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Evidence for leadership in health care


The delivery of clinical care is based on careful research to determine the most effective way of providing care for patients. At the same time the NHS spends huge amounts on leadership development without a clear understanding of what kind of leadership and leadership development has most impact on patient outcomes.

I have spent the past two years undertaking a review of the evidence on leadership and outcomes, with a particular focus on what is known about leadership in health care. The findings are published today as Leadership and leadership development in health care: the evidence base.

One observation to come out of this work is that much of what is written about leadership and much effort on leadership development in the NHS is based on fads and fashions rather than hard evidence. Moreover, successive reviews often fail to draw on the evidence base, only adding confusion via strong opinion to the vast body of writing on what constitutes good leadership in health care.

The evidence is clear though: leadership at every level – from frontline leadership in wards, primary care and community mental health teams to board leadership in trusts to national leadership in overseeing bodies – is influential in determining organisational performance.

The task for leaders at every level is to ensure direction, alignment and commitment within teams and organisations. Direction ensures agreement with and pride in what the organisation is trying to achieve; alignment means effective co-ordination and integration of the work; and commitment means everyone in the organisation makes it a personal priority to ensure the success of the organisation as a whole, rather than focusing only on their individual or immediate team’s success in isolation.

Previous research showed that leadership is required not just to develop inspiring visions but to make these visions a reality for staff at every level by: agreeing clear aligned objectives with all teams, departments and individual staff; offering supportive, compassionate and enabling people management; encouraging and supporting learning, innovation and quality improvement; and nurturing effective team-working.

The evidence shows that such leadership embodies honesty, kindness, altruism, fairness, accountability and optimism. It is not preoccupied with target-setting, rules, regulations and status hierarchies.

The evidence points towards what we call collective leadership. Such a culture is characterised by shared leadership where there is still a formal hierarchy but power is more dependent on who has the expertise at each moment. Leadership is most effective when all staff – especially doctors, nurses and other clinicians – accept responsibility for their leadership roles. Collective leadership is characterised by leaders working together to nurture a shared culture, adopting leadership styles that are consistent across the organisation, and co-operating and supporting each other across boundaries within the organisation.

Integrating health and social care services will also require leaders to co-operate between organisations, prioritising overall patient care rather than the success of their component of it. That means leaders working collectively and building a co-operative, integrative leadership culture – in effect, collective leadership at the system level.

Developing such collective leadership for an organisation depends crucially on local contexts and is likely to be best done ‘in house’ with expert support, integrating both organisational development and leadership development. The NHS needs to use evidence-based approaches to leadership development in health care to ensure a return on the huge investments made. In particular, we know that experience of leadership is the most valuable factor in enabling leaders to develop their skills, especially when they have appropriate guidance and support. A focus on how to enhance leaders’ learning from experience should be a priority.

National-level leadership needs to embody developmental, appreciative and sustained approaches, with NHS organisations seen as partners to be supported. Organisations including Monitor, the Care Quality Commission, NHS England and the NHS Trust Development Authority need to demonstrate collective leadership and positive cultures, and support the health service to do the same by the way they interact with NHS organisations.

The challenges that face health care organisations are too great for leadership development to be left to chance, to fads and fashions or to piecemeal approaches. Our review suggests that approaches to developing leaders, leadership and leadership strategy can and should be based on robust theory with strong empirical support and evidence of what works in health care. Organisations need to develop and implement leadership strategies that will create cultures that deliver high-quality, compassionate care to meet the health care needs of the populations they serve.