Making sense of the Francis focus on leadership

The Francis report placed an emphasis on strong leadership at every level of the NHS.

It called for openness, transparency and candour.

‘The Francis report placed an emphasis on strong leadership at every level of the NHS’

Of the 290 recommendations, a significant section is devoted to leadership, promoting shared training and a shared code of ethics based on a leadership framework that enforces standards and accountability.

Following this, it becomes important to review the various leadership styles at play within the NHS. Purposeful leadership has been developing across British healthcare systems over the past few decades and the concept of a “dispersed leadership framework” is rather new.

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Enhanced effectiveness

This leadership style is based on the leader’s ability to impart to fellow workers self-discipline, courage and ethical approach.

A rather innovative concept of dispersed leadership casts a light on different dimensions where an organisation is not seen as a pyramid shape but as a square, proactive and efficient model.

‘The NHS needs to rethink the way power and accountability are shared across the heterogeneous system’

Distributed theory generates an interesting question on how “formal leaders” minimise their own roles yet enhance effectiveness.

As organisations the NHS need to rethink the way in which power and accountability are shared across the heterogeneous healthcare system. The term “distributed leadership” has been coined. 

It emphasises enhancement of function through empowerment mechanism and can be subdivided into the following categories:

• substitution for leadership;
• super leadership;
• self-leadership;and
• shared leadership.

Substitution for leadership

Substitution for leadership means the non-important parts of the workload are delegated to subordinates. It has many important contributions such as the optimum use of manpower and resources, reduction in vertical leadership, a clear directive to redesign the organisation, and the ability to integrate micro level insight.

For example, clinical directors can delegate their various workload to other consultants, senior nurses, secretaries and senior trainees, which helps them focus on the major issues of the department and the trust.

Super leadership

Super leadership theory examines the result of success or otherwise when a leader prepares, supports and empowers his or her followers. There are three basic components: training and supporting others; allowing participation in decision making; and delegating substantial responsibility to subordinates.

Those who demonstrate super leadership, for example, would make it an essential component of the action plan of each trust to develop their junior consultants for future leadership roles through a planned mentoring and structured process.

Self-leadership

“Self-managed teams” theory is based on the 1980s Japanese innovation in devolution. In this concept a formal leader selects members for specific assignments, for example to monitor progress, provide feedback, set out goals and communicate organisational expectation.

An example could be when a high infection rate was identified in a Care Quality Commission visit. A task force team is developed to identify the core problem, look for solutions and monitor progress self-sufficiently in close relation with the trust executive board.

Shared leadership

“Shared leadership” emphasises a combination of vertically distributed forms of leadership working through the feedback loop of shared vision, which can be observed at multiple levels concurrently.

There are three factors for success: capability of the subordinates, capacity of the super leader to delegate and willingness of the organisation within.

Context and capability

Distributed leadership can be observed as a bottom-up communication process by which the complex adaptive systems learn and develop. It cannot be forced onto a network or mandated.

Not everyone will be leading at the same time and in the same style. It will depend on context, need and capability. As always, some members engage themselves in leadership activities more than others.

Clearly it can be engineered by offering new opportunities to lead, by generating a broad based leadership framework and by providing the creative spaces for dialogue and discussion within the network.

‘The barrier to change observed in the NHS is organisational inertia’

The Medical Leadership Competency Framework project, led by the NHS Institute for Innovation and Improvement, describes leadership as a main competency required by all clinical professions.

Many clinicians have a clear idea of what needs to be improved within a service and how to achieve that objective, but lack the empowerment to go ahead.

The barrier to change observed in the NHS is organisational inertia. This refers to established organisations that have a rigid system in order to continue on its current course. Culture and hierarchal structures also remain barriers to change.

Managing the change process

Factors that characterise creating the right leadership culture, according to the King’s Fund, include an open environment, adopting the right leadership styles and long term vision.

Promoting multiple and distributed sources of leadership that stretch over complex social and situational contexts present a compelling view of leadership to restructure activities and relationships in the NHS.

‘Successful change leadership has to invest time in finding common ground and building credibility’

Healthcare management professor Samia Chreim and her colleagues suggested in 2010 that a model of collective leadership is more appropriate in the complex setting of healthcare against a standalone leader.

Successful change leadership has to invest time in finding common ground across stakeholders and in building credibility and trust.

Having an agent whose main responsibility is to manage the change process is likely to bring more success than asking busy healthcare practitioners to take on this charge.

In the latter case there is the likelihood that the focus and momentum of change will be diluted and there will be lack of accountability.

Doing it differently

Distributed leadership can be an essential organisational condition for the NHS in the 21st century.

A distributed corporate perspective breaks down the barriers between leaders and followers, and achieves an optimum engagement and outcome within a very heterogeneous environment of the NHS.

‘Staff will feel empowered and have breakthrough ideas which will raise the bar of morale’

As a result, it brings openness to meet the leadership requirements of the NHS as highlighted in the Francis report.

It is time to start looking for the extended competencies among staff where shared roles can be delivered in a multidisciplinary environment. It is all about doing things differently – service redesign with a leadership bonding.

Clinicians, nurses and other allied healthcare specialists will feel empowered and will come forward with breakthrough ideas and with ownership capability which will raise the bar of morale across the system.

Debabrata Biswas is an masters student in medical leadership at the Royal College of Physicians and national head and neck oncology surgery fellow, and Professor Simon Rogers is clinical head of breast, ear, nose and throat, ophthalmology and the maxillofacial business unit, both at Aintree University Hospital Foundation Trust; and Jaydip Ray is consultant and clinical director of otolaryngology, head and neck surgery at Sheffield Teaching Hospitals Foundation Trust