Context is everything in health leadership

Among all the issues with which a beleaguered NHS is grappling, leadership should be uppermost. But is it?

It will certainly be high on the agenda of the incoming chief executive Simon Stevens. 

What sort of leadership does the NHS need? Is the Leadership Academy’s new fast-track leadership development programme likely to meet the challenges ahead? We remain doubtful.

The constant reinvention of the leadership framework driven from the centre is part of the problem, creating confusion and lack of clarity about what is needed. 

Local challenges

In its place we favour investing in building leadership capacity and capability at the local level, drawing on real life challenges facing the health and social care system which, in our experience, differs across the NHS throughout the UK.  

The challenges of change and transformation cannot be driven from the top via a directive or mandate. We know such an outmoded approach does not work and until the NHS moves away from the default position of a central controlling mindset there will be little change.  

‘One size does not fit all and appropriate leadership needs to be adapted to particular cultures and challenges as they change’

Locally led cultural change rooted in particular contexts with a bespoke approach to using fewer competences is the way forward. A system of leadership development that ignores context, is structured around a fixed set of competencies and favours a “sheep dip” approach to churning out leaders is not. 

Our own research shows that it is local challenges, relationships and potential pitfalls that preoccupy local leaders. In contrast, the national contextual backdrop is often seen as a given – frustrating and with little scope for influence or change.

Successful leadership in one situation or setting may not occur or survive in a different context. One size does not fit all and appropriate leadership needs to be adapted to particular cultures and challenges as they change.     

Whole system approach

The health system has never been more complex or politically driven.

It is no longer sufficient to produce leaders of healthcare services. We need leaders and leadership that can add value to health through adopting a whole systems approach.

Integration between health and social care is high on the agenda, but so too is preventing ill health and keeping people healthier longer so they do not create pressure on already hard pressed secondary care services.

If the burden of disease is largely the result of avoidable lifestyle related illnesses then we should be tackling them at source. For too long public health leaders have successfully analysed and described the problems and what needs to be done but have fallen short in both successfully leading and implementing the necessary changes and influencing national policy change.

‘The health challenge requires an end to silo thinking and the shoring up of potentially failing organisations’

The health challenge requires an end to silo thinking and the shoring up of potentially failing organisations at the cost of inappropriate patient care. Leaders should be recruited with knowledge and understanding of complex systems, “wicked issues” (problems whose causes and solutions are diverse and not fully known in advance) and whole system approaches to transformational change. 

We need leaders who are able to work with and through others to influence and bring about intra- and inter-organisational change in a range of leadership forms, including adaptive, engaged and collaborative leadership, and not leadership invested in the individual.

Working in isolation is gone

Leadership trends follow societal changes. The economic downturn coupled with big failures in the banking and business sectors means that the age of the individual organisational leader working in isolation has gone.

Consequently, we require leaders who do not assume they know it all and have all the answers but who are able to ask questions and draw on a range of knowledge and skills to address problems for which there are no simple or easy answers. 

Above all, leaders should be working to ensure that trust, and not suspicion, exists between professionals and managers, and between the workforce and government.  A bullying culture and unnecessary structural upheaval contributed to the systemic failure that gave rise to the care failures at Mid Staffordshire.  

We cannot recall another time when paying attention to the development of relationships and the “soft issues” of leadership have been as important.

Multifaceted and multidimensional problems are the very essence of a complex system. Seeking to reduce these to a set of simple precepts to be resolved by a range of competencies is both simplistic and seriously misses the point about what is required of, and from, leadership for health in the 21st century.

Boosting the bottom line

Investing in the right sort of leadership is not the whole story. There needs to be evidence of demonstrable improvements in bottom line performance and transformation.

If investing in leadership development cannot demonstrate that then whatever is being done should be stopped and a different approach pursued. 

When Simon Stevens takes up his new post in the spring he may wish to pose some penetrating questions about the current approach to leadership development. 

For starters, we offer the following:

• Are current approaches able to demonstrate they are helping people deliver change and transformation across their local health and social care systems?
• Can current approaches show they are helping people get the basics right for patients and deliver improved bottom line performance?
• How would the Leadership Academy convince the new NHS chief executive that he should continue to invest in it?
• What would be the impact of stopping current approaches to leadership development? What difference would it make?

David Hunter is professor of health policy and management at Durham University and Neil Goodwin is visiting professor of leadership studies at Manchester Business School