System Leadership – part three

In Part Two of System Leadership, we looked at the barriers to developing effective system leadership and provided a practical framework to support the development of distributed leadership. Attain’s approach to leadership development is an extension of our delivery model, which focuses on working in partnership with our clients as a single unified team. Adapting this ethos into a leadership development approach, means that we are able to focus on the specific development needs of individuals and the teams and/ or organisations they work in. We blend our collective expertise with best practice in both healthcare and organisational/leadership development to foster accountability and practical solutions to enduring challenges. By supporting the development of staff at every level in every type of organisation, we have supported systems in developing a transformative leadership culture; this is supporting organisations and systems in achieving the Next Steps of the Five Year Forward View [i]. 

In this article, which represents Part Three of the series, we will outline our approach and its advantages relative to alternatives currently in operation in the NHS.

 PART THREE

Leadership development is one mechanism for responding positively to some of the challenges faced by the health system.

The need to do increasingly more, with less during periods of prolonged uncertainty has resulted in an increased focus on staff development in the NHS and the wider public sector over the past decade. In addition to programmes that have been delivered at local and regional levels, a number have been delivered nationally.

The benefits of effective development are widespread and have the potential to impact every element of patient experience.

The value of leadership development in healthcare is widely understood, a wealth of studies conducted over the past 20 years have highlighted a range of benefits of investing in this[ii], including four key areas of improvement:

The quality of patient care and safety

1. The wellbeing of staff
2. Performance management
3. Care quality

 Specific examples include:

•  The RCN Clinical Leadership Development Programme[iii] was founded in 1995 with the aim of identifying how nurses in recognised leadership positions could improve the quality of patient care. The programme was tested on a total of 28 nurses across four acute hospital trusts in England over an 18-month period. The study found a significant improvement across a number of leadership dimensions for individual participants and evidence of improvement in the quality of patient care.
• A study in Belgium concluded that a Clinical Leadership development Project (CLP) for nurses[iv] at a large acute hospital resulted in improvement from both participant and patient perspectives. Participants reported that more effective leadership promoted more effective communication, greater responsibility, individual empowerment and job clarity.  From a patient perspective, there were also to improvements reported in patient-centered communication, continuity of care and interdisciplinary collaboration.
• An evaluation of a clinical leadership programme for senior clinicians[v]  in NHS Lanarkshire focused on 44 senior clinical managers. It was found that the programme resulted in a positive change in attitudes, behaviors and performance with specific examples of improvements in clinical practice and other organisational benefits.

 Leadership development is not just for ‘leaders’

Whilst the examples above and many traditional approaches have focused on the development of the leadership/management cadre, more recent approaches have focused on the development of a ‘leadership culture’. Signs of this fundamental shift in thinking preceded the findings of the Francis Report (which highlighted problems associated with leadership and culture in the NHS) but gained greater impetus after its publication.  

 The Francis report[vi] highlights the impact of “an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities”. The report concluded that responsibility for the failures ran across the NHS and called for a "fundamental change" in culture, to ensure that patients are put first. At the core of the report’s recommendations is the concept of shared accountability, which needs to be developed at all levels and in all elements of the health services. Development of a leadership culture, particularly one which empowers and encourages individuals to raise their performance, will be an important mechanism by which this is achieved consistently and across a health and care system. 

• Failure to yield the return on investment in leadership development

At present a lot of effort (and money) is being expended to support leadership development and culture change through approaches and methodologies that are broadly similar to those that have been used (with some success) in the past to develop senior leaders in single organisations or departments. The commonality of elements across several nationally provided programmes irrespective of target participant group (Chief Executive vs. frontline) is evidence of this approach. Whilst these programmes have been successful in supporting the development of high-performing individual leaders, it can be argued that this is of limited effectiveness in an environment in which (i) system working is fast becoming the norm and (ii) effective brokering and tactical compromise are critical success factors. Other shortcomings can be summarised as follows:  

•  Formal vs. informal leadership/accountability

Most existing programmes tend to focus on formal leadership roles and presuppose that the individual has a defined accountability and is part of a management framework with line managers, reports etc. This at times creates a disconnect with participants who do not identify as leaders, even though they have clear areas of responsibility and a requirement to lead. This approach does not, within itself address the key issues identified in the Francis Report.

•  Overreliance on competencies

Much of the learning in current programmes is competency based, which by design is backward looking. It is clear that recent contextual shifts mean that performance in the healthcare system as it was, is no longer an effective predictor of performance in the healthcare system as it is, or indeed will be.  If we want to avoid repeating mistakes of the past, we need programmes that are forward-facing and aligned to our desired future state and system-wide culture. 

•  Lack of team/ organisational context

There is no specific consideration within these programmes of organisational context, culture or ways of doing things - some approaches will be more successful in some organisations than others. The development needs of leaders in organisations in special measures or turnaround is likely to be different than those on a more stable footing. There is also a risk of creating disharmony in teams through the use of leadership style or approaches that are misaligned to organisational culture or values or the developing system.

•  The “I” in team

Development programmes are often highly individualistic[vii], they tend to focus on the individual needs and aspirations of the participant[viii]. This by design encourages individuals to prioritise their development needs over and above those of their team, organisation or the wider system. Whilst a number of team-based elements have been introduced into a number of nationally delivered development programmes in recent years, the focus is on how groups of individuals work together, as opposed to how the team works as a whole. Superficially these may sound similar, but it marks the difference between:

• Individuals with specific accountabilities working towards a common purpose and
• A unified team, with shared accountabilities working towards the same purpose. 

The latter approach will be more effective in driving the system transformation desired.

•  Highly generic materials and approaches

Processes, approaches and materials tend to be poorly differentiated, irrespective of seniority or organisational focus. This means that only a proportion of any development is likely to be directly relevant to each participant[ix].

•  Limited understanding of the NHS and its context and culture

Programmes may be delivered by providers who are completely external to the NHS. Whilst these facilitators are often experts in occupational psychology and related fields, they typically bring little detailed knowledge of how it ‘feels’ to work in the NHS and insight into the practical challenges facing individuals, groups or organisations locally.

 Opportunities for greater value for money

Despite the shortcomings summarised above, several of these approaches have resulted in positive participant experiences and some short-term tangible improvement in the quality of service delivery. However, it is likely that they are not enabling the best possible outcomes over the longer-term. In a study conducted in 2011 by Roebuck[x], it was noted that despite substantial investment over a 20-year period, leadership development in the NHS had not delivered a noticeable performance uplift. The author notes, “This previous poor level of success in leadership development in the NHS suggests that a totally new approach is required in the future to stand any chance of being effective in the time available”. It could be argued, six years later, that the cost to the health system of leadership development programmes as currently configured, substantially outweighs any benefit. Given the tight financial constraints across the health and care services and the range of initiatives focused on improving effectiveness and efficiency, it is logical and appropriate that we should apply the same principles to development processes. 

 Attain’s approach is different and is focused on creating a contextualised development environment.

 Our approach to leadership development is an extension of our day-to-day delivery ethos and is focused on working in partnership and the effective transfer of the hard and soft skills required to be effective at individual, team, organisational and system levels. This approach overcomes several of the shortcomings inherent in many of the programmes currently available. This is because it has been developed by staff with a wealth of experience in working in the health and care system, at the frontline and on supporting complex change. Our approach supports the development of individuals and teams within their specific context, with a full comprehension of organisational culture, strategic priorities and local ways of doing things. This ensures that the ‘social dimension’ of learning is addressed and provides a highly contextualised development environment - evidence (internally and externally) shows such an approach to be highly effective[xi]. Attain combines a range of techniques and approaches including:

•  Development planning: looks beyond the specific current requirement of the role to consider what it will need to deliver in the future and the criticality of its interactions across the system
• ‘On the job’ learning: ensures that all development is impactful to the specific context of the role and the system surrounding it
• Coaching/mentoring: provides a firm foundation for the acquisition of new knowledge and the development of new skills
• Self-directed learning: fosters the development of a learning culture, which is critical to effective leadership
• Action learning sets based on the specifics of the role: develops their ability to solve real problems, by taking action and reflecting on the results

 Attain has delivered bespoke programmes across organisations and across systems that have resulted in clinical, financial and operational improvements. This has led to positive paradigm shifts in the experiences of patients and staff and the performance of their teams, organisations and systems.

 Combining our excellence in delivery with our development approach has resulted in tangible improvements in the capability of individuals, teams and organisations. Four highlights of our track record across England are:

1.  A North-East CCG: We delivered a bespoke commissioning development programme to 25 senior commissioners to support delivery of the commissioning strategy transformational programme. This resulted in tangible improvements in business planning, transformational redesign and implementation of initiatives.
2. A North-West CCG: We trained 32 CCG managers in the adoption of revised QIPP governance and PMO processes. The development process supported the delivery of QIPP schemes, which were identified as having the potential to release ￡30 million in savings.
3. A South-East CCG: We engaged to design and deliver an organisational development programme that would support the CCG in becoming an outward facing, patient-focused, listening organisation with strong relationships with its partners and strong culture. This resulted in:

• Staff with a better understanding of their roles and responsibilities and how these contribute to realising the CCG’s vision;
• The development of clearer processes and working practices; and
• A more patient-focused organisation as evidenced by commissioning intentions.

4.  A Primary Care Alliance: We delivered a bespoke organisational development programme to a developing primary care Alliance which planned to become part of a GP federation. This resulted in:

• Participants reporting a wider understanding of policy to enable them to make informed decisions and 
• Participants increasing their knowledge and understanding in relation to the topics covered and application to the future federation.

 A better, more effective way to develop

 In summary, the magnitude and speed of change signaled by the Five Year Forward View and the change in culture and practice outlined by the Francis Report, require a different approach to traditional leadership development in the health service. The development of leadership attributes across systems, even amongst staff groups without formalised leadership responsibility, will support the creation of a better leadership culture in which everyone is accountable for meeting the needs of the people they serve, as cost effectively as possible. 

References

[i] NHS England. Next Steps on the Five Year Forward View March 2017

[ii] Firth-Cozens J, Mowbray D. Leadership and the quality of care. Quality in health care. 2001 Dec 1;10(suppl 2):ii3-7.

[iii] Cunningham G, Kitson A. An evaluation of the RCN clinical leadership development programme: part 2. Nursing Standard. 2000 Dec 13;15(13):34-40.

[iv] Dierckx de Casterlé B, Willemse AN, Verschueren M, Milisen K. Impact of clinical leadership development on the clinical leader, nursing team and care‐giving process: a case study. Journal of Nursing Management. 2008 Sep 1;16(6):753-63.

[v] Sutherland AM, Dodd F. NHS Lanarkshire's leadership development programme's impact on clinical practice. International journal of health care quality assurance. 2008 Sep 5;21(6):569-84.

[vi] The Mid Staffordshire. NHS Foundation Trust. Public Inquiry. Chaired by Robert Francis QC.

[vii] Kalra VS, Abel P, Esmail A. Developing leadership interventions for black and minority ethnic staff: a case study of the National Health Service (NHS) in the UK. Journal of health organization and management. 2009 Mar 20;23(1):103-18.

[viii] Hewison A, Griffiths M. Leadership development in health care: a word of caution. Journal of health organization and management. 2004 Dec 1;18(6):464-73.

[ix] Edmonstone J. What is wrong with NHS leadership development? British Journal of Healthcare Management. 2013 Nov 1;19(11).

[x] Roebuck C. Developing effective leadership in the NHS to maximise the quality of patient care: The need for urgent action 2011

[xi] Kaplan, K. and Feldman, D.L. (2008), “Realising the value of in house physician leadership development”, The Physician Executive. September-October, pp. 40-46.