Francis unwittingly calls for more 'female' behaviours

Judith Smith from the Nuffield Trust co-wrote a really thoughtful piece for HSJ’s Women’s Week earlier this year on encouraging women into senior leadership roles in health. She follows a long line of (mostly) women presenting arguments for a better gender balance.

‘While action is plentiful − how many equality “initiatives” have you come across in your career? − the impact is less so’

The arguments are well rehearsed − ranging from “Is there a problem?” to “Is there a significant difference between female and male leadership styles and behaviours, and if there is, how do we address it?”

Although better than it has ever been, there stubbornly remains an imbalance of gender in leadership positions in all industries.

Stubborn status quo

Point of care or service responsibilities in service industries are largely done by a female workforce and the management or leadership of that workforce, particularly at senior levels, is predominantly male.

‘Research suggests a detrimental impact on diversity in leadership at times of economic pressure’

Where there have been signs of vertical integration and balance, we still see a horizontal imbalance. Where women are successful in promotion to senior positions, they are doing so in fairly narrow and horizontally restricted professions that typically have less senior power such as human resources, health and nursing.

The research is prolific, the analysis diverse and the outcomes depressingly similar. And while action is plentiful − how many equality “initiatives” have you come across in your career? – the impact is less so.

What is more, research suggests a detrimental impact on diversity in leadership at times of economic pressure.

Academic references on the subject are easy to find and HSJ has given voice to the debate in the last few months.

Gender rebalancing

If we take the Francis report as a point of reference for gender in healthcare, I can point to some differences that addressing the imbalance might make such as putting care at the heart of what we do; taking collective as well as individual responsibility; privileging both the recipients and deliverers of care in decision making; distributing power; increasing collaboration across services; and greater integration of care around the patient.

‘The behaviours demanded in both reports are much more typically represented in female norms of behaviour than in male’

Don Berwick’s review picks up many of these themes and adds others: valuing staff, rewarding the behaviours you most want to see, being inclusive and collaborative and more compassionate in your leadership.

Most of what Francis and Berwick say about leadership − forgive me for pointing out the obvious point that both reviews were led by men − is a set of behaviours that fall much more within a female paradigm of leading than they do in the predominant male style of leadership.

The behaviours demanded in both reports are not only very different than the current predominant style but also much more typically represented in female norms of behaviour than in male.

This brings us to our first challenge, asking if there really is a difference in male and female leaders.

A few years ago I was part of the team that launched Top Leaders, a suite of support programmes for the most senior leaders in health, which aimed to do three things:

• to support existing leaders in their posts (personal development);
• to help those already in senior positions prepare themselves for roles for which there was perceived to be a recruitment problem (talent management); and
• to help those leaders identify and support those around them to prepare themselves for more senior roles (succession planning).

I would argue that I failed in the second two and I can point to all kinds of reasons: the NHS was not ready to address issues of talent identification; the programme started just before the reforms and so found itself deep into organisational change; and personally failing to win some of the key arguments that existed and still exist around recruitment.

‘Women negotiators who promote their own interests strongly will suffer judgement that is likely to be detrimental’

But the personal development element did work. Supported by an exceptional team and innovative providers and faculty, many of these leaders did get access to important development from which we continue to see some positive impact.

One of the most enduring elements was the personal diagnostic, which has given us a comprehensive leadership review of around 2,000 people. It told us much about senior leadership styles, behaviours, competencies and preferences.

What did it say about the difference between male and female leaders? Is there a difference? Does the difference align with traditional models of male and female leadership? Does it hint at any of the changes needed to address Francis or Berwick?

Unequal judgement

A recent study published by Catherine Tinsley, professor of management and head of the management group at Georgetown University’s McDonough School of Business, focuses on one specific element of the leadership task: negotiation.

‘Those who are leading our services share so much more that is similar in their backgrounds and lived experiences than is different’

I paraphrase, but she says that women negotiators who promote their own interests strongly will suffer judgement that is likely to be detrimental, while women negotiators who do not promote themselves and act in ways regarded as traditionally more “female” will not suffer social judgement but are likely to have their competence questioned. These same judgements do not apply to men.

The Top Leaders data was illuminating − not because there is a marked difference at the most senior levels but because there was a striking convergence of styles, unseen in any other industry. There were some difference in organisations but otherwise across profession and gender our leaders are strikingly similar. 

At a level just below board, the data showed a broader range of styles in women, who were more likely to have coaching, affiliative and collaborative leadership styles. For a fuller analysis of the data visit the NHS Leadership Academy website.

Four ways forward

So, what can we do that has not already been done? My suggestions are not new but might prompt debate, discussion and discord − all great ingredients for change. 

The first is recognising the importance of difference for safety and quality. Our restrictions on thinking and ideas come in part from the sparsity of difference in life experience, however it is gained: gender, race, sexual orientation, age, class, education − whatever you name. Those who are leading our services share so much more that is similar in their backgrounds and lived experiences than is different.

We should all be arguing that valuing difference not only makes for a better future for the NHS − more equal, more efficient, more appropriate and a more sustainable NHS − but also enriches our lives enormously.

‘To the men who have read this piece, despairing at the assumptions you think I am making – you are the key to making the difference’

The second goes directly to those people in national and influential positions, responsible for choosing who speaks, writes, presents and does the circuits – people like Chris Ham, Mike Farrar and Sir David Nicholson. Please, let us invest enormous energy in ensuring those voices are more representative.

We have a huge pool of really inspirational people to draw on. Lisa Rodrigues speaks warmly and wittily on age; Ruth Hunt from Stonewall talks compellingly and hilariously on LGBT rights in health; the NHS Leadership Academy’s own Yvonne Coghill is passionate on race and culture in health; while Ruth Sealy from Cranfield School of Management is authoritative about what makes boards work well.

There are a great many women whose voices should be heard at a national level, who can tell stories, share their own life experiences and present evidence on how we can make a difference.

My third suggestion is to the men who have read this piece, despairing at the assumptions you think I am making − you are the key to making the difference. Our success will be down to all of us, men and women, who believe better diversity will make a difference, doing all they can to address the imbalance.

My fourth relates directly to my third point. Women who advocate on behalf of other women have greater impact and suffer less socially negative perceptions. This played out in our judging for HSJ Inspirational Women 2013; those women who advocated on their own behalf were judged harshly, while those who advocated on the behalf of others were much better regarded.

Positive action not only promotes the kind of behaviour we want to see, but also a different kind of leadership, increasing the opportunity for women to see and know better role models and provide a more collaborative work environment.

Karen Lynas is deputy managing director and head of programmes and practice team at the NHS Leadership Academy