Investing in leadership post-Francis

What did I think of the Francis report? I guess we all see what we’re looking for. Everyone “knows” who should resign and precisely why and yet these same people, most of us, ironically reflect what Francis writes in his report − wilful blindness, the bystander phenomenon (everyone sees, no one responds) and normalisation of deviance.

‘The Francis report provides the single greatest leadership challenge the NHS has ever faced’

The significant worry is that I, and many others, know that Mid Staffordshire is not an isolated case. There are, at this moment, several other hospitals that have descended to that life-threatening state.

These same hospitals will be regulated as “paper safe” but are most certainly not “patient safe” − and everyone working there knows it.

Instead of the “friends and family” test, we should ask staff if they or their family would be treated in their own hospitals. They know.

Our greatest challenge

The overwhelming culture described by Robert Francis was disempowerment. The report provides the single greatest leadership challenge the NHS has ever faced. And if we always do what we’ve always done, we’ll always get what we’ve always got.

As we head into the most severe financial cuts yet experienced by the NHS, there can be no doubt, no matter what the rhetoric, that a drive to cut costs in the context of increasing demand, will inevitably affect again and at scale on the duty of care to patients.

Rather than a disaster for patient care, the timely emergence of a new cadre of clinical leaders could allow this challenge to become the NHS’s finest hour.

‘So much of what is said about NHS leadership conjures up shroud waving, hypocrisy and weasel words’

Can leadership be taught? There is an abundance of expensive leadership programmes, the majority of which are well evaluated by participants. Traditional NHS leadership programmes offer excellent skills acquisition and development of knowledge and technical competence and they are currently stacking up to do more of what they’ve done before.

We don’t need a randomised controlled trial to tell us what every healthcare worker knows − some wards, teams, departments, divisions and hospitals are better led than others and this perception goes well beyond able management or command.

Filtering down

The units that stand out have engaged, motivated and often inspired staff, because good leadership filters down into the places that staff surveys don’t touch − but that makes all the difference to patient experience and outcomes.

Effective leadership development programmes have economic consequences and yet procurement exercises seldom explore the methodologies offered beyond the cost per head and the rollout logistics.

There has been enormous investment in leadership development but because the end product is so difficult to measure, there has been little proper rigour in assessing its effectiveness. Besides mapping agreed standards against framework domains, competencies and levels, there is little understanding of how to bridge the leadership “knowing/doing” gap.

What matters most to doing the right thing in those critical leadership moments is not what we do but what we chose not to do, our shedding of distractions, countering peer pressure and our natural propensity for obedience and comradeship. Leadership cannot be taught, it has to be learnt.

What everyone knows

So much of what is written and said about NHS leadership conjures up shroud waving and evokes hypocrisy. The NHS is characterised by the high impact of the highly improbable.

Without uncertainty there would be no need for leadership.The legislation underpinning the about to be implemented NHS reforms cannot command that everyone should be patient-centred, courageous, selfless and team players.

‘The lack of systematic accountability and the clinical variation of the past cannot continue’

Everyone knows that doctors influence doctors and nurses influence nurses − everyone knows and nothing else works. Doctors and nurses are not managed into patient care, they are led. Behaviours and values are the lynchpin of sustainable performance.  

At its core, leadership is a purely moral and emotional activity. It is unconnected with seniority and only loosely related to intellect and it is about the ability to engage, motivate and inspire. It is defined by our values and implies having moral courage, integrity and the conviction to accept accountability.

Experimental programme

Working in partnership with the armed services, for which the acquisition of this same set of skills is equally critical, at UCL Partners, we have developed an experiential leadership programme spread across three modules over nine months.

The modules include self-awareness, self-management and leading teams, accessed through a selection process. The faculty is composed of proven leaders and the learning is based on our growing awareness that people believe their own data, no one else’s.  

Delegates learn about their blind spots, their hidden areas of fear and prejudice and their underestimated and undiscovered talents. They believe footage of their own performance because it is their own data.

The training’s emphasis is on experiential learning. This leadership programme seems to be equipping individuals with that quality of qualities: moral courage.

Without acquiring these critical interpersonal character components, there cannot be competence in social skills such as communication, negotiating, influencing, team working, decision making and situational awareness. We see the acquisition of these skills as the learning outcomes against which the programme should be assessed.

Deep cultural problems

The UCL Partners NHS Staff College is uniquely an experiential, very practical, grounded initiative that has proven to be immediately relevant. The programmes are quality assured by working with proven highly trained military directing staff and NHS leaders.

How will we lead colleagues who are not team players? How will we deal with the fear and anxiety of being honest? In so many ways, this was easier to do some years ago until the ascendency of targets and finance moved healthcare from a clinically led service to a managed service.

More regulation, more appraisal and revalidation emerged as paper-safe solutions but are seen by many as false governance and reassurance. And yet the lack of systematic accountability and the clinical variation of those years cannot continue.

‘The programme ethos is an aspiration to do the right thing, particularly on a difficult day’

A central challenge for clinicians and leadership development lies deep in the culture of medicine and the apprenticeship model − don’t do as I say, do as I do. Clinicians have developed a mindset that while someone else manages the system, our job as clinicians is to deliver excellent care to patients.

We are loath to tell the truth to a colleague, even in the patient’s best interest. We respect clinical variation as our professional right, even to the detriment of safety and quality. We seek to influence, but only at a distance. We abhor self-regulation and deny our duty to self-police.

Awaken clinicians

For these reasons, few clinical role models today have built their careers on organisational leadership. The college attempts to address this gap: it serves to awaken in clinicians a sense that the delivery of excellent care requires effective organisations and systems, and that taking on leadership and management roles can be a highly effective way to deliver one’s calling. Whatever happens now needs to be from the ground up.

We aim to have a third of all participants on the college from primary care and consultants learn alongside nurses, allied health professionals and managers. To date, more than 350 have been through the programme.

The questions around the events in Mid Staffordshire Foundation Trust lie in how it was allowed to happen. Understanding our leadership role will inevitably progress towards redefining self-regulation, self-policing and embracing a philosophy of positive preoccupation with failure and telling truth to power.

The staff college leadership programme ethos is an aspiration to do the right thing, particularly on a difficult day.

Aidan Halligan is director of education at University College London Hospitals Foundation Trust, and chief of safety at Brighton and Sussex University Hospitals Trust