Our view at the Fund is that leadership in NHS organisations needs to be collective and distributed rather than located in a few individuals found at the top of these organisations. Involving doctors, nurses and other clinicians in leadership roles is essential, particularly in the clinical microsystems that comprise the basic building blocks of hospitals and other health care providers.
Organisations in which skilled clinical leaders work with experienced managers are able to draw on different sources of expertise as they improve performance. One of the most important roles of leaders is to develop the cultures that are conducive to the delivery of high-quality, patient-centred care.
Research has shown that there is a close correlation between staff experience and patient experience. Patients receive better care when it is delivered by staff working in teams that are well led and have clear objectives, and where staff report they have the time and resources to care to the best of their abilities.
This highlights the critical role of team leaders, often experienced nurses, who develop a climate in which patients are treated with dignity and respect, and motivate their colleagues to do the same. The work of Michael West and others provides compelling evidence of the influence of staff engagement on organisational performance, and the role of leaders in promoting engagement.
Leadership by politicians exerts an important influence and this can be for ill or for good. I have argued elsewhere that current politicians lack experience outside politics. This means that Health Secretaries find themselves leading one of the biggest and most complex organisations in the western world with little, if any, understanding of how to discharge this responsibility effectively. Hardly surprising therefore that their record is distinctly mixed and often criticised.
One of the consequences of rapid turnover among politicians and of short-time horizons is lack of consistency and a tendency towards hyperactivity. This militates against the commitment seen in high-performing organisations to a long-term vision of improvement that is well communicated and understood.
Another unfortunate tendency is for politicians to reorganise the NHS on a frequent basis. Inevitably, this distracts attention from the much more important issues of quality improvement and service transformation.
An important lesson from high-performing organisations is the need for alignment of goals and leadership at different levels and coherence in the approach to improvement. The challenge is how to achieve alignment in a large and complex system like the NHS, which is more like an armada than a battleship. National leaders – politicians and others – have a critical role in creating a coherent national framework to enable those running NHS organisations and services to bring about change at scale and pace.
Both leadership development and training in quality improvement need to be priorities for NHS organisations themselves rather than being outsourced to national agencies. Vacancies in senior leadership positions in NHS organisations are an indication of the failure of recent approaches to talent management in the NHS, including the Top Leaders programme, which was intended to increase the supply of qualified people for these positions.
NHS organisations may need external support in strengthening leadership and redesigning models of care, but this is best provided by agencies with an established track record in these areas. Any national agencies should be small and expert, focusing only on those activities that cannot better be done at a local or regional level.