Beginning with the end in mind? by Vijaya Nath and Roger Kline

The government has launched what it calls the ‘most far-reaching review’ of NHS leadership since the Griffiths report of the early 1980s. The history of the NHS is littered with such reports, many forgotten without trace. Both the timing and the terms of reference are curious. Has the Secretary of State asked himself whether such a Review, heralded by threats of sackings of leaders valiantly trying to catch up on huge waiting lists when grossly under-resourced, really contributes to the leadership culture that research says we need?

Nevertheless, it may be helpful to consider what the Review should consider.

Firstly, Griffiths was tasked to drive up “effectiveness” but this Secretary of State says he wants greater “efficiency”. Not only are these terms not the same, but the pursuit of greater efficiency can easily undermine the rather more important healthcare goal of greater effectiveness. In the last few years, the NHS has started to move away from the obsession with “efficiency” that led to Mid Staffordshire. It is developing a more evidence-based approach to leadership which understands that inclusion and continuous improvement are the bedrock of effective leadership and management. Effective leadership emphasises NHS staff not just as a cost but as its crucial asset, to be treasured and cared for. Recent decades are littered with the ghosts of targets and bullying tactics that Secretaries of State thought could magically solve the mismatch between resources and clinical capacity.

Secondly, as Google, as hard edged a company as any, discovered through their Project Aristotle, “the capabilities of the individual team members mattered less for team performance than group processes (how team members shared information and collaborated)” and “in particular, when individual members attached a low interpersonal risk to voicing their ideas or making mistakes, they were more likely to share novel information or challenge the status quo. In turn, the group was able to access and integrate a greater diversity of thought to drive innovation and to improve judgment and decision-making”.

Psychological safety is a bedrock of inclusion. The NHS has a workforce that is 78% female with 21% staff of Black and Minority Ethnic heritage. It is learning, sometimes painfully, and certainly too slowly, that discrimination is a serious obstacle to effectiveness and compassionate patient care. #MeToo and Black Lives Matter are not optional extras for good leaders, they are priorities. We increasingly know that ‘psychological safety’ is a prerequisite of safe effective care, inclusion and improvement whereas bullying and harassment undermine it. Those clinicians (36% BME and increasingly female) who have begun engaging in larger numbers with general management may well turn away since a macho response risks taking them even further from their commitment to compassionate care.

Diversity and inclusion could provide an opportunity to demonstrate the counter to ‘group think’ which the recent Covid 19 parliamentary report highlighted when it stressed ‘a greater diversity of expertise and challenge—including from practitioners from other countries and a wider range of disciplines—should be included in the framing of the National Risk Register and the plans that emanate from it. Plans for the future should include a substantial and systematic method of learning from international practice during the course of an emergency’.

Thirdly, the NHS showed during Covid, despite huge staff shortages, how innovative and effective it could be. Entire wards and buildings were repurposed, and staff redeployed in large numbers at short notice. Consider the immense vaccination mobilisation, whose effectiveness is a stunning contrast to the disjointed Test and Trace programme. The NHS showed itself able to draw on expertise from the armed forces looking at an aspect of leadership known as followership and thereby co-created Nightingale wards when unconstrained by resource pressures and actively encouraged and supported by politicians. Perhaps those tasked with leading this newest inquiry could use an approach like Appreciative Inquiry to examine what is possible when we harness the talent and diversity of the NHS’s people.

Fourthly, if the Review wants to engage clinical leaders it must understand that clinicians are motivated by the differences they can make to patients, users and the communities they serve with regards health (physical and mental) and wellness (proactively looking at prevention). Much of the lack of efficiency today is waste which binds the feet and the spirit of NHS staff every time they go to work. So, health, wellness and efficiency matter especially for NHS staff. One iteration of the Quadruple Aim is Better Health, Better Care, Lower Costs and Joy at work. Foregrounding the quality of care, and the patient and user voice will be essential if clinicians are to be central to integrated care, and bolster the increasingly beleaguered primary care, or grossly under-resourced mental health services.

Fifthly, it would be a mistake for the Review to primarily focus on whether the NHS is over-managed or has poor productivity. Neither are true. A decade ago one of us noted that the proportion of staff who are leaders and managers is almost certainly much lower than in either the private sector (or the army). On a full-time equivalent basis, the number of managers rose from 2.7 per cent to 3.6 per cent of NHS employment. “The NHS in England is a £100 billion-a-year-plus business. It sees 1 million patients every 36 hours, spending nearly £2 billion a week. Average NHS annual productivity growth has been three times higher (1.5%) than in the economy as a whole (0.4%) in recent years.

Finally, attention needs to be paid to stress and turnover rates at every level. Specifically, the current turnover rates of chief executives and the poverty of support available to prevent burnout will continue except for those who yearn for more command and control (for themselves). It will deter women and Black and Minority Ethnic leaders from seeking to become CEOs because they know they will be held to a higher standard. We do wonder if such a Review would have been announced with such an aggressive fanfare just weeks after the appointment of the NHS’s new CEO had that appointment been male rather than female.

The presence of an experienced NHS Chair (Linda Pollard), and whatever influence NHS CEO Amanda Pritchard can have, may ensure some understanding of diversity, inclusion and improvement culture (and diversity of thought) alongside the General who the Secretary of State heralds with tough words about redundancies for “underperforming” CEOs. Conversely, the military’s adoption of Robert K Greenleaf’s “Servant Leadership” model can be helpful in helping NHS leaders foreground the qualities of leaders’ who gain ‘followership’ These qualities include but are not limited to listening, empathy, healing, awareness, persuasion, foresight, stewardship and building community. Important in enabling the new adaptive and democratic leadership practises which we witnessed in pandemic to be sustained.

The history of NHS leadership reviews hitherto reveals a consistent failure to understand NHS decision making is not linear but immensely complex. They confuse problems for which there may be well-developed technical responses with other more disruptive challenges (such as a serious outbreak of infection) for which there is no predetermined solution. Instead, supporting those tasked with leadership at every levels requires engaging minds and hearts. It requires the Review team to draw out the best examples of NHS leadership in primary care, communities, ward to board across all disciplines, ‘beginning with the end in mind’ to learn from and to emulate.

We’ve suggested some key themes the Review should focus on if it is to avoid joining the graveyard of previous reviews which sank without trace. We can certainly do better on leadership. In our view the noise around the launch of this one does not bode well, but this does not mean this Review has to suffer the fate of its predecessors.

Vijaya Nath 

Vijaya Nath is Director and Founder of Contemplative Spaces. Vijaya brings over 31 years of experience in developing leaders in the private and not-for-profit sector. For the past 23 years she has worked with leaders in health and care, in the four countries of the United Kingdom, Ireland and internationally. She has significant experience in the design and development of innovative leadership programmes and senior organisational development consultancy. Vijaya is an experienced board level facilitator and coach.

She was the recent past Director of Leadership Development at the Leadership Foundation and led a team who worked on Leadership Development and related interventions for the UK’s Higher Education Sector. Previously as Director of Leadership Development at The King’s Fund, she established a portfolio of interventions including networks, open programmes and thought leadership in medical/clinical leadership. She has led and continues to design and facilitate a number of international study tours. These include Senior Leaders Retreat: Seattle which features learning from health and non-health organisations that are leading-edge in quality, innovation and leadership and integrated care

Vijaya has published and written a number of papers on Leadership Development and has influenced thought leadership in the areas of Medical Engagement, Quality Improvement in Health, Equality & Diversity, and the importance of advancing Women in Leadership. She is a visiting professor at Milan’s SDA Bocconi School of Management and was appointed as a Trustee of Windsor Leadership in 2017. Contemplative Spaces was founded in April 2018.

Roger Kline

Roger Kline is Research Fellow at Middlesex University Business School. He authored “The Snowy White Peaks of the NHS” (2014), designed the Workforce Race Equality Standard (WRES) and was then appointed as the joint national director of the WRES team 2015-17. Recent publications include) the recent report Fair to Refer (2019) to the General Medical Council on the disproportionate referrals of some groups of doctors (co-authored with Dr Doyin Atewologun) and The Price of Fear (2018), the first detailed estimate of the cost of bullying in the NHS, co-authored with Prof Duncan Lewis.

Declaration of interests

We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.


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