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Trust me, I'm a leader: creating a climate for higher performance

Managers will need to build a culture of mutual ownership and trust, rather than leading from the front, to affect the breadth of change to combat the cold economic front sweeping across the NHS, say John Drew and Helen Bevan.

Winter is approaching. And as the temperature drops, typically we respond by battening down the hatches, retreating inside and huddling around the fire with the people we love and trust best.

There are some parallels in what is happening now in the NHS: funding is flat, daily life seems much more of a struggle than it was during sunnier days, organisations are in transition and there is a risk that leaders retreat inside with what they know and with who they know.

So at exactly the time people need to be led – and to hear the story of how they will survive this long season of winter and build hope of seeing spring again – that kind of visible and inspiring leadership may not be present.

Analysis by the NHS Top Leaders programme shows that the predominant senior leadership approach in the English NHS is a “pacesetter” style. Pacesetter leaders set high performance standards and live them out daily in everything they do. They roll up their sleeves and lead from the front rather than delegating to others.

This style is a natural enough response to an NHS leadership mission which has focused on delivering national targets, achieving financial balance and, in some cases, system level changes. However, pace-setting leaders may not be so effective at motivating and energising the workforce for the long term, or building the trusting relationships across organisational boundaries currently needed for the breadth of change.

A winter’s tale

As winter draws in, this leadership style is likely to be less effective in a world where goals and priorities are locally determined, where success depends on collaboration and partnership between organisations and where many of the hierarchical mechanisms for coordination and control of performance that have characterised the NHS in the past are fast diminishing.

The NHS Institute for Innovation and Improvement has recently published Leading Large Scale Change: a practical guide, which considers the evidence about those leaders who have delivered rapid change at scale and sustained it over time. This research shows that these leaders are much more likely to have built their efforts on a platform of commitment – collective action towards a different future and a shared purpose – rather than compliance with standards, performance targets or operating rules.

In the current context we believe that leaders will need to get beyond the foundation of compliance to develop a commitment-based strategy; ownership, meaning, mutual trust and understanding.

Now is the season to build on the bias towards a pacesetter style by deliberately incorporating partnership, trust and collaboration into our leadership styles and processes. For example, developing sustainable local health economies requires a collaborative approach to rethink and implement different ways of delivering care along the major pathways. This in turn will require much more give and take between organisations. And all of this requires trust.

How to build trust at an individual level

  • Be clear about your own values and demonstrate them in all your leadership interactions;
  • Be deliberate in modelling the behaviour you want to see in others;
  • Tell your personal story that demonstrates your values through your experiences and model vulnerability when you tell your story;
  • Be seen to be honouring and delivering all the personal commitments you make to others;
  • Acknowledge the contributions of others;
  • Assume that all the resources and assets you need for change are already there in the system and build on existing strengths;
  • Assume the best in others;
  • Demonstrate that you are an active learner and seek feedback from others.

Much of our social behaviour – including beyond the world of work – is based on what academics call “strong ties”. We have strong ties with “people like us”, people with the same backgrounds, life experiences, beliefs and values. People are far more likely to be influenced to adopt new behaviours or ways of working from those with whom they are most strongly tied.

A change dynamic based on strong ties has a lot going for it, but it also has its limitations. Peer-to-peer spread can reinforce silos and group think and restrict our ability to spread change or information beyond the professional or peer group. This is particularly crucial given the trend towards integrated care, which seems the most likely way to reconcile the need to assure high quality care for an ageing population more characterised by long term conditions and at a time of such massive financial challenge and uncertainty.

The alternative is a change strategy which incorporates “weak ties”. When we build weak ties, we deliberately seek to build bridges between groups and individuals who do not have strong or historical links, and therefore to move from “them and us” to an “us and us”, based on a platform of shared purpose and shared values.

In other words, we bring together a coalition of disparate interests and perspectives by working on defining a joint future, in which the inter-dependencies are made explicit and worked through. In the history of large scale change, it is often those leaders who have been able to unite people through weak tie relationships who have created the most profound and radical change.

The most important factor in our ability to influence change through weak ties is the extent to which we are able to build trust into these relationships.

Research into organisational behaviour suggests that senior leaders act as “signal generators” whose words and behaviours are constantly scrutinised, interpreted and – like it or not – amplified in the organisations we lead. So the signals we send through our leadership actions speak much louder than our words, and reverberate throughout the whole organisation or system.

The theme that resonates throughout this discussion is the importance of trust. It is a word which is on most NHS letterheads, since it is embedded in the name of the majority of NHS organisations. What would it take for trust to become equally embedded as a practice and an attitude across the NHS system, and what difference would it make?

Evidence suggests that, in our world of pacesetting leadership, this might not be happening widely. The UK Institute of Management and Leadership recently published its 2011 “index of trust”. It showed that chief executives of large healthcare organisations are among the least trusted by their workforce in any sector in the UK economy (see graph, attached right). Healthcare chief executives scored an average of 55 points on a “trust index”, compared with 57 points for CEOs in local and national government, 62 points for those in the private sector and 66 points for those in the voluntary sector.

In the aftermath of the Mid Staffordshire Foundation Trust public inquiry, we will surely see a hard push for much stronger governance processes in the NHS. And yet governance can only do so much. In his book The Speed of Trust, Steven Covey argues that the way for organisations to cope with and thrive under the rate of external change we are now seeing is to make trust the core design principle for change. This is both a leadership challenge and a big opportunity. To make this practical, action is needed at both the individual and organisational level.

Three factors for trust

In The Trusted Advisor, Charles Green sets out an equation for high trust organisations which is based on three factors in the numerator: credibility, reliability and intimacy.

Credibility is primarily about words and technical credentials and NHS leaders and healthcare professionals are likely to score highly on this factor. Reliability is harder as it has to do with delivering on our commitments that we make to others. Intimacy is also challenging as it is to do with the recognition and handling of emotions.

Trust has been defined by the US management academic Scott Williams as “the expectation that another party will not allow you to be harmed at a time when you are vulnerable”. If, as leaders, we want people to take risks and make themselves vulnerable, we have to act in ways that enable them to feel psychologically and emotionally safe in their relationship with us.

Even if all of three factors for trust are in place, they can all be undermined by strong self-orientation – leadership behaviours that seem to say “this is all about me, not you or us”. Leaders can learn skills of trust building and rebuild trust that has been lost. These principles are also relevant to trust between the patient and the caregiver, as well as within working teams and across whole organisations.

Leaders must invest now to build the trusting relationships they will need to develop the organisational foundations for high performance and joint models of delivering care in the harsh funding climate. If we can do this we are likely to perform better on many fronts: delivering more value to the people we serve, building thriving collaborations and partnerships, enhancing our ability to retain staff and innovating and implementing change more quickly and at greater scale.

How to organise for trust

  • Create organisational integrity by continuously connecting leadership actions with core purpose and local values;
  • Use the NHS constitution as a powerful symbol of values and intent;
  • Purposefully build a work environment that is ethical, productive and positive;
  • Use data and analysis to show the bigger picture and challenge entrenched positions;
  • Use expert facilitation to support relationship building. Sometimes entrenched positions cannot be resolved from within the existing system and external support can make a big difference;
  • Consider ways to create a different dialogue. For instance, in redesigning the major pathways of care across whole health economies. Working together to come up with a jointly owned answer builds trust as well as commitment to act;
  • Consider novel forms of governance. For instance, an integrated care pilot in North West London has based its governance model on that of a club (an “unincorporated association”), with members opting in and agreeing to follow a set of rules in order to overcome the disincentives and organisational barriers to closer collaboration.

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