A return to values-driven leadership or more of the same?

As Secretary of State for Health Jeremy Hunt reminded the audience at this year’s NHS Confederation annual conference, ‘values-driven leadership matters in every walk of life, but it matters more in health care than anywhere else’. He suggested that people in the NHS work at the ‘intersection between the financial, the operational and the moral’ and challenged the audience to lead through modelling the values of those they lead.

So what does values-driven leadership look like? Although the priority assigned to these values varies as individual motives vary, frontline teams are often driven by moral imperatives, to provide care and comfort to the patients and relatives they serve, while there is a perception that those who lead them often look for the ‘efficiencies’. This has traditionally led to an adversarial standoff and the casualty, it could be argued, has been quality of patient care.

During one of my previous roles in the NHS, I was involved in a national ‘values’ exercise conducted at great expense by an external agency around the strapline ‘patients – central to what we do’. I heard first-hand the derision with which the clinical profession approached this exercise; they already knew patients were central to what they do, this was a value they signed up to when they joined the health service.

Thinking about how to define the values of those who must now lead across a system in the challenging period ahead took me back to our report on the practice of system leadership which draws on the experiences of 10 senior leaders, who give some very candid reflections on their successes and failures.

Many of those interviewed resisted being labelled as system leaders. Their reluctance may be due to another belief: that to achieve change you need to give credit to others. They exemplify the Chinese philosopher and poet Lao Tzu’s saying: ‘A leader is best when people barely know he exists, not so good when people obey and acclaim him, worse when they despise him ... But of a good leader who talks little when his work is done, his aim fulfilled, they will say, “We did it ourselves”.’ However, without the motivation and effort of individual leaders, the changes they set out to achieve would never have happened. What they collectively embodied was values-driven leadership, the style of leadership that is built from demonstrating the component parts of trust: ‘character and competence’.

Values-driven leadership that comes from prioritising the moral and clinical imperative will win hearts and minds on the front line. But these values need to be strengthened by investing in and building capability in quality improvement and innovation. There is a danger that placing financial imperatives first drives behaviour that runs contrary to what we have acknowledged through our work on culture. If leaders in health and social care ignore the watershed moment highlighted by Mid Staffordshire – from which we have committed to creating compassionate cultures in which patients and their carers flourish – then the rhetoric on values-driven leadership may give way to cynicism as before.

At the NHS Confederation annual conference, The King’s Fund set out to make the case that understanding organisational culture is essential in order to provide firm foundations for developing high-quality, compassionate and continually improving care; this is crucial for developing values-driven leadership. The conference also marked the launch of our culture assessment tool – in collaboration with Aston OD – to help organisations understand and diagnose their culture.

On his first speaking engagement as new Secretary of State for Health here at The King’s Fund, Jeremy Hunt was asked a question we posed to many leaders that day: ‘What leadership qualities do you most admire?’ His answer began ‘Listening, truly listening’. My wish as we go forward at a critical juncture for health and care is that all leaders, from the Health Secretary to those leading on the front line, go even further and demonstrate true values-driven leadership.

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#544064 Pinkey A. Stewart
Leadership Development/Employee Engagement Strategist

Interesting article. I applaud Mr. Hunt on stressing the importance of intersecting finances, operations, and moral character in the health care profession. These values are important to any industry, not just health care. The problem I find is that while leaders, talk about such values, they have a difficult time operationalizing or making actionable the behaviors that will bring about the desired performance results. Intersecting the values -- which values take priority over others? How are these measured to determine true ROI? These are questions leaders should ask before beginning to implement a strategy that will align these values. Thank you for this great article.

#544164 Umesh Prabhu
Medical Director
Wrightington Wigan and Leigh FT

Good to see everyone joining the band-wagon on values based leadership. In Wrightington, Wigan and Leigh FT this is exactly what we did in 2010 to turn the Trust around. Our staff feedback was bottom 20% in the country and that was the burning platform but the CEO Andrew Foster was determined to transform the Trust.

We had Listening in to action and listened to our staff, their frustrations, their unhappiness, pockets of bullying. With the help of staff we defined our values, leaders and managers behaviour which would uphold these values. We asked our staff to identify clinical leaders who are good clinicians, but also nice human beings, good team players and whom they saw as leaders of their Division and departments. We asked consultants, speciality doctors, GPs, juniors and nurses and in each department one or two names came forward and many of them were not in leadership position.

We then encouraged these clinicians to apply for leadership positions, we had excellent appointment process based on values. We changed some leaders who were not bad people but had no leadership skills to step down from leadership position. Today everyone can see the benefit of values based leadership.

Value based leaders have very high moral values, they are very self-disciplined and always put patients at the heart and uphold the values of the Trust and look after staff very well and create a culture where staff are happy and proud to work. They also implement good governance and accountability.

Sad reality is NHS is good at using many buzz words and today's buzz word is values based leaders but many do not understand the true meaning of values based leadership. In values based organisations diversity and inclusion thrives.

#544165 Umesh Prabhu
Medical Director
Wrightington Wigan and Leigh FT

Just forgot to add that very well written article Vijaya Nath.

NHS is about kindness, caring and compassion and we must appoint leaders who are kind, caring and compassionate towards both patients and staff. This is what values based leadership is about. They create a culture where all staff are happy and feel proud to work and do their best for their patients. Happy staff - happy patients.

#544166 Andrew Singfield
Senior Manager - Advancing Change Team
NHS Improving Quality

Many thanks for this thought provoking blog.

I like the concept of the 'intersection' that Jeremy Hunt uses - describing a place where finance, operations and morals come together. One of the challenges the NHS faces in building widespread leadership is that historically we have been too accepting of a crude pigeon-holing of leadership values. 'Caring about patients' has been allowed to be the crusade banner for doctors whilst 'balancing the books' has been an accepted priority for managers. Shifting the debate to how good leaders (be they clinicians or managers) can focus on multiple competing demands in an authentic and accepted way has got to be healthy for the NHS. It helps to move discussions about transforming NHS services away from damaging polarized debates (that cast managers as penny pinchers and clinicians as shroud wavers) to potentially more grounded dialogues among leaders.

Interestingly, as the blog says and some of the comments show, there are places where this is already happening but we don't always hear about these leaders. They 'walk quietly', getting on with their jobs and working with others to tackle the wicked problems where goals relating to finances, good patient care and performance targets compete for air time, often seemingly at odds with each other. These leaders hold the tension and resist going for the simplistic solutions that meet one goal but miss the point. This not only requires a whole host of interpersonal skills but also a fair degree of personal courage.

#544169 Chris Heginbotham
Visiting Professor
University of Cumbria

Vijay Nath describes a process that demands our attention as a way of changing health care. For over fifteen years we have placed an emphasis on evidence-based medicine and health care but we have not given values-based health care sufficient weight or emphasis. Bill Fulford, Ed Piele and Heidi Carroll in their excellent book, 'Essential Values Based Practice: Clinical Stories linking Science with People' (Cambridge University Press, 2012) demonstrate the importance of values as complementary to evidence. A lot of evidence is in any case value laden (e.g. QALYs) but the values base is rarely made explicit. Values-basing is the practice of recognising and acting on the differing values held by all those engaged in making health and social care decisions. It is not about 'value' from a monetary aspect, but about all those values that we brng to any health care decision.
Values-based practice is effective not because it allows everyone's expectations to be satisfied but because it provides a transparent, fair and balanced process. A helpful starting point theoretically is Hume's principle that you cannot derive an 'ought' from an 'is'. No matter how many descriptive facts (evidence) are established nothing follows about the rightness or wrongness of what should be done without the addition of some evaluative premise. Value judgments are not merely expressions of feeling or preference: they aim to say what is really good or bad, right or wrong, just or unjust, in virtue of the objective principles and reasons that can be applied to the choices available. So values-based practice requires a method in which there is full involvement of health professionals and patients, together with a process of reasoned argument in a spirit of open and respectful enquiry taking into account all the values and evidence available.
Unfortunately what so often happens is that patients values are subsumed to a discussion of financial reosurces as if those patienst preferences had little meaning. True perosnalisation would give the patient and professional values much greater importance. Values-based leadership would make a real effort to ensure that all values are identified and included in the decision making process.

#544189 Ruth Taylor
Anglia Ruskin University

Thank you for this blog Vijaya. Values-driven leadership is core to what we are aiming to do within our education. As educators of the 'next generation' of professional, we are in a fantastic position to make a positive impact in the way that you describe. It is not hard, as an individual, to subscribe to values-driven leadership. But it is hard to ensure that we (I!) enact consistently and with integrity at all times. It requires reflection, self-awareness, determination, and a vision for how we can do things differently (where that is needed). I am often inspired by our students who demonstrate these values - and who we must support within the wider system to take forward as they move through their education and into qualified practice. I truly believe we can make a difference. One example of where the students at my university have made, and continue to make, a difference is their student-led 'Stop the Pressure' conference. They brought together professionals and service users to discuss the issues, and to pledge to make a difference in their practice - a ripple effect of a few students who have impacted on a large group who will impact again in their own practice areas.

#544202 Isabel Hemmings
Chief Operating Officer
Sheffield Children's NHS Foundation Trust

Thank you Vijaya, this was a helpful article and I liked the Lao Tzu quote! Given the big issues facing us in the NHS at the moment, collaboration with our staff and our patients is essential, and listening is an essential part of that collaboration, as is humility. Good leaders know that they don't have the answers. We all have to deal with the reality of our context and the emphasis has to be to create an environment where good ideas and innovation can flourish, and where we realise we're all in this together. Most leaders I know care, and care a lot, and similar to clinicians, most managers came into, and stayed in the NHS because of their values and from the satisfaction they get from supporting improvement in patient care.

#544301 Hugh McIntyre
Consultant Physician
East Susex Healthcare Trust

It will, said the Chief Executive of the NHS on July 7th, fall to the "Intellectual capacity of clinicians" to deliver the Clinical Leadership that will release “value” in healthcare.
Is this just code (possibly unintentional) for devolution of rationing to the individual clinician – or, if such a pragmatic view were seen as too cynical, how am I, and colleagues, to be equipped to take on the delivery of best outcome at best cost to the person before me?

It is hard to know what Clinical Leadership actually is. For General Practitioners, of 15 leadership capacities (1), even the first three: “Be comfortable with uncertainty”; “Be honest with yourself” and “Drive responsibility downwards” imply a self awareness and interpersonal skillset reflecting years of insight and development. Not touched upon were the ethical, moral and fiscal value sets required to understand, translate and deliver reasoned advice to aging populations facing increasingly complex care options. The current major investment in Leadership alraedy underway throughout the NHS presumably rests upon the belief that such skills can be acquired by training in mid-professional life.

A recent review of the evidence on leadership and outcomes (2) contrasted the research base beneath clinical care with the “huge amounts” spent by the NHS on leadership development “without a clear understanding of … impact on patient outcomes”. Driven by “fads and fashions” rather than hard evidence, successive reviews have added only “confusion [and] strong opinion”. The report endorses a move away from a “preoccupation with [remote] individual leader development” to “in place” development of a “cooperative, integrative leadership culture.” Although contextualizing, as opposed to decrying, the importance of individual leader development the report leaves open what it is that befits the leader for the role in the first place?

Lord Keogh also said: "Big industry hire and fire on value - train on competency - we need to do same". It is their values that identify the nascent leader and it is to their values that prospectively evaluated “in place” training should add the competencies of resilience, cooperation and facilitation. But value must first be nurtured. If value is integral to the successful leadership of healthcare then it must be integral to the process through which care is learnt. Trying to “bolt on” value as an afterthought to the learning of medicine is surely an admission of failure? The “new epoch for health professionals' education” (3) requires that the clinicians of the future understand the ethical, social and pastoral aspects of healthcare as well as they do the scientific and technological. It is to the early nurturing of those with the “intellectual capacity” for leadership that we need to look to, to prepare the clinical leaders of tomorrow.

1. GP Enquiry Paper - The leadership challenge for general practice in England Kings Fund 2011.
2. Leadership and Leadership Development in Health Care: The Evidence Base. Kings Fund. 2015
3. A new epoch for health professionals' education
Richard Horton The Lancet, Vol. 376, No. 9756, p1875–1877

#545048 Bhav Seera
Digital marketing
London Management Centre

This is a very interesting article, some similar points that I agree with as written on http://www.lmcuk.com/leadership-management-blog/.
This article on kingsfund is a fascinating discussion point as it questions values vs leadership and I will definitely recommend this to some of my colleagues.

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