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

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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.


Judith Ball

Comment date
14 August 2015
I enjoyed this blog, and agree there needs to be cultural shift in the NHS. However, I do have concerns when a subjective word such as positivity begins to be mentioned. Nurses are habitually informed by leaders they are being negative if they question any imposed policies, even if the concerns are legitimate and impact patient care. It could be argued that nurses are remaining as positive as they can manage in a stressful climate, where they are often understaffed either due to difficulties in recruitment or sickness rates. When staffing levels are suboptimum then short cuts to achieve care begins. This is the slippery slope into lack of compassion, brusqueness and the poor performance resulting in a lack of respect to others...not only to patients but other NHS colleagues. Compounding this the staff cannot then be freed to training updates, clinical supervision etc. which escalates the problem. I do not agree this gives a free reign to the mood hoovers, as these very negative influences must be challenged. However, I am becoming disenfranchised with the lets be positive stance when clearly the NHS has many negative issues to address. Lets address some basic needs to ensure patient safety first such as staffing levels. The acute sector has made some strides towards this aim, community nursing has no limits to the extent of caseload that a nurse can take. There is research to say fewer nurses poorer patient outcome. We ignore that at our peril. So what are the NHS contingencies for workforce planning for the future? We cannot continue to use agency employees at such a cost, and take staff from abroad. Trusts need to start training far more nurses, and instill a cultural shift from inception. Perhaps this may be the reason the survey demonstrated such a difference between managers/leaders and the remaining staff at the coalface.

Carol Munt

Patient Partner & Advocate,
Comment date
10 August 2014
I wonder how many Boards take 'responsibility for consulting with all staff and stakeholders (including patients and the community) to develop a strategy for leadership.'
This is something which is overlooked too often and where collective leadership fails miserably.


Freelance OD Consultant and Mindfulness Coach,
Future Lives Consulting and Coaching
Comment date
14 July 2014
Thanks Michael for this thought provoking blog.
I'm wondering if there is another facet to collective leadership and how we as leaders work together to enable cultural change in the NHS? That is how we enable helpful leadership behaviours through role modelling, encouraging, praising, appreciating and recognising them and also how we go about having conversations with each other when leadership behaviours fall short of the mark? If we simply berate or punish or give feedback we are simply doing more if the old style command and control style leadership. How can we skilfully with wisdom or clarity and compassion address these unhelpful behaviours so that we model the behaviours and leadership style we aspire to see? Happy to discuss in more detail. Best wishes. Taravandana

George Coxon

Various health and social care,
Various H&SC
Comment date
27 May 2014
3 quick points on leadership
1- yes it's about ownership and loyalty to each other, the work and the leader
2- without followers there's no leader. See YouTube Derek Sivers clip ' how to start a movement'
3- this weeks HSJ has an excellent piece citing Anna Dugdale ( CEO at Norfolk and Norwich FT ) promoting the emotionally engaged leader Surely that's what we're all looking for and looking to become ?

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