Laura Holmes of The Leadership Team at the NHS Institute for Innovation and Improvement has selected The future of leadership and management in the NHS: No more heroes  as Article of the Month.

Critique of The future of leadership and management in the NHS: No more heroes

The King’s Fund Commission on Leadership and Management in the NHS was established in September 2010, with the aim of making recommendations on how to strengthen and develop NHS management and leadership in the context of the quality and financial challenges now facing the system. A series of papers were commissioned from experts in the field and these were considered alongside submissions from organisations and individuals interested in management and leadership. The final report was published in May 2011, in the midst of the ‘listening exercise’, and it is evident that the coalition government is intended as one of the primary audiences for this report.

The report considers a wide variety of evidence and makes a number of assertions, observations and recommendations. I would like to highlight four key claims made by the report.

The NHS is under-managed

Much is often made of the ‘rise of NHS bureaucracy’ and many politicians and commentators have claimed over-management as the cause of this. However, the NHS is a £100 billion per year business - larger than all FTSE 100 companies bar the banks, BP and Shell - yet it operates with only 45,000 managers.

As the report observes, assessing the level of management in the NHS is “like squeezing a block of unreconstituted jelly” (p.7), given the number of possible ways of defining terms and cutting data. The following examples are highlighted:

• NHS Information Centre: total staff numbers in the NHS rose by 30% during the period from 1999-2009, but the number of managers rose by 84%. This statistic has been used by politicians as an example of the ‘unacceptable’ rise in management positions, though this left the total percentage of managers in the NHS workforce at just 3.6% (up from 2.7%).
• Analysis of Binley’s database (Walshe & Smith 2011): between 1997 and 2010, the number of managers rose by just 37% in England (and reduced in other UK countries), despite the fact that spending on health doubled during this period.
• Office for National Statistics (ONS): in June 2010, the proportion of managers in the UK workforce as a whole was 15.4% but, under their definitions, in the NHS it was just 4.8%.
• Evidence given to the Health Select Committee by David Nicholson indicated that the NHS spends less than 10% of its overall budget on management.

From the evidence above, the Commission concludes that the NHS may well be under-managed in comparison to private and voluntary sector organisations. The ONS figures certainly seem to support this claim, though some form of comparison of costs with the private or voluntary sector on the last point would strengthen it further. That said, one can only imagine how unmanageable that block of jelly would become in attempting to identify comparable benchmarks, not only between organisations, but between sectors.

The NHS is over-administered

The Walshe & Smith paper highlighted a fascinating statistic: that while the number of NHS managers in England increased, the number of managers in Scotland, Wales and Northern Ireland stayed static, or even reduced. The report speculates that this may be attributable to the complexities of the internal market in the English system, alongside the significant number of additional policy initiatives and new regulators. The Commission draws upon a 2009 report put together by the NHS Confederation and the Independent Healthcare Advisory Service, which indicated that NHS organisations were at that point subject to 35 different regulators, auditors, inspectorates and accreditation agencies, many of whom required essentially the same information but delivered in slightly different ways.

The report’s assertion that there is “appreciable evidence that the NHS is over-administered” (p.viii) is somewhat undermined by the research it cites by the Nuffield Trust, which looked at the performance of the four UK health systems following devolution. The study concluded that England spent less on health care, had fewer nurses and doctors per head, but delivered more patient care and had shorter waiting times, (though interestingly no mention is made of care quality in the report).

Nonetheless, the Commission’s recommendation, which echoes that made by the NHS Confederation and Independent Healthcare Advisory Service in 2009, still stands. Regardless of whether the very high levels of regulation and audit in the English system drive improved performance, it is incontrovertible that there will be substantial scope for administrative efficiencies in aligning and streamlining the competing demands for information from different agencies.

Leadership matters

The report draws an uncontroversial distinction between management (getting the job done), and leadership (the art of motivating people toward a common goal), repeating the current mantra that leadership must extend from the board to the ward, involving both clinicians and managers. Evidence from a number of recent studies indicates correlations between high quality management and leadership and a range of outcomes such as higher quality patient care, improved productivity, higher CQC performance ratings, higher clinical governance scores and reduced patient complaints.

The report draws heavily on Ross Baker’s study of high performing organisations from different health care systems, which forms another of the commissioned papers. He concluded that these organisations share a common focus on quality allied to leadership development, and on developing the improvement expertise of leadership teams rather than just individuals. The examples cited all emphasise the point that high performance is driven by an ethos of leadership for improvement. This resonates with the approach taken by NHS Institute Leadership in recent years as we have been striving to ensure that our programmes and interventions help individuals to understand that leadership must be for a purpose and not an end in itself.

Probably the most critical finding from the Baker study however, is that high performing health care systems most commonly have long serving chief executives and manage the transitions between leaders in a way that preserves strategic direction. The exceptionally high turnover of chief executives is one of the most intractable problems in the NHS, and may well be the most significant barrier to achieving system-wide transformation.

The NHS needs a 'post-heroic' model of leadership

The Commission notes that the dominant model of leadership in the NHS has been one of the leader as ‘superhero’ – the single individual at the top of the tree that can make or break organisational performance – as exemplified by the rise of the turnaround chief executive. The report asserts, rather than evidences, that this model is no longer suited to the NHS context given the increasing requirement to work and influence across organisational boundaries. However, the alternative ‘post-heroic’ model is articulated powerfully and persuasively by Kim Turnbull James in another of the commissioned papers:

“Leadership must be exercised across shifts 24/7 and reach to every individual: good practice can be destroyed by one person who fails to see themselves as able to exercise leadership, as required to promote organisational change, or who leaves something undone or unsaid because someone else is supposed to be in charge.” (Turnbull James 2011)

The ‘post-heroic’ model of leadership involves multiple actors with both formal and informal leadership roles working collaboratively. Leadership is distributed, not in the sense that individuals at lower levels have enhanced leadership roles, but in the sense that leadership is understood in terms of new practices and organisational interventions. Crucially, leadership development is no longer focused primarily on developing individual competences and behaviour, but on the development of the whole organisation, its practices and processes. This chimes with the earlier findings from Baker study.

Though we may recognise and accept the ‘post-heroic’ model as one which has great value in the current NHS environment, we are long way from truly embracing the paradigm shift that this requires in our thinking around leadership development. A significant majority of the programmes and interventions on offer nationally are designed to develop individual leaders at different stages in their career. For me, the most profound challenge raised by the Commission’s report is to consider how genuinely ‘post-heroic’ distributed leadership can be nurtured and grown in organisations and what we, as part of the national leadership development resource for the NHS, can do to support this.

Commissioned papers

These are all available from the Kings Fund website at http://www.kingsfund.org.uk/leadershipcommission.

·         Roebuck, C (2011) Developing effective leadership in the NHS to maximise the quality of patient care

·         Grint, K & Holt C (2011) Followership in the NHS

·         Turnbull James, K (2011) Leadership in context: Lessons from new leadership theory and current leadership development practice

·         Hartley, J & Benington, J (2011) Recent trends in leadership: Thinking and action in the public and voluntary services sector

·         Walshe, K & Smith, L (2011) The NHS management workforce

·         Baker, G Ross (2011) The roles of leaders in high performing health care systems