Transforming leadership culture after Francis

The Francis report held up a mirror to the NHS emperor’s new clothes swathed with targets. It exposed the disastrous consequences of creating cultures of fear, bullying and blame.

‘As the Francis inquiry revealed, behaviour is highly susceptible to the influence of culture’

While there has been a resounding response that the NHS must transform its culture to one of transparency and candour by strengthening the right kind of leadership, the Department of Health has made it crystal clear that this, in turn, must be led by NHS boards that “put quality at the heart of all they do … [by which is meant] patient safety, effectiveness of care and patient experience”. To enable this to happen, boards may well need some practical support.

Here we encounter the first major problem − what does research show effective boards do that enhances quality and patient care? Astonishingly, there is almost none. We discovered this in a recent review of the academic literature relating to the association between board activity and quality outcomes. The comments of Harvard researchers echo those from across academia: “Little is known about whether or how boards are engaged in issues of clinical quality and if their activities influence care.” 

Matter of perception

This is, perhaps, unsurprising given that care is ultimately delivered by trust staff. However, as the Francis inquiry revealed, behaviour is highly susceptible to the influence of culture. The DH states that boards need to understand how they can best lead and govern, to embed a culture in which high-quality care is intrinsic to everyone’s role and responsibilities.

Much of our recent work has been supporting trust boards to strengthen the positive effect they have on the organisation’s culture, and minimise any unintended negative impact. We now have early data from our board leadership and “governance 360” instrument used by several trusts, which has enabled us to identify specific board leadership behaviours that significantly:

• affect the commitment, motivation, engagement and wellbeing of senior leaders in the trust (clinical and non-clinical);
• influence the confidence of external bodies and governors, in the ability of the trust to deliver high-quality care and sustainable performance; and
• affect how the board works effectively as a team.

One key finding that was fairly consistent across trusts was that there were significant differences between board members’ perceptions of how well they lead and govern the trust, and those of the senior leaders, both clinicians and managers, who report to them.

In each case, the board members’ ratings were higher. When you consider the range of implications − such as whether the board promotes a culture of blame rather than of learning; how clearly the board communicates the trust’s vision and translates it into meaningful strategic objectives; the extent to which a focus on targets detracts from the quality of patient care − the need for boards to seek feedback about their impact becomes a critical imperative.

A scale of feedback

The board leadership and governance 360 tool comprises eight measurement scales, which cover leadership, governance and team working. The scales were developed from four major sources:

• Rigorously validated leadership behaviours that enhance engagement (a model we have extensively validated in the NHS, and internationally in healthcare and other sectors).
• Research on effective teams (including our own recently completed investigation of team leadership behaviours that predict quality and innovation in multi-professional teams, sponsored by Yorkshire and the Humber strategic health authority).
• A review of contemporary literature on board governance competencies.
• Mapping the above against Monitor’s requirements.

An assessment is completed, anonymously, by board members (rating the whole board); two internal groups of raters, typically senior managers and senior clinicians; and two groups of external raters, such as commissioners and other trust and local authority chief executives. Governors may be included in one of these groups.

Crucially, it also includes “impact measures” that assess the board’s impact on outcomes critical to determining the board’s leadership, management and governance effectiveness.

Raters are only asked questions to which they can reliably respond.

How to make a board more effective

Statistical analyses identified which of the areas of board effectiveness most powerfully predicted the outcomes (impact measures) that increase sustainable quality and patient care, depending on the rater group. Space limitations necessarily mean that discussion of the findings must be brief.

1. What significantly affects board members’ engagement and wellbeing?

Boards need to work as effective teams. Two key aspects of how board members work together significantly predict their own levels of engagement. These are:

• Engaging as an effective team (comprises 13 behaviours), including: understanding each other’s roles and responsibilities; making effective use of expertise in the team; devoting sufficient time to discussing pressing or strategic issues; and turning ideas into action.  
• Personal qualities and values (12 behaviours), including: transparency, integrity, commitment to patients and the community; being approachable; and supporting senior managers when appropriate.

One specific dimension of how the board works together significantly predicted their levels of wellbeing and reduced stress:

• Constructive challenge (seven behaviours) involves being both willing and able to challenge data presented to them, including by experts, in order to make the best decisions. But, importantly, it also involves being prepared to modify ideas after listening to others’ point of view.

2. What significantly affects senior managers’ and clinicians’ engagement and wellbeing?

The board has its most significant impact on senior managers’ and clinicians’ ability to perform effectively through how it is seen to be:

• Connecting and influencing (11 behaviours), including: encouraging staff involvement in board discussions to enhance decision making; monitoring progress on delegated tasks in a constructive and supportive way; keeping in touch with what is happening in the organisation by walking around, listening and talking; and communicating positive expectations of what staff can achieve.

3. What aspects of boards’ leadership, governance and management significantly predict external raters’ confidence in their trust’s effectiveness?

External raters’ confidence in a board’s ability to deliver the highest quality of care and safety to patients can be seen to be an outcome variable. Our study found this was significantly predicted by their perceptions of the board as “ensuring shared vision”, which encourages the active involvement of a range of relevant internal and external stakeholders, and by their “personal qualities and values”.

Their confidence in a board’s ability to achieve the organisation’s objectives is significantly predicted by four scales: “connecting and influencing”; “effective performance and risk management”; “engaging as an effective team”; and “ensuring a shared vision”. Confidence in the board’s ability to sustain trust performance was significantly predicted by “effective performance and risk management” and “engaging as an effective team”.

Practical implications for boards

This is the first study of which we are aware that provides 360-degree based research evidence identifying which specific board behaviours and activities significantly predict the effect that boards’ leadership and governance has on creating the kind of culture that Robert Francis urged.

By modelling engaging leadership, boards will also increase the engagement and wellbeing of senior clinicians and managers, who will, in turn, model this for their colleagues, so eventually it will become endemic to the NHS.

NHS boards need to show the courage and transparency of the boards involved in our study. By undertaking such a “public” review and feedback process, and allowing their data to be used in research, they have enabled us to see the way forward for transforming the culture of the NHS, for the benefits of the communities it serves.

Beverly Alimo-Metcalfe is professor of leadership and director at Real World Group, Juliette Alban-Metcalfe is chief executive at Real World Group