Rediscovering our purpose

The findings of the Francis Inquiry into the terrible failures of care at Mid Staffordshire NHS Foundation Trust shone a light on a trust where ‘an unhealthy and dangerous culture’ dominated; where meeting targets and achieving foundation trust status were valued more than the needs of patients. Francis concluded that these failings were not limited to Mid Staffordshire but that ‘aspects of this negative culture have emerged throughout the system.’

The third leadership review from The King’s Fund, Patient-centred Leadership: Rediscovering our purpose, looks at the main findings of the inquiry and asks what we can do to prevent such failures of care in the future: ‘Nothing less than a transformation of systems, leadership and culture is needed if the lessons of the Francis Inquiry are to be learned and acted on.’ Nicola Hartley, Director of Leadership Development at The King’s Fund, tells us what this means for NHS leaders.

A culture of care

‘The challenge is how do we change the culture of the NHS, both in its entirety and in individual organisations? We must move to a culture of care, away from the culture of fear that can exist in some organisations, to improve patient care,’ says Nicola. The need for change is clear: in our leadership survey, 43 per cent of senior managers and leaders said that organisational culture was the biggest obstacle to improving care.

‘As well as moving to a culture where patient care is the driving force, we need to strengthen leadership at three different levels, as described in previous work from the Fund,’ argues Nicola. ‘The three lines of defence against poor quality care are frontline clinical teams; the boards leading NHS organisations; and national and regulatory organisations.’

Leading change

‘Somebody has to set the standard for what’s right and what’s expected’, says Nicola. ‘Leaders of national and regulatory organisations need to move to the fore in terms of creating cultures where the patient and their care is of paramount importance.’

Nicola explains the implication of this: ‘It will sometimes require leaders to put the needs of the wider system ahead of the needs of their own organisation. That’s beyond collaboration; it’s working for the greater good, where the common goal is the best possible care for the patient. That’s quite contradictory for leaders who are used to driving their own organisations.’

Boards have a pivotal role to play. However, the leadership review survey showed that respondents saw boards as having less impact on the quality of care than clinicians, managers and the government. ‘If this finding is representative of the NHS as a whole, then it suggests boards should be doing more to exercise clear and visible leadership to improve quality in their organisations,’ says Nicola. ‘What’s very clear is that the board, whether that’s the board of a system-level organisation or an NHS trust, has an absolute responsibility for setting and monitoring organisational culture and they do that by what they say and how they behave,’ argues Nicola.

The part clinicians need to play is also clearly set out in the review: ‘Nowhere is leadership more crucial to improving care quality than on the front line – in wards, clinics and practices.’ The review concludes that nurses and doctors need support to do that, with recognition, training and resources.

Demands on leaders

These changes place great demands on leaders. ‘It’s a big change,’ says Nicola. ‘We have created a cadre of leaders who operate with a heroic and pacesetter style, which we talked about in our 2011 review, The Future of Leadership and Management in the NHS: No more heroes. This year’s review builds on this, arguing that we need leaders with a style that is shared, distributed and adapted.’

‘The Francis report gives an impetus, and also permission, for this change to happen,’ says Nicola. ‘Permission to change is one thing but knowing what the new skills set looks like, and then knowing how to adapt what you do to match that, is quite another. This will require self awareness and courage, to break out of old, often successful, operating models and embrace new styles.’

Future leadership development

To deliver the changes in culture and leadership style demanded by the Francis report, we must review how we approach leadership and organisational development. The focus should be on developing individual performance in order to improve the team, organisation or system.

Nicola explains how leadership development programmes offered by The King’s Fund are based on a key principle: ‘We work with real issues, creating bespoke interventions that employ a range of methods – alongside offering expert policy analysis. This underpins all our leadership development work, particularly as we look to develop new programmes to meet the needs of today’s NHS. ’