The six barriers to making leadership development in health a priority

Chris LakeChris Lake, head of professional development at the NHS Leadership Academy, considers the barriers to making leadership development a priority in health. 

It could be argued that when it comes to investing in leadership development, the health sector is the poor relation. Here are some of the reasons why.

Lack of money (or the willingness to invest it): We spend over £100bn a year on health, but the proportion of spend on leadership and management development and other organisational development (OD) initiatives as a proportion of this is incredibly low in comparison to many other businesses, even to the rest of the Civil Service. According to The missing link: effective management and leadership training in the NHS which was published in 2012, annual spending on management and leadership training for NHS provider employees equates to approximately £260 per employee compared to £320 in the private sector.

Lack of rigour: In several sectors there’s a very structured approach to leadership development tied to career progression. The military and the police service both require development and assessment, for example through promotion boards, before leaders are appointed to more senior roles. You do your development first, then you’re promoted. Other organisations too articulate clearly the knowledge, skills, attitudes and behaviours necessary to succeed in leadership roles. They provide structured on-the-job development alongside development programmes, and assessment to say whether or not aspiring leaders are fit to practice at the next level of influence. In the NHS, it’s quite common for people to be promoted first, and development to do the job is almost an afterthought. There should be a minimum expectation of management competence, leadership behaviours, knowledge, attitudes and values running right across the NHS. 

Lack of support: When you do take up a leadership role, you might excel, you might do the job to the required standard, or you might fail. However, getting people into senior jobs can be a huge challenge, and keeping them there can even more difficult. We constantly hear from our programme participants and colleagues about the demanding situations they face day in, day out. Today’s NHS has a difficult culture where staff can find it hard to have a voice, to feel valued, to develop and progress. 

This isn’t true everywhere; there are islands of appreciative, nurturing, enabling culture, but in the NHS, resilience is definitely a core characteristic. I’m not denigrating resilience as a good thing to have, but the fact that our system requires it in such spadefulls is a bit of an indictment of the culture. Wouldn’t it be better to run organisations where resilience was desirable rather than essential? Organisations fit to house the human spirit. Just as it isn’t acceptable to move into a leadership role with no training, nor should it be acceptable to be unsupported either, especially in your critical first year in post.

Lack of strategic direction: The NHS – with its workforce of 1.4 million and its challenges in filling key leadership roles, has no well-developed strategic framework for leadership development. The Academy is currently working with a consortium of NHS bodies to rectify this. Guided by the National Leadership Development and Improvement Board, several organisations are working together to develop a strategic framework for leadership development and improvement. Lead collaborators in this process include colleagues from NHS Improvement, NHS England, Professor Michael West, senior fellow at The King’s Fund, and more. The framework won’t be a top-down strategy – that’s been tried, and not worked, before. Instead, it will be an enabling framework that describes what leadership development can be delivered locally, regionally and nationally. More, a strong theme of the framework will be the actions and behaviours of the Arm’s Length Bodies in modelling an enabling environment where leadership flourishes. 

Lack of respect for leadership development: We don’t fully acknowledge the impact that leadership and management practices have on organisational performance and patient care. The horrific failures at Mid-Staffs occurred because of a failure of leadership. Michael West’s research has proved that high-quality leadership leads to lower patient mortality. When we realised that prescribing too many antibiotics lead to increased antibiotic resistance, superbugs and more deaths, the NHS took it seriously and took action. We need to do the same with leadership, development, team work and organisational culture, or we could end up back in Mid Staffs territory. I’ve heard a few people whisper that there’s another Mid Staffs out there somewhere – we just don’t know where it is. But we don’t want it to emerge in the future.

The demonisation of leaders and managers: The value of leadership and the worth of managers and management within healthcare is questioned, and that needs to change.  Politics and media combine to see management as bureaucracy and managers as bean-counters - an overhead to be reduced at all times. No other industry I’m aware of demonises management in the same way. We look at high-performing organisations like Apple and we tell inspirational stories about Steve Jobs. Yet senior leaders in our healthcare organisations are too often portrayed as bureaucrats and an expensive resource. 

Some of our hospital trusts are very large businesses in their own right with turnovers of half a billion pounds not uncommon. These organisations need managing and leading, but we’ll only reward people for this depth of responsibility somewhat begrudgingly. And beyond the boardroom, managers dedicating their working lives to coordinating care in service of patients and their families see themselves called number-crunchers. Media and politics tend to love the doctors and talk about nurses as angels. I too value hugely the skill and dedication of all clinicians working across our NHS, but I also value the finance managers who get best value for our tax-pounds, the service managers who develop ever-better systems for patient care and the HR managers who support the human systems at the core of organisations.

I’ve listed above six barriers to making leadership development in health a priority.  There’s definitely work to be done. I’m not despondent though. I see many examples of good practice in the participants we meet on Academy programmes – and great evidence of the difference leadership development is making. And I visit organisations that are shining examples of leadership practice with a culture of development. We just need to make that the norm.

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