Leadership is a generic term, so when we talk about leaders in the NHS we need to be clear about who and what we are talking about and to avoid making absolute distinctions between leaders and managers.
How should current and future leaders equip themselves to meet the burgeoning challenges facing the NHS?
Accomplished leaders undoubtedly need to have a vision but any view of the future needs to be grounded in detailed understanding of the basics, which is a key management competency. I would strongly suspect any leader who said details were unimportant to them. Having a vision is not enough. It has to be to built on a strong foundation, with an understanding and clarity about the challenges, difficulties and opportunities presented in providing healthcare in the here and now. The rest is determined by the political system.
There is a belief in some quarters that the way forward is to bring in bright, motivated and successful people from outside the NHS. While very occasionally this might benefit the service, generally exogamy is misguided (Rose 2015). The raw vision which comes from within brings the best results.
A lack of willingness on the part of current leaders to speak out on issues that really matter, presumably feeling that to do so would be disloyal in some way, is a real problem. Why, for example, is no-one pointing out the tremendous healthcare pressures that were experienced by services this past winter? Or questioning why the government has stopped publishing key statistics which highlight the problems? The silence of managers on the junior doctors’ dispute has also been deafening — this despite a IHM survey revealing that six in 10 healthcare managers (58 percent) backed the strike action taken by junior NHS doctors, with more than four in 10 (43 percent) saying they ‘“strongly” supported it (Cramer 2015). Only a third (33 percent) said they opposed the action yet the voices of the majority were notable by their absence. The emperor has no clothes. Whoever will tell him?
The rhetoric from the government should be challenged. It is NHS managers on whom the service depends and without the space, scope and encouragement to challenge the status quo and articulate their vision it is far harder for them to flourish and grow.
It is no secret that there is a lot of disquiet about where the NHS (Commons Select Committee 2015) is going and how much of the Five Year Forward View — which contains some very good ideas — can be delivered when there is not enough money in the system. This creates a dilemma. What can NHS leaders do about it?
The answer is that they have to be realistic about what can and cannot be achieved. A vision cannot be built on sand but once it has been clarified, agreed upon by the Board and teams across the organisation, I’d urge leaders never to give up on it. Listen downwards - the best way to incrementally alter the NHS is through bottom-up leadership. Look to influence part of a slightly wider world. Arm yourself with a clear, up-to-date sense of the pressures and challenges that the organisation faces and make a distinction between the scope there is for addressing them and ‘pie in the sky’ solutions.
It must also be remembered that the NHS is sometimes one organisation and sometimes a hundred, so another challenge for leaders is to attune their antennae to all the signs and signals around decisions that are being taken nationally and what those on the ground are understanding and advising locally.
In the current tight financial climate, those leading NHS organisations have a number of options: limit what they do, do it less well, or find more efficient ways of doing it. The answer may well be a combination of all three, but it is vital that they don’t focus on one at the expense of another. They need to be separated out. Each will have its appeal, consequences and limitations and these need to be thoroughly examined and understood.
It is essential that leaders do not spend all their energy on spectacular solutions, but on those inescapable facts they have to address and fix. Again, if an aspirational solution is being proposed as the way forward, they must look closely at its intended outcome and potential consequences. Understand, criticise, self-criticise, calibrate the risk. By all means take a carefully considered risk — but always safeguard the basics.
And then there is the question of how a good leader responds t o change. While all plans must obviously have a high degree of robustness, I share the sentiments of the economist John Maynard Keynes who, apparently, when faced with his detractors, was paraphrased as saying: “When facts change, I change my mind. What do you do?”
The strength and capability of the NHS is enormous and we are rightly proud of it. The service is also a highly transparent organisation, constantly in the glare of the public eye, whom we often hugely underestimate in terms of what they know and how they cope with real situations. Ownership is part of their right. Leaders must remember that we are all in this together.