Commentary

Leadership in the NHS

leader: first published as 10.1136/leader-2019-000159 on 23 September 2019. Downloaded from http://bmjleader.bmj.com/ on March 21, 2020 by guest. Protected by copyright.
Roger Kline ‍ ‍

Business School, Middlesex Inclusion: essential leadership and leadership. The dominant cultures within those
University, Barnet, London, UK prerequisite or optional extra? national bodies deeply influence behaviours and
In healthcare, leadership is decisive in influencing priorities at local level. Robert Francis blamed the
Correspondence to
Roger Kline, Business school,
the quality of care1 and the performance of hospi- failings of Mid Staffordshire Foundation Trust on
Middlesex University, Barnet, tals.2 How staff are treated significantly influences an institutional culture which put the ‘business of
London NW4 4BT, UK; care provision and organisational performance so the system ahead of patients’. Evidence to his Public
​roger@​kline.​org.​uk understanding how leaders can help ensure staff Inquiry concluded there was a ‘pervasive culture of
are cared for, valued, supported and respected is fear in the NHS and certain elements of the Depart-
Received 19 June 2019
Revised 9 August 2019 important. Research suggests ‘inclusion’ is a critical ment for Health. The NHS has developed a wide-
Accepted 1 September 2019 part of the answer. spread culture more of fear and compliance, than of
Inclusion may be regarded as the extent to which learning, innovation and enthusiastic participation
staff believe they are a valued member of the work in improvement’.7 Top-­down management, exacer-
group, in which they receive fair and equitable bated by government policies, contributed to wide-
treatment, and believe they are encouraged to spread poor treatment of staff. There was a failure
contribute to the effectiveness of that group. Inclu- to mitigate that poor treatment.
​bmjleader.​bmj.​com
sive workplaces and teams value the difference and
uniqueness that staff bring and seek to create a sense
of belonging, with equitable access to resources, Why?
opportunities and outcomes for all, regardless of The first reason was denial. In his Public Inquiry
demographic differences. Inclusive organisations report, Francis concluded that ‘there lurks within
are more likely to be ‘psychologically safe’ work- the system an institutional instinct which, under
places where staff feel confident in expressing their pressure, will prefer concealment, formulaic
true selves, raising concerns and admitting mistakes responses and iavoidance of public criticism’ and ‘an
without fear of being unfairly judged.3 institutional culture which ascribed more weight to
In hospital settings, managing staff with respect positive information about the service than to infor-
and compassion correlates with improved patient mation capable of implying cause for concern’.8
satisfaction, infection and mortality rates, Care The pressure to send ‘comfort seeking’ rather than
Quality Commission (CQC) ratings and financial ‘difficult’ information upwards is strong. Example:
performance4 as well as lower turnover and absen- 2 years after the Francis Report, when presenting a
teeism. By contrast, ‘disrespect’ in medicine is a Trust Board with their own (dreadful) data on race
threat to patient safety because ‘it inhibits collegi- equality, one Non-­Executive Director asked where
ality and cooperation essential to teamwork, cuts ‘my’ data came from. I explained it was from the
off communication, undermines morale and inhibits Trust’s own web site. The Board had not been told.
compliance with and implementation of new prac- The second, linked, reason is that we often
tices’.5 Yet, 24% of NHS staff in England report struggle to have honest conversations when
that they are subject to bullying, harassment or ‘mistakes’ or poor behaviour occur, whether about
abuse by fellow workers and managers, impacting bullying or racism or in appraisals or feedback. We
on increased intentions to leave, job satisfaction, may prefer (in society, in workplaces, in teams)
organisational commitment, absenteeism, presen- to live in false harmony since any type of change
teeism, productivity and the effectiveness of teams, creates conflict even though sustained efforts to
costing the NHS at least £2.28 billion annually.6 address conflict can pay dividends for staff and
The NHS has an extraordinarily diverse workforce, care.9 The result can be doubly challenging—staff
but workforce and NHS staff survey data show who are unable to share their concerns and managers
many staff experience systematic discrimination in anxious about even seeking them or having honest
many aspects of their NHS working lives notably informal conversations as ‘protective hesitancy’10 is
in recruitment, development, disciplinary action triggered, since both may not feel it is ‘psycholog-
and through bullying which are likely to adversely ically safe’ to have such discussions. Without trust,
© Author(s) (or their impact on patient care and safety. people may just ‘shut down’ leaving no capacity to
employer(s)) 2019. Re-­use The NHS is a complex archipelago of national and have honest conversations or be vulnerable, crit-
permitted under CC BY-­NC. No
commercial re-­use. See rights local bodies, networks, commissioners, regulators ical in examining options in, for example, clinical
and permissions. Published and providers. Though the Health and Social Care decision-­making.
by BMJ. Act 2012 changed the relationship between Minis- The third reason is the mismatch between
ters and Arm’s Length Bodies, it made little change demand and resources. Two decades of ‘control
To cite: Kline R. BMJ
Leader Published Online to how the NHS workforce was managed and led totals’, ‘savings targets’ and staff shortages have left
First: [please include Day with a continuing stream of expectations, require- local leaderships under immense pressures, often
Month Year]. doi:10.1136/ ments, targets, inspections and funding decisions fearful of blame and knowing senior leader turn-
leader-2019-000159 which fundamentally influence workforce culture over is astonishing. Example: the Mid Staffordshire
Kline R. BMJ Leader 2019;0:1–4. doi:10.1136/leader-2019-000159    1
 Commentary
Hospitals NHS Trust Board agreed in January 2005 that 180 by how an organisation’s leaders behave. What leaders focus on,

leader: first published as 10.1136/leader-2019-000159 on 23 September 2019. Downloaded from http://bmjleader.bmj.com/ on March 21, 2020 by guest. Protected by copyright.
posts had to go because ‘the trust had a statutory requirement to talk about, pay attention to, reward and seek to influence, tells
break even at the end of the financial year’, yet, when I trawled staff what leadership values they should take note of.20 Yet, the
through Trust Committee minutes between 2005 and 2008, I NHS Long Term Plan (2019) devotes less than two pages to lead-
found no mention of the countervailing duty of care to patients ership and talent management.
(or indeed staff).11 Such tensions continue to exist today. We know that leaders who demonstrate a commitment to high
The fourth (crucial) reason is a fundamentally flawed human quality and compassionate care directly affect clinical effective-
resources (HR) paradigm which, until recently, has dominated ness, patient safety and experience, the health, well-­being and
much NHS practice on tackling discrimination, bullying, whis- engagement of staff and the extent of innovation. Evidence of
tleblowing and disciplinary action. ‘Policies, procedures and the links between psychological safety, supportiveness, positivity,
training’ have been seen as key to safe, effective means whereby empathy, leadership (in aggregate compassionate leadership)
individual staff can raise concerns about bullying, discrimina- and innovation is deep and convincing.20 Without such a focus
tion, unfair disciplinary action and unsafe practice. But research teams may be more vulnerable to learnt helplessness or outright
suggests this approach is fundamentally flawed as a means of bullying.
improving organisational culture.12 Such ‘methodological indi- A lack of psychological safety, unaddressed conflict and
vidualism’ is underpinned by the individualistic nature of UK dissonance between financial and performance targets and the
employment law and has dominated the treatment of NHS staff. motivations of staff to care can be demoralising. As one Clinical
A response to bullying that is focused on individualism may also Director told me recently ‘staff feel ground down by talk of effi-
treat toxic leadership behaviours as the exception whereas data ciency and throughput because in a time of resource famine this
and research suggests they are widespread.13 Example: the NHS can take the humanity out of what we came into medicine to do’.
Employers guidance on bullying at work (2006–2016) stated Such concerns are well captured by Unwin’s focus on embed-
‘employers can only address cases of bullying and harassment ding relational intelligence (kindness, emotional intelligence) as
that are brought to their attention’,14 yet, employers had (and powerfully as rational intelligence (regulation, measurement and
have) a wealth of local data on prevalence which could have efficiency)21 Leaders who regard staff primarily as a cost rather
enabled them to be proactive and preventative. than an asset and who fail to listen to the most junior cleaner,
This HR paradigm has also driven the Ministerial response talk with the admin clerk, admit mistakes or engage in repeated
to whistleblowing, much of which has focused on (unsuccess- acts of kindness and support are not role models for their staff.
fully) protecting those individuals raising concerns rather than Example: I recall being told by one CEO a few years ago, when
changing the organisational climate in which such concerns are I asked why he hardly spoke with staff as we walked around his
ignored or rejected.15 Similarly, until recently, tackling discrimi- hospital, that if he did that he ‘wouldn’t have time to do his job’.
nation largely relied on individuals raising concerns despite the
likelihood that legitimate complaints would not be upheld and
would certainly not change institutional discrimination. Progress So what might NHS leaders do better?
on the ‘compassionate and inclusive’ treatment of staff may be There is an extensive literature on healthcare leadership, but
seen as too difficult for many teams and organisations, especially relatively little conducted to a high academic standard.22 We do
if the behaviours of national bodies do not match their exhor- know, however, that top-­down approaches to leadership are the
tations to local bodies. Yet, the evidence is that when sustained least effective way of managing healthcare organisations whereas
evidenced interventions, applying ‘human factors’ science and inclusive and compassionate leadership helps create a psycho-
incentivising a learning culture not blame, replace a retributive logically safe workplace where staff are more likely to listen and
culture with a restorative one, there are very substantial gains support each other resulting in fewer errors, fewer staff inju-
for staff and substantial benefits to organisations, saving 2% of ries, less bullying of staff, reduced absenteeism and (in hospitals)
staffing costs in one Trust.16 reduced patient mortality.23
The fifth reason is that, unlike NHS clinical interventions, we Research suggests that in such an inclusive environment team
have too rarely asked of HR interventions ‘why do you think creativity improves, innovation is more likely, information is
this is likely to work?’ For example, in response to bullying or processed more carefully, risk awareness improves, produc-
discrimination, the default answer has been more ‘training’. Yet, tivity improves, turnover declines and where organisational
the largest study of diversity initiatives found that ‘attempts to leadership better represents the diversity of staff, there is more
reduce managerial bias through diversity training and diversity trust, stronger perceptions of fairness and overall better morale
evaluations were the least effective methods of increasing the of staff.24 Inclusive leadership is more likely to encourage the
proportion of women in management’.17 Similarly, Unconscious patient and carer involvement associated with higher levels
Bias Training, widely used in the NHS, may be helpful but the of innovation and improvement, and to promote higher staff
evidence it changes decision-­making is limited.18 It is difficult to engagement—itself a good predictor of patient satisfaction,
understand why HR directors and Boards did not ask whether patient mortality, quality of care and staff well-­being is higher
initiatives on diversity, bullying or whistleblowing were eviden- and also helps create inclusion.
tially based. However, command and control are deeply embedded in
The final reason has been a failure to systematically use the senior NHS leadership behaviours. Status and funding are used
decisive influence of management and leadership to help create to either support or, in effect, beat up local leaders, confusing
a culture in which staff (including managers) are valued and bullying with accountabiity. The behaviours of national bodies
respected. After all, hospitals with more managers achieve better largely shape what local leaderships do or don’t do. Where NHS
clinical and financial performance, higher patient satisfaction trusts are highlighted as being particularly innovative, effective
and reduced infection rates than those with fewer managers.19 and safe employers, it is unclear how many of them became so
Culture, or ‘how we do things round here’, is shaped by formal because of top-­down support.
organisational values (NHS Constitution and local policies), by Dixon-­Woods et al4 found that six key elements were neces-
values, behaviours and knowledge that staff learn, and (crucially) sary for sustaining cultures of high quality compassionate care
2 Kline R. BMJ Leader 2019;0:1–4. doi:10.1136/leader-2019-000159
 Commentary
for patients: inspiring visions operationalised at every level by Inclusive leaders understand that while demographic diver-

leader: first published as 10.1136/leader-2019-000159 on 23 September 2019. Downloaded from http://bmjleader.bmj.com/ on March 21, 2020 by guest. Protected by copyright.
leaders; leaders ensuring clear aligned objectives for all teams, sity is crucial, inclusion is what helps leverage that diversity.
departments and individual staff; supportive and enabling people When interventions to improve behaviours and culture are
management; high levels of staff engagement; leaders focused on proposed, inclusive leaders ask why they are likely to work,
ensuring learning, innovation and quality improvement in the since research suggests many are simply not evidenced. Tack-
practice of all staff and effective team working. Inclusive leaders ling cultures of fear should be seen as a means of improvement
help achieve such cultures by providing a limited number of not just of statutory compliance. Improvement methodologies
challenging but manageable priorities. can create small but continuous learning and gains, though it
remains unclear how much quality improvement initiatives
improve quality.27
Some practical steps
Inclusive leaders adopt a ‘public health’ approach to changing
Individuals organisational climates and institutional barriers, ending the
Individual inclusive leaders challenge the status quo and make
excessive reliance on responding to individual grievances (poli-
diversity and inclusion a personal priority. Such leaders do not
cies, procedures and training) and instead are proactive and
leave it to those subjected to poor behaviours to challenge them.
preventative.
Such leaders will want to be aware of, and understand, the
Above all, inclusive leaders understand the decisive impor-
perspectives and experiences of staff who are ‘outsiders’, facing
tance of their own role and behaviours. Values are central to
discrimination, bullying, struggling with unsafe workloads or
good leadership. Boards that demand changed behaviours from
other pressures. For such leaders, placing themselves ‘in other’s
their managers without modelling those themselves will fail.
shoes’ can help understand what life is really like in their organ-
Example: I remember meeting a past Secretary of State for
isation, department or team.
Health who banged the table as he announced he would ‘stamp
Such leaders are modest about their own capabilities, admit
out’ bullying. I thought ‘well, that won’t work’. It didn’t.
mistakes, and create the space for others to contribute. They
Leaders have to respond to problems for which there may be
show awareness of personal blind spots as well as flaws in the
well-­developed technical responses (eg, managing shift patterns
system and work hard to ensure fairness in all they do. They
and on call) as well more unpredictable and disruptive challenges
listen, show deep curiosity, demonstrate kindness and seek to
(such as a sudden loss of a major contract or a serious outbreak
understand those they work with.
of infection).28 When resolving the latter type of challenge inclu-
sive leaders draw on diverse knowledge and experience; instead
Teams of staff being presented with a predetermined solution cooked
Bullying and discrimination create uncertainty, erode self-­ up in a dark room, they create a space for collaborative discus-
confidence and undermine the fair and consistent treatment sion in which diverse staff bring a range of ideas and potential
of team members which is crucial to the trust which underpins solutions into discussion
effective team working. Recognition of the deep human need Creating safe spaces, where staff can share concerns in the
to belong, and the anxiety everyone may feel when speaking knowledge they will be listened to and respected for doing so,
up or sharing ideas in front of others for fear of saying some- are essential as NHS leaders grapple with even more complex
thing that may appear stupid or wrong, can help create effective cross-­disciplinary, cross-­organisational challenges. The leaders’
teams.25 Teams are more inclusive (and effective) when they are primary role is to enable such discussions. The most important
clear about their purpose, have a small number of agreed team person in the room is the one who knows what to do, which
objectives with regular feedback, clear roles, good information-­ may well not be the most senior person present. Effective leaders
sharing and a strong commitment to quality improvement and recognise that all members of the organisation/team play leader-
innovation. In such teams, inclusive leaders enable and facilitate ship roles at various times in their work. Inclusive teams will also
discussion and shared decision-­making and, however, intense the be more likely to recognise that among the most valuable sources
pressures, ensure teams take time out to reflect on their work of information are the reports and voices of patients, carers and
such as a Schwarz Round or a postoperative theatre debrief. staff. Such teams will be more likely to enable staff to counter
pose their professional duty of care to countervailing pressures.
Good leaders are effective ‘story tellers’ but such stories best
Organisations
emerge alongside, and often arise from, collaborative listening,
Inclusive leaders apply a similar approach to improving staff
including from patients and carers. They understand that ‘the
treatment as to any other factor impeding good patient care.
art of leadership lies in polishing and liberating and enabling the
They listen to staff and patients, understand relevant research,
gifts of others’.29
find other organisations successfully tackling similar issues and
The evidence that caring better for staff has multiple benefits
adapt or adopt evidenced approaches using real-­time data from
has grown as service pressures have increased. The 2019 NHS
staff surveys, workforce reports, patient feedback, clinical risk
Long Term Plan acknowledges the crucial importance of caring
indicators and soft informal staff intelligence that may be direct
for staff to improve patient care. That will only happen if NHS
or proxy measures of culture. For such leaders, budget pressures
are not simply counter posed to caring for and supporting staff leaders at all levels speak truth to power and act on the evidence
since that approach prevents either being achieved. that understanding and enabling inclusion is an essential pre-­
A majority of NHS line managers are staff at Band 7 or below. requisite for success, not an optional extra.
Most managers have both managerial and clinical roles. Many
Funding  The authors have not declared a specific grant for this research from any
clinicians may not identify as ‘leaders’ but they lead teams. All funding agency in the public, commercial or not-­for-­profit sectors.
lead in some way and all need support to learn how best to bring
Competing interests  None declared.
about what can be complex, time consuming and personally
daunting challenges. The recent NHS leadership development Patient consent for publication  Not required.
strategy makes inclusion central to progress and is helpful.26 Provenance and peer review  Commissioned; externally peer reviewed.

Kline R. BMJ Leader 2019;0:1–4. doi:10.1136/leader-2019-000159 3

 Commentary
Open access  This is an open access article distributed in accordance with the 14 NHS Employers. Guidance: bullying and harassment. 2006 patient safety concerns in

leader: first published as 10.1136/leader-2019-000159 on 23 September 2019. Downloaded from http://bmjleader.bmj.com/ on March 21, 2020 by guest. Protected by copyright.
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which intensive care units. Soc Sci Med 2017;193.
permits others to distribute, remix, adapt, build upon this work non-­commercially, 15 Tarrant C, Leslie M, Bion J, et al. A qualitative study of speaking out about patient
and license their derivative works on different terms, provided the original work is safety concerns in intensive care units. Soc Sci Med 2017;193:8–15.
properly cited, appropriate credit is given, any changes made indicated, and the use 16 Kaur M, De Boer RJ, Oates A, et al. Restorative just culture: a study of the practical
is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/. and economic effects of implementing restorative justice in an NHS trust. MATEC Web
Conf 2019;273:01007.
ORCID iD 17 Kalev A, Dobbin F, Kelly E. Best practices or best Guesses? assessing the efficacy of
Roger Kline http://​orcid.​org/​0000-​0002-5​ 896-​8802 corporate affirmative action and diversity policies. Am Sociol Rev 2006;71:589–617.
18 Atewologun D, Cornish T, Tresh F. Equality and human rights Commission research
report 113 unconscious bias training: an assessment of the evidence for effectiveness.
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4 Kline R. BMJ Leader 2019;0:1–4. doi:10.1136/leader-2019-000159