require a completely different way of thinking than we managed for the ‘Nicolson Challenge’ of £15-20bn by 2015. £30bn cannot be achieved through the optimism bias that we can continue to do more with less, it needs a completely different way of doing things and will require a really innovative way of thinking about how services can be delivered, in order to survive.
There has been a lot of research about the impact of leadership, my favourite is The Fish Rots from the Head by Bob Garratt (2009) based on the Chinese proverb. Bob makes a compelling case that the culture of the organisation and its subsequent success or failure starts in the Boardroom. Having spent time both on a Board and working with them, the impact that small number of people has culturally on an organisation should not be underestimated. Boards need to develop a new way of thinking about and working with their greatest asset – their staff – in order to meet the challenges we face head on.
My personal view is that the best managers work closely with and stand behind the clinicians. I have always been a firm believer that managers are there to facilitate clinicians delivering the best possible care to patients. I have always had very good working relationships with my clinicians and have seen what truly great clinical leadership can achieve. Engaging with staff at all levels is key to improving the quality of service delivery and as the Kings Fund and Michael West have prophesised, “happy staff = happy patients”.
The CQC have their detractors and their sceptics, but as part of their well-led domain assessment, they are starting to see a direct correlation between the relationship the Board has with the consultants and the level of staff engagement on the quality of service delivery. This is a significant finding. They will be the first to admit that they haven’t quite got their assessments quite right but they are learning, adapting and improving all the time and isn’t that the sign of good leadership in itself?
Throughout the command and control years, we have developed a culture that is resistance to what some leaders consider to be interference from the Centre, such as CQC inspection. Yet on the other hand there is a high degree of inertia in the system, as a result of so many years of waiting for the next set of instructions from the Centre with many leaders having an almost ‘learned helplessness’ which means that the much needed change is not happening quickly enough.
It seems to me that we need to make way for the new types of leaders. Those that can navigate the system and are able to negotiate and collaborate with other health and social care organisations across all of the sectors including voluntary and independent, to form alliances that will bring together all of the resources available to them to deliver the best outcomes for the patient.
When I joined the NHS graduate scheme in 2002, it was considered that you earned your stripes and went up through the acute sector ranks when you would eventually move from a Chief Operating Officer to a Chief Executive Officer role, and the bigger the Trust the better. This career route doesn’t feel fit for purpose any more and those young ambitious managers that are coming up through the ranks now, who want to work closely with their clinicians in an innovative way, are finding it hard to forge their way through. We are losing many to the Big 4 consulting firms and the voluntary and independent sector, where they have the freedom to take chances, think differently and make the change they want to see. This to me is a tragedy for the NHS and could signal its demise if we can no longer retain our talent.
We need to ensure we nurture and manage our talent much more actively within the NHS. The Graduate Scheme was voted the number 1 best scheme in the country again this year so we can attract the best so how do we retain them? My view is we need a 4 point plan:
Identify – organisations need a process of identifying who, across all levels and professions, within the organisation is their talent. A good appraisal system should be able to do this, but identify them quickly let them know you have ‘spotted’ them so they feel appreciated.
Develop – wherever your talent is in your organisations, whether they are clinicians or managers, people need some form of structured development programme to stretch them, help them to learn new things and most importantly try it out and consolidate that learning
Permit – give staff the tools, space and permission to innovate. Sometimes this may mean that ideas they have don’t go to plan but you learn much more from failure that you do from success
Reward – often staff in the NHS have an intrinsic set of values which means pride in their work and a sense of achievement is worth more than monetary reward. Promoting the innovative work that staff have done is enough to keep them motivated and to motivate others to achieve more.
If we are able to nurture the talent at all levels in our organisations and recognise that system leadership rather than just good hospital management is the skill set that will drive the change over the next five years, then the NHS just may have a chance of rising to the 2020 £30bn challenge. The status quo isn’t an option.