If it’s about NHS culture, it’s about leadership

There are plenty of issues to keep NHS leaders awake at night: financial concerns, the winter crisis, the junior doctors’ strikes and experiences of poor-quality care are all in the news. But what about some of the underlying issues behind the headlines?

NHS leaders are concerned about staff reporting high levels of bullying and harassment and are considering strategies to deal with this. They are also concerned with high levels of discrimination reported by some groups of staff and are considering strategies to deal with this.

And there need to be strategies to deal with high levels of staff stress and absenteeism. And then the ambition for the NHS to be the largest learning organisation in the world requires a strategy for ensuring continuous improvement. And there is a need to develop system leadership, which will require yet more strategies. Plus the need to address the shortage of leaders throughout the NHS, which requires a further strategy. So what we end up with is a patchwork of strategies, sewn more or less together in a diffuse set of responses to these important concerns.

If we want to deal effectively with all these issues, then, first and foremost, we need to develop organisations with cultures that deliver high-quality, continually improving and compassionate care. Research shows that such cultures are sustained by organisations that have:

  • an unwavering commitment to providing safe, high-quality care
  • a commitment to effective, efficient, high-quality performance
  • behaviours characterised by support, compassion and inclusion for all patients and staff
  • ways of working that focus on continuous learning, quality improvement and innovation
  • enthusiastic co-operation, teamworking and support within and across boundaries.

We see these values and behaviours in high-performing trusts such as Wrightington, Wigan and Leigh NHS Foundation Trust; Salford Royal NHS Foundation Trust; Northumbria NHS Trust; East London NHS Foundation Trust; and Frimley Health NHS Foundation Trust. These organisations have seen considerable improvements in patient outcomes and staff wellbeing as a result of their efforts.

If one can achieve it, all can achieve it. The question is, how? To find answers to this question, The King’s Fund and NHS Improvement are working on a two-year programme to help trusts to identify their cultural issues and to take appropriate action to develop a culture that enables and sustains safe, high-quality, compassionate care.

Research reveals that leadership is the most significant influence on culture. Every interaction by every leader, every day, shapes the culture of the organisation. So we need leadership that is focused on ensuring constant commitment to all the elements that contribute to a nurturing culture. And we need to ensure we have leaders, and a pipeline of leaders, in place to provide that focus. Not interim leads, vacant leadership posts and make-do-and-mend approaches to leadership that are now commonplace in parts of the NHS.

Ultimately we need one strategy – a leadership strategy. This must ensure we have the right number of leaders in each area of an organisation over the next five years to nurture and sustain caring cultures. We need to identify the qualities these leaders need in order to meet challenges and we need to recruit, develop and select accordingly.

We must develop and continually reinforce the right leadership values and behaviours – such as developing and empowering people, encouraging shared learning and continuous improvement, building trust and co-operation, supporting inclusive climates, and managing performance – needed to nurture these cultures.

This means a move away from command-and-control leadership – still the dominant style in the NHS – to collective leadership. Not because of ideology but because international research evidence demonstrates that collective leadership is associated with high-quality care. Collective leadership is where staff at all levels act to improve care – within and across organisations. It means ‘leadership of all, by all and for all’.

The two-year programme announced today will pilot new online tools to support trusts to diagnose their cultural issues, develop collective leadership strategies to address them and implement any changes. Culture change and leadership transformation must happen at all levels of the NHS, from national bodies through to all provider organisations if we are to achieve and sustain consistent cultures of high-quality, continually improving and compassionate care. We hope this work will play an important part in supporting this.

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#545664 Jon

Hi Michael - Regarding the two year pilot, what was the rationale for pilots with high performing trusts. Would it not have been useful to have included under performing trusts as well? Kind regards

#545665 Lee adams
Retired local government and nhsmanager

This is great but will only work if local government and primary care use the same approaches to ensure whole system sings from same sheet
So we need a whole system leadership strategy

#545666 Lee adams
Retired local government and nhsmanager

This is great but will only work if local government and primary care use the same approaches to ensure whole system sings from same sheet
So we need a whole system leadership strategy

#545670 Sarah
Strategic Development Manager

Excellent article, which outlines a key issue if the right style of leadership bring in place across the NHS, but I can't help but consider how the many very good leaders are stymied by the lack of a cohesive overall single strategic direction of the NHS. The fact is, the NHS is an industry, a brand, not a single organisation. It has 6 'leads organisations, NHS ENgland, Monitor, the TDA, the CQc, Public Health England and Heath Education England attempting to get the many different organisations to work together in a market driven system that was designed to create competition to drive up standards. As improvements are needed in almost every part of the system, despite the many reforms, increased scrutiny and a daily set of negative press, it is fair to argue that the system that the NHS operates within is fundamentally flawed and no amount of good leadership will fix that, unless someone somewhere is brave enough to address the issue and create a single responsible body with one set of strategic intentions, one board and one set of people with the courage to open up the debate about what the 21st century NHS needs to be and needs to deliver.

There is no doubt that the care delivered daily on the ground is of good quality; caring, compassionate and effective. When things go wrong, it is normally as a result of 'system' failures rather than anything else, as the machine of change grinds very slowly through the individual priorities of the many different organisations, professional bodies and vested interests. The NHS, as things stand, would be bankrupt within weeks without the constant and increasing flow of funding, and despite the funding is increasingly under financial pressures - yet overall the staff still go out of their way to care, look after vulnerable people and heal the sick and injured.

In conclusion, collective leadership in the NHS is an unattainable utopia, a symptom rather than a cause, in a system that has been assembled and modified to create a commercial market place that is not fit for purpose.


Michael i have read quite carefully what you suggest -------As a Secondary School educated person there are comments made about your article i find quite typical of why the system is not working -- plain speaking and straight forward do and don't will work ---why because unless communication is clear to all ---the system stays broke --every person who as the power to make changes in Leadership ARE PRECISELY THE SAME PEOPLE who are part of the same old school from before 2010 who cannot and do not understand that it is precisely themselves who have and are still creating -- completely the wrong culture to make the NHS work any where near how it should --FRANKLY speaking
i know a lot of your readers will raise there eyebrows when i say bodies inside NHS do not want culture change ----why because they have no interest in making things work ,because they come from a culture of our pensions and retirement packages making them safe no matter if the NHS goe's under -----INNOVATION and the courage to carry plans through needs supporting
It seems we have some highly intelligent and innovative management in the NHS --but because once again those at the top of management have once again failed to take notice of those S/USERS and CARERS not EXCLUDING staff at the bottom of the ladder
I could bore some people with my findings
Yes i am a director of financially struggling recovery org
my credentials follow
20yrs in engineering ---- while i had early signs of MH probs
25yrs as a small business promoter in music
during this time i recovered from heart by-pass
and many years operating in MH and GOVERNOR of a TRUST
Without salary !!!
Please consider my points when writing about new changes
but it seems that people like myself have to take a back seat
while some people come up with plans without thinking them through ---why because it is easy to talk than actually talk the talk
Please understand this is not a attack on you MICHAEL but I hope I have given pause for thought -----if only for the NHS

#545705 Peter Levin
West Cornwall HealthWatch

I do find this an astonishingly inward-looking blog, and in that respect it actually typifies one of the major failings of the NHS today. Out here in the real world, there is a culture that is very different from that within NHS management (including commissioning) circles - different in terms of attitudes, expectations and ways of communicating. Out here it's non-hierarchical, non-deferential, questioning, jargon-free and straight-talking. Please check out my recently-published piece 'Involving the public in NHS commissioning: A culture clash in Cornwall' to see what I mean: http://bit.ly/1WMIlYE

#545706 Peter Levin
West Cornwall HealthWatch

PS to the above: From which it follows that the most urgent task today is to find means of bridging the culture gap between NHS organizations and the outside world. I think that may well provide a whole new take on 'leadership' issues.

#545870 Simon nevitt
GP trainee

Agree. This nebulous idea of "leadership" as a cure for all ills is just a sideline/distraction from the fact that the NHS is bust. These type of ideas are just dancing around the elephant in the room that we can't afford the NHS as it stands. More wasted money in leadership courses etc etc but why not just put the right people in the right job with the right qualifications in the first place. Shoehorning people/doctors/nurses/midwives into roles they shouldn't be doing is a complete waste of time and money!

#548147 jessicalacy

Leadership training for youth is an investment in our present and future. Yet providing effective training can be challenging in terms of time and curriculum—especially in high-poverty communities, as we discovered in a pilot study of leadership training at an inner-city middle school. Leadership has gained importance nowadays. It has become more crucial be it high school or any organization to go have a leadership programs.a growth of nation depends on its youth, if the youth have leadership quality its nation will surly grow. nowadays core values are missing in younger generation thus it have become important for high schools to have a leadership programs for the students. i would like to recommend mr. chris salmon https://vimeo.com/120517175 who is noted attorney, lecturer & author whose regularly speaks at leadership conferences across the country, mr. salamone has shared his views on various subjects relevant to law, government, and leadership at fordham university, georgetown university, harvard university, columbia university, and many other leading scholastic institutions.

#548972 Ethan Nolan

We all need good leadership attitude to develop our personal growth and confidence level. Most probably, due to lack of leadership, we are unable to improve our all round performance such as; confidence, creative ideas, innovative thoughts, and success strategy. I would like to follow the instructions present here about leadership to improve my personal success. Thanks for such a wonderful post.

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