How can improving leadership help to transform the NHS?

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Leadership is the golden thread that runs through any discussion of NHS reform and improvement. This encompasses leadership by doctors and other clinicians; leadership by managers of NHS organisations; and leadership by politicians at a national level.

Our view at the Fund is that leadership in NHS organisations needs to be collective and distributed rather than located in a few individuals found at the top of these organisations. Involving doctors, nurses and other clinicians in leadership roles is essential, particularly in the clinical microsystems that comprise the basic building blocks of hospitals and other health care providers.

Organisations in which skilled clinical leaders work with experienced managers are able to draw on different sources of expertise as they improve performance. One of the most important roles of leaders is to develop the cultures that are conducive to the delivery of high-quality, patient-centred care.

Research has shown that there is a close correlation between staff experience and patient experience. Patients receive better care when it is delivered by staff working in teams that are well led and have clear objectives, and where staff report they have the time and resources to care to the best of their abilities.

This highlights the critical role of team leaders, often experienced nurses, who develop a climate in which patients are treated with dignity and respect, and motivate their colleagues to do the same. The work of Michael West and others provides compelling evidence of the influence of staff engagement on organisational performance, and the role of leaders in promoting engagement.

Leadership by politicians exerts an important influence and this can be for ill or for good. I have argued elsewhere that current politicians lack experience outside politics. This means that Health Secretaries find themselves leading one of the biggest and most complex organisations in the western world with little, if any, understanding of how to discharge this responsibility effectively. Hardly surprising therefore that their record is distinctly mixed and often criticised.

One of the consequences of rapid turnover among politicians and of short-time horizons is lack of consistency and a tendency towards hyperactivity. This militates against the commitment seen in high-performing organisations to a long-term vision of improvement that is well communicated and understood.

Another unfortunate tendency is for politicians to reorganise the NHS on a frequent basis. Inevitably, this distracts attention from the much more important issues of quality improvement and service transformation.

An important lesson from high-performing organisations is the need for alignment of goals and leadership at different levels and coherence in the approach to improvement. The challenge is how to achieve alignment in a large and complex system like the NHS, which is more like an armada than a battleship. National leaders – politicians and others – have a critical role in creating a coherent national framework to enable those running NHS organisations and services to bring about change at scale and pace.

Both leadership development and training in quality improvement need to be priorities for NHS organisations themselves rather than being outsourced to national agencies. Vacancies in senior leadership positions in NHS organisations are an indication of the failure of recent approaches to talent management in the NHS, including the Top Leaders programme, which was intended to increase the supply of qualified people for these positions.

NHS organisations may need external support in strengthening leadership and redesigning models of care, but this is best provided by agencies with an established track record in these areas. Any national agencies should be small and expert, focusing only on those activities that cannot better be done at a local or regional level.


Clare Charlton

PMO Support,
Comment date
22 May 2014
Thanks for the blog, its an important note to take that we should be allowed to work as teams, however there also needs to be some listening done within those teams and to higher levels of all members of staff, not just those with higher pay grades.

Having worked up from a Band 3 admin to previously a band 8b I have always listened to the people in my teams and taken their ideas on board too, often staff members who have been with the organisation longer than I have, my managers, many of which were graduate training scheme members, encouraged me to do so and it was the right move. I however feel that this is rare. Even implementing national policy, I was privileged to be able to consider options from all levels of healthcare teams within A&Es and it made a huge difference to our success. Without the whole team on board we would never have achieved what we did.

The listening, team work and united front needs to come from all levels and the coal face not to be ignored like sometimes it feels.

Taruna Chauhan

healthcare business consultant,
T Chauhan Consultancy Ltd
Comment date
20 May 2014
This is nothing new but it is backed up by the Kings Fund. I have always believed that for the NHS to work and teams to work it has to be a team effort not rules from the top, which don't make sense at the coal face!

Steve Turner

Steve Turner Innovations CIC
Comment date
19 May 2014
I don't know how to say this in the right way, but I'll try.

This blog contains a really important message which benefits from being backed by the Kings Fund, research and top expertise, but it's not telling us anything new.

It really illustrates the need for leaders to listen to staff and to patients more, and for politicians to allow them space to do this.

Most lay people could have told us (and indeed did tell us) that:
- there is a relationship between positive staff and positive patient experiences
- there is a need for a less rigid hierarchy ('distributed leadership')
- that the effect of political leaders can be negative
- that we need to stop constantly re-orginaising

...years ago.

Sometimes less really is more...

I'm glad to see the tide is turning.

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