Leadership: commitment beats control

Government, its agencies and NHS managers must adopt a leadership approach that will enable the 1.3 million NHS staff to pull through tough times without seriously damaging their own health, and consequently reducing the quality of patient care.

Increased stress raises sickness rates, absorbing even more of the scarce resources

A major dilemma facing leaders is how to get more out of staff with fewer resources, particularly when evidence from the Boorman review into NHS health and wellbeing suggests many NHS staff are already experiencing high levels of job related stress.

Eighty per cent of staff in this survey admitted that their levels of stress directly and negatively influenced the quality of care they provided.

Increased stress raises sickness rates, absorbing even more of the scarce resources.

Lord Darzi made it clear in his next stage review that quality improvement will only be achieved by innovation, led by an empowered workforce, and that previous top-down bureaucratic change initiatives must be replaced by “change that is owned and driven locally through staff who are engaged, energised and committed”.

Unfortunately, we must remain mindful of consistent evidence showing that when managers are under pressure to deliver, they often default to a “command and control” approach. No surprise then that accusations of bullying surface as demands increase.

Perhaps particularly worrying is that many of these accusations are directed at government representatives close to their political masters - effectively working counterproductively to increase the kind of employee-driven activity the health service desperately needs.

With this double challenge - reducing stress and increasing quality - the single most important focus for NHS leaders is to increase staff engagement. This is something that the government recognised in the MacLeod review, Engaging for Success.

Engagement works

The good news is that we now have solid research evidence as to what style of leadership is most effective in engaging staff and increasing productivity. This comes from two separate three year investigations we conducted, as well as substantial evidence from data collected in numerous trusts that have used the transformational leadership questionnaire, the 360 degree instrument based on the findings.

The results clearly show that adopting this leadership approach significantly increases staff motivation, satisfaction, commitment, morale, self-confidence, engagement, and wellbeing.

The more recent of our major research studies, a three year longitudinal investigation funded by the NHS service delivery and organisation research and development programme and undertaken with partners at King’s College London, is one of the first studies to show that embedding this particular leadership approach in the culture of teams predicts high levels of morale, wellbeing, increased productivity and ability to successfully implement change.

In the most effective teams:

• all staff felt involved in developing the vision and how to achieve it;
• there was clarity of desired outcomes (often stretch goals);
• constructive challenge and innovation were strong;
• individuals felt empowered as they were trusted to take decisions;
• ideas were listened to;
• time was made for staff to discuss problems and issues;
• there was high face to face communication;
• leadership passed to different members for certain activities as was appropriate;
• there was a strong sense of team focus and social support at all times.

It is essential that trusts ensure their leaders are highly competent in their role. But research is increasingly showing that competence, while crucially important, is not enough.

To improve organisational performance - including high levels of patient safety - you must create teams with an engaging culture.

This is a particularly important responsibility for the most senior managers, since it is they who largely determine culture through the leadership behaviours they role model.

As the Darzi and Boorman reviews clearly state, the ultimate responsibility for the governance of a trust rests with the board, which is duty bound to gather evidence of how effectively leadership is permeating its culture.

When managers have to make difficult decisions about where to focus their attention, a quote from US leadership guru Warren Bennis sums it up: “The soft stuff is the hard stuff.”