Collective leadership: fundamental to creating the cultures we need in the NHS

Positivity, compassion, respect, dignity, engagement and high-quality care are key to creating the cultures we need in the NHS. And, just as importantly, we must deal decisively, consistently and quickly with behaviours inconsistent with these values, regardless of the seniority of people exhibiting them.

Yet in our most recent survey of NHS staff, two-fifths of those surveyed felt that negative behaviours – typically incivility, aggression, discrimination, carelessness, brusqueness and poor performance – were not being dealt with in a timely or effective fashion in their organisation. How then can we ensure that positive NHS cultures, with a focus on patient care, are encouraged, and inappropriate behaviours and performance are reduced?

The NHS is facing challenges that require fundamental changes to the way care is delivered. Because of shifting demographics, new patterns of care needs, new treatment methods, increasing demands and huge budget pressures, the service must adapt on a scale never seen before. It will require leaders, within and across organisations, to learn to work together with a shared vision of providing continuously improving, high-quality and compassionate care. This means greater integration between health and social care, and the involvement of other agencies, including housing, leisure and education, in many instances. At the very least, leaders within health care organisations will have to ensure  their activities and efforts are joined up, to ensure patients have integrated, consistent, coherent care, not disintegrated, contradictory and confusing care. So how can organisations shape their culture of care?

In two reports published this week, The King's Fund explains how. Overall, the most important influence on behaviours in NHS organisations is the culture – 'the way we do things around here'. It was the key problem identified by both Robert Francis and Don Berwick in their reports resulting from the appalling failures at Mid Staffordshire NHS Trust. And the most important influence on culture is leaders in organisations, leaders from top to bottom and end to end. What they focus on, attend to, monitor, model, reinforce and do shapes the culture. Every interaction by every leader shapes the culture of the organisation.

We will not make sufficient progress by continuing to develop leadership in a piecemeal and ad hoc way. The King’s Fund argues that boards must develop a clear, coherent, powerful leadership strategy to nurture the NHS cultures we will need for the future. This will involve identifying the number of leaders needed in each area of the organisation over the next five years, making sure thatleadership reflects the diversity of the staff and local community, and pinning down the skills, competencies and knowledge leaders require to achieve the organisational vision – for example, improving compassion, equality, staff engagement and openness. It will also involve identifying collective leadership capabilities – how leaders work together to implement organisational strategies and to nurture cultures, which individual leaders working alone cannot accomplish.

Collective leadership is leadership that prioritises leadership of all, by all and together with all. This means moving away from the dominant command-and-control, hierarchical and pacesetting styles of many NHS leaders to quite a different leadership culture. It is a leadership in which all take responsibility for ensuring high quality patient care and all are accountable – for example, by speaking up when they see unsafe or inappropriate behaviour, regardless of the seniority of the staff concerned. It also means attracting, developing and sustaining leaders who are committed to working together to create a leadership culture underpinned by core values. Collective leadership means leaders and teams working together across boundaries within and across organisations in the interests of patient care and community health. This requires us to change the way we think about leadership by seeing leadership as the responsibility of all – anyone with expertise taking leadership responsibility when appropriate.

Boards must take responsibility for consulting with all staff and stakeholders (including patients and the community) to develop a strategy for leadership and for creating a leadership culture that ensures effectiveness. In these challenging times, collective leadership – planned, designed, developed and delivered – is the key to creating NHS cultures that deliver high-quality, compassionate and improved care for patients and communities.

This blog is also featured on the British Medical Journal website.