The importance of good leadership is regularly emphasised in policy documents from all four UK countries and investigations of high profile failures regularly cite poor leadership as a contributory factor.
The ever increasing pressure to deliver huge efficiency savings in the health budgets in all four countries of the UK, along with the recently published white paper Liberating the NHS in England, heralds a period of tremendous change for the health service.
The growing trend towards care pathways that span traditional organisational and service boundaries, together with an increasing number of providers, is likely to create new leadership challenges. And all this comes just at a time when the dissolution of strategic health authorities, primary care trusts and arm’s length bodies, such as the NHS Institute for Innovation and Improvement, is likely to have a significant impact on the morale and size of our existing senior leadership cadre.
This raises several important questions: what type of leadership will be required? What sorts of leaders do these turbulent times demand? How best can leadership and leaders be supported?
‘For leaders at all levels to survive, and indeed thrive, they need to be able to live with ambiguity, and accept that uncertainty and unpredictability are inescapable’
The answers to such questions are always influenced by the way we look at and understand the world. First, we see leadership as, essentially, being a relational act. It is the way leaders transform relationships that, ultimately, transform services. Second, it is helpful to think of the health sector as being a complex adaptive system. From this perspective it can be understood as a diverse collection of systems ranging from individual patients and staff, to services, organisations, professions and policy makers that act in ways that are not always predictable and whose actions are interconnected.
The health sector in this view is seen to be much more than the sum of the parts, with control distributed throughout the sector rather than centralised in the government health department or board of the health organisation. Viewing the health sector through this lens, rather than conceptualising it as a machine where leaders exert control and make changes by pulling levers, for example, allows for different insights about leadership and different types of development interventions to emerge.
Using the complex adaptive systems lens means that leadership can be viewed as an activity that occurs within a relationship rather than being viewed as a position of formal authority such as head of nursing, chief nursing officer or chief executive.
Leadership is no longer seen to be exclusively the property of individuals but is recognised as being developed and applied within a particular dynamic context. Leadership becomes less about control and more about influence. Systems are seen to be self organising - constantly transforming and adapting themselves to meet external challenges. Patient leadership too comes to the fore with patients being recognised as co-producers of their health.
For leaders at all levels to survive, and indeed thrive in the contemporary healthcare context, they need to be able to live with ambiguity, to accept that uncertainty and unpredictability are inescapable. Rather than aiming for control and stability, leaders need to have and maintain a clear vision and be able to enhance the adaptive capacity of their organisation.
Creating the conditions that are necessary for successful evolution and change to take place is essential. Leaders will need to pay attention to relationships and their local environment and encourage connectivity between staff; ensure good information flows; and actively seek and value diverse perspectives, including nurturing productive conflict. As such, they need to ask good questions rather than attempt to have all the answers.
Developing leaders who have highly developed relational skills, resilience and the honed ability to enhance adaptive capacity requires working with them in their wider organisational and service context. It is likely to require investment in developmental interventions and approaches that are informed by complex adaptive systems thinking.
Leaders will need to have an understanding of organisational culture and the macroeconomic agenda, as well as national policy and politics. Technical knowledge is also vital. For example, they will need to know what works in improving quality and relevant approaches, methods and tools to deliver this improvement. They must have relational skills, be able to engage with others, and work on their individual skills, qualities and capabilities in order to enhance their self awareness and authenticity. They must also truly know their own strengths, motivations, patterns, needs and limitations.
Abigail Masterson and Pippa Gough are assistant directors at the Health Foundation