Leading for better healthcare

The Health Foundation believes that effective leadership is central to improving the quality and performance of healthcare. Yet surprisingly little is known about how different approaches to leadership development can contribute to tangible and sustained improvements in organisational performance.

The Health Foundation is testing different approaches to improving leadership in healthcare through a £20 million programme over five years. Through distinctive award schemes, the Foundation is supporting some of the best and brightest healthcare leaders, individually and in teams, and evaluating the most effective ways to invest in leadership development.

The leadership challenge

Improving the quality and safety of healthcare requires leaders to address some of the biggest issues in public service reform. Against a background of tightening finances, today’s healthcare leaders must:

• successfully position their teams and organisations within health economies which offer much greater choice to patients
• respond creatively to greater demands for high quality out-of-hospital care
• meet demanding targets for access without compromising patient safety
• maintain and increase clinical engagement in improving patient care, in the face of shifting organisational boundaries
• take advantage of opportunities to develop patient-led services through new forms of practice-based commissioning.

In order to address these challenges, leaders need to be equipped with a range of skills and competencies which reflect what effective leaders do. The Health Foundation’s leadership award schemes have been designed to embody these characteristics.

Leaders lead in context

Leadership is always about, or in relation to, some other activity. It doesn’t have value as a quality on its own. Many established approaches to developing health service leaders have taken participants out of the work place, and tried to instil knowledge and skills out of context. Our award schemes keep leadership development closely related to the real situations, problems and challenges that leaders are facing, enabling them to turn their insights into tangible improvements for their organisations and especially for patients.

“You know, out of all the clinical directors, he’s the one whose leadership decisions are very much influenced by the broader picture.” --Leadership award holder’s chief executive

“I think we spend time in the health service worrying that a particular policy decision doesn’t seem to fit our own particular bit of the service or deal with our current problems. The award scheme has helped me to understand more of the broader context in which we are working. I have been able to rise above the things that seem like they don’t suit me or aren’t particularly well thought out and work towards the wider aim of the policy.” -- Leadership award holder

Leaders combine hard and soft skills

The best leaders combine technical competence with highly-developed people skills.

Yet it’s common for individuals to be offered opportunities which focus exclusively on personal development (for example, improving awareness of working styles and preferences or building self-confidence), or on professional development (acquiring role-specific expertise such as quality measurement techniques), but not both. The Foundation’s leadership award schemes provide a combination of personal and professional development opportunities, and use a variety of interventions – coaching, mentoring, masterclasses, learning sets, overseas experience and personalised support. We test the relative effectiveness of these interventions and value for different people in different circumstances.

Leaders lead across organisations

Health service leaders need to motivate and inspire staff from many different disciplines and professional backgrounds. Unsuccessful attempts to change services often have their roots in a failure to engage a key group of staff, such as clinicians. The ability to work across system boundaries, and to communicate with staff from different professional backgrounds, is crucial.

THE VALUE OF LEARNING TOGETHER

 Working across organisational boundaries is emerging as a central theme of our award scheme evaluations. A number of our schemes deliberately mix professional groups (for example, in multidisciplinary learning sets) with positive results.

The value of multi-professional group learning suggests moving away from uni-disciplinary leadership programmes. In addition, there seems to be great value in learning alongside colleagues from different health economies across the UK, whereas most NHS development activities are limited to the local health economy rather than being national or even regional in their scope.

 “You must have a mix of managers and clinicians … we each get so much from learning more about what the other does and we challenge each other.” --Leadership award holder

Leadership is shared by teams

There is increasing recognition that developing individual leaders can only make a partial contribution towards the changes in professional behaviour needed to improve complex systems of healthcare. All team members need to be involved in developing and improving team work, not just the leader – especially where good patient care requires people to work across boundaries. We believe that leadership development can usefully focus on developing the potential of whole teams, in the context of the specific challenges and issues that they face. We are testing this approach through our Shared Leadership Initiative.

Leaders need investment before they reach the top

Leaders exist at all levels of an organisation, and the process of quality improvement requires wide engagement. Yet it is common for individuals to reach a top leadership position – perhaps even board level – before it is thought that they might benefit from leadership development. Rather than providing leadership development for those who have already made it to the top, we want to establish which are the best points to provide support, and find robust ways of identifying high potential leaders at earlier stages of their careers – perhaps while they are still delivering services, equipping them to act as effective champions for quality improvement.

Leaders lead change

Research suggests that only organisations with a strong collective approach to leadership succeed in sustaining the change process over time.[1] Many healthcare organisations will recognise the ‘two steps forward, one step back’ phenomenon that accompanies attempts to change the way services are delivered. Change seems more likely to flow from a shared vision of better services, rather than attempts to impose a blueprint for change.[2]

For leadership development to be effective, individuals need the active support of the organisations for which they work. Opportunities to try out new skills and approaches on real projects and challenges play an important part in consolidating learning. They also mean that organisations as well as individuals reap rewards from leadership development.

SUSTAINING IMPROVEMENT

We want to ensure that quality improvements are sustainable over the long term. Sustainability can include leaders developing others, continuing their own development and exerting influence beyond the life of the leadership scheme. Whilst our leadership programme is at an early stage, there are encouraging signs. These include award holders deciding to continue their own learning after the award scheme has finished and the extension of quality improvement initiatives that began life as individual projects and grew as award holders succeeded in leveraging additional financial and people resources.

While the relationship between leadership and organisational performance is well understood in the private sector, [3] research to establish the same link in the health sector is in its infancy.[4] There is evidence to demonstrate that leadership development has had a beneficial impact on the individual participants, yet very little is known about how it contributes to better healthcare quality over the long term. One of the least understood, and most crucial, issues concerns the mechanisms by which leadership is transmitted through organisations, an area which the Service Delivery and Organisation (SDO) is currently exploring.[5] Significant questions remain about the most effective ways to develop healthcare leaders.

We are testing our assumptions about how leadership development can contribute to quality improvement through comprehensive evaluation of our award schemes. Most evaluations of leadership development initiatives only look at their short-term impacts, and at their impact on individuals rather than organisational or team performance.[6]

We believe that some of the real benefits of our leadership programme to the health service will be seen in the medium term, which is why we will track our leaders well beyond the duration of their awards. We will also compare them to a control sample of NHS leaders so that we establish whether the outcomes we observe are directly attributable to our programme. Our aim is to use the evidence from our comprehensive evaluation to make a significant contribution to our understanding about what makes good and effective healthcare leaders.

Ten principles for effective leadership development

The best available evidence suggests that the following principles should underpin effective leadership development in the health service. Some of the assumptions may seem incontrovertible, yet they have not been robustly tested before now.

These are the principles on which The Health Foundation has based its leadership programme and which we are testing:

1. Individuals’ leadership ability can be enhanced through appropriate support and training
2. Effective leaders combine technical competence and subject expertise with highly developed people skills, including developing others
3. It is important to cultivate leaders at all levels of the organisational hierarchy, and in all organisational subgroups 
4. To be effective as leaders, individuals and teams need the active support of the organisations for which they work
5. There is value in identifying high-potential individuals at earlier stages of their careers, and providing them with support at that stage, rather than concentrating only on those at the top already
6. It is possible to develop leaders to work more effectively across organisational boundaries
7. It is possible to support leaders to communicate more effectively with a wide range of stakeholders
8. The right sort of investment in leadership development delivers a good return on investment for organisations and the wider service
9. With the right support, effective leaders can sustain their own momentum, contributing to better health care quality over the long term
10. Better leadership can make an impact on the quality of healthcare at a national, regional, organisational, team and individual levels.

Notes

1. Denis J-L, Lamothe L, Langley A (1999) The Dynamics of Collective Leadership and Strategic Change in Pluralistic Organisations Briarcliff Manor, New York, USA, Academy of Management Journal

2. Pettigrew A M, Ferlie E, and McKee L (1992) Shaping Strategic Change: Making Change in Large Organisations: The case of the NHS London, Sage

3. Collins J (2001) Good to Great (Why some companies make the leap and others don’t) London, Random House Business Books

4. Ovretveit J (2005) The Leader’s Role in Quality and Safety Improvement Stockholm, Swedish Association of Local Authorities and Regions

5. Bailey C and Burr J (2005) Luck, Legacy of Leadership: the contribution of leadership to sustained organisational success in NHS Trusts (interim report) Cranfield, Cranfield School of Management

6. Kellogg Foundation (2002) Evaluating Outcomes and Impacts: A Scan of 55 Leadership Development Programs Brookline, Massachusetts, USA

Dr Kathy Bamford

Leaders for Change

Reader and Honorary Consultant Medical Microbiologist, Hammersmith Hospital

“I’ve been developing a framework in a cardiology setting which helps health professionals assess risks to patients. One of the biggest challenges was that an automatic link is not always made between patient safety and risk management. There were a number of cultural barriers to overcome and it was vitally important to create a supportive and open environment that encouraged a certain level of questioning.

My work has been incorporated into the action planning for the cardiology unit, and has now been adapted for use in other areas too. I received support from the National Patient Safety Agency to help me in guiding the process. I’m determined to spread the word about my work to see if it can improve the quality of patient care in different settings. The next step is to trial the framework in another trust.

This award has opened doors for me, allowing me to develop my skills so that I am now more confident in making change happen.”

Dr Jonathon Gray

Quality Improvement Fellow

Clinical Director, Consultant and Honorary Senior Lecturer in Medical Genetics, Cardiff and Vale NHS Trust

 “I am working on a project to develop quality indicators in genetics and establishing how to make best use of data and resources so that people have the information they need to make a positive impact on clinical outcomes. The fellowship has offered me the ideal opportunity to learn the science and methodology behind quality care so that I can build these into innovative new genetics services in the UK.

The fellowship has taught me some valuable lessons about leadership, management and strategic thinking which will help me develop personally and professionally. It has also helped me to develop networks with others which will enable me to lead quality improvement work at a local and national level back in the UK.”

Angela Knight-Jackson

Leading Practice through Research

Health Visitor

 Heart of Birmingham Teaching Primary Care Trust

“Through my project I am evaluating whether training health service staff in cultural competence can help provide a more culturally-sensitive service.

With my mentor’s support, I have improved my ability to network more effectively and I have been invited to speak about my research to a range of audiences. I have also been nominated to sit on my organisation’s research and development board.

I aim to use the results of my research to advise healthcare trusts in developing race equality schemes. I have been hearing about inequalities in health services all the years I have been nursing – now I want to challenge them and move things forward.”