Build collective and distributed leadership

The most successful health care providers – like high performers in other sectors – are reducing reliance on top-down leadership in favour of collective and distributed leadership, where all staff are supported to play leadership roles. Rather than concentrating power at the top, these providers are devolving decision-making in their organisations, alongside major programmes of cultural change, so that staff at all levels have the authority, responsibility and resources to improve care.

We know that distributing power and authority in this way helps to create a more engaged workforce. Research from multiple sectors shows that staff are more engaged if they have responsibility for their work and influence over their working environment (Towers Perrin HR Services 2003).

Conversely, we know that staff are more likely to disengage when operating in overly bureaucratic environments with layers of hierarchy and control. According to Paul Plsek, Chair of Innovation at the Virginia Mason Center in the United States, ‘a learning organisation seeks to develop skills in the process of leadership at all levels of the organisation, and seeks to flatten hierarchy and eliminate rigid policies’ (Plsek 2013).

However, we cannot underestimate the challenges of developing a collective leadership culture within many NHS organisations, given the legacy of rigid hierarchies and ‘command-and-control’.

For many top-performing providers, it requires huge commitment to develop a new leadership philosophy. It takes time and effort to redesign decision-making structures and equip staff at different levels to play different roles, alongside concerted programmes to deliver the necessary cultural change. In the early 2000s, University College London Hospitals NHS Foundation Trust stripped out layers of management and gave clinicians joint managerial and clinical responsibility for the performance of their divisions, with the role of ensuring both quality of care and financial sustainability.

Alongside these types of changes, staff at every level must be given explicit authority to identify opportunities for improvement or to raise concerns, and – just as importantly – opportunities for these contributions to be considered fairly and acted on. In manufacturing, Toyota and Alcoa famously introduced the right for staff to stop the production line if they identified a defect or a safety concern. In health care, forwardthinking providers are developing similar approaches – not just to improve safety, such as finding a lost swab in an operating theatre, but also to tackle unacceptable behaviours in a caring profession, such as discourtesy, bullying or harassment.

For a further discussion of these issues, see our other recent publications: Exploring the CQC’s well-led domain: how can boards ensure a positive organisational culture? and Developing collective leadership for health care.

Board members should ask the following questions

  • Do we have a leadership strategy and a leadership development plan?
  • Do we have a clear understanding of our current leadership culture and the leadership culture we are trying to create?
  • What approaches have we developed to empower staff throughout the organisation to play leadership roles?
  • Are we absolutely sure that staff can speak up when they have concerns and that their concerns are considered fairly?

Next: adopt supportive and inclusive leadership styles