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Leadership in the NHS

Sue Weekes

Is the NHS suffering from a dearth of strong leaders? Sue Weekes asks what's happening with leadership in the NHS

Leadership has become something of a sitting duck whenever problems surrounding the NHS make the news. While the flurry of reports and reviews already published in 2013 identify a raft of highly complex issues which have led to shortcomings in the service in areas such as patient care, poor leadership is usually cited as being at the root cause of many of them.

Commenting on the review by Sir Bruce Keogh into the quality of care and treatment provided by 14 hospitals in England, published earlier this year, Chris Ham, chief executive of The King's Fund, said problems ultimately reflect poor leadership and "failure to develop the right culture of care at the hospitals identified". Indeed the report by the NHS medical director of NHS England said that it did not see "sufficient evidence" to demonstrate that many board and clinical leaders were effectively driving quality improvement and added that in a number of trusts, the capability of medical directors and/or directors of nursing "was questioned" by review teams. Among the common concerns highlighted was "poor articulation" of the strategy for improving quality. Meanwhile a Health Select Committee report published this summer raised concerns regarding accountability when it came to addressing challenges in the area of urgent and emergency care.

If this money had gone into medical leadership, we'd have a much better service.

Whatever the detailed findings of these and other reports (Keogh is also undertaking a review into urgent and emergency care), there is no getting away from the broad leadership challenge that faces the NHS: how can it be expected to continue to function effectively and deliver high standards of service and patient care against a backdrop of massive cost control? A report by NHS England found that it could face a funding gap between its budget and increasing costs of £30bn by 2020-21.

Keogh hit the headlines this summer when he said the NHS needed to learn from the commercial sector and adopt the "more for less" mindset of businesses such as PC World or Dixons which have managed to keep prices down but offer more sophisticated products. The press quickly picked up on the fact that Dixons stores had actually become Currys and the website had disappeared last year. Clearly though, the NHS can learn something from the world of business and Keogh's other ideas include giving more of a voice to the junior doctors whom he believes could become the organisation's change agents to spread new ideas and improve quality. Fifteen innovation fellows are also being appointed from the world of business, politics and medicine to mentor NHS executives.

Is commercialisation the key?

Linda Holbeche, co-director of The Holbeche Partnership and a practice leader in areas such as HRM, organisational development and leadership, doesn't believe the NHS needs more commercialisation. "As this would mean a further diminution of why people wanted to work for it in the first place," she says. "But I do think there is a need for more commercial discipline in terms of being focused and becoming more expert in making interventions that could make a difference."

Holbeche, who is also a former policy and research director at the Chartered Institute of Personnel and Development, suggests that some of the NHS' problems stem from "a slow erosion" over the past 10-15 years of what was once "a strong ethos" within the organisation. "All of the cost pressures, political interference and the outsourcing of this and the managing of that has encouraged a system which has seen some people become rather more jobs-worth in attitude and an extreme example of this is Mid-Staffs," she comments.

Professor Andrew Kakabadse, professor of governance and leadership at Henley Business School and who has worked with the NHS for some 30 years, doesn't think it has a leadership problem but a political one. Rather than channel resources and investment into the frontline, he says, these have gone into "continuous cost control". "That's why you have so many cost-based managers and so many people looking at accountability and costs," he says. "If this money had gone into medical leadership, we'd have a much better service."  

Professor Kakabadse, who is also a Parliamentary advisor, reckons the danger in viewing the NHS as a commercial business is that it would end up being run like a "cut-price retail business" trying to deliver the cheapest service to the customer. "If you said, let's run it like the John Lewis Partnership with its emphasis on customer care and service, then I'd say 'fantastic'," he says. "But in the NHS we don't have leadership training on service delivery, we have it on cost and managing costs."

Holbeche says that in the era of cost constraint, there could be a case for some "strong-armed" leadership interventions if the NHS is to work across silos such as the manager-clinician divide. She stresses, however, that any measurable outcomes from these must be drilled down to a local context so individuals understand how they can make a difference. She adds that she would be extremely loathe to see such a programme outsourced to one of the big consultancies though as it is more likely to dissipate into a massive drain on resources with no measurable benefits. Instead she favours the determined drive by outfits like NHS Employers and the King's Fund to improve the institution from within and believes organisational development (OD) practitioners could be central to the challenge.

"So you could have this mass customisation at senior management level, followed up by capable support from internal OD practitioners who could help people through the changes they are trying to make to their own behaviours and the team's effectiveness," she says. "That could be quite a good combination and a more sustainable investment which would mean the NHS ended up with cadres of people able to make a difference."

There is no easy answer to the ills of the NHS and it's highly likely that the finger will continue to be pointed at leadership in future reports and reviews. Professor Kakabadse says there will be continued calls for more leadership training but emphatically states that leadership cannot solve the problem of under-funding. "If there was proper investment we would have a completely different form of leadership training. We would be looking very much as to how the medical profession would be taking a forward role and breaking down some of the barriers to this and we would be looking at service delivery," he says. "We don't have a leadership or management problem, we have a philosophical one and the question is do we want a health service that looks after its population or not?"

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