Regulators are looking at what being well led really means at all levels of an NHS organisation but there is still room for improvement, says Michael West




Culture – the way we do things around here – is the most important influence on the ability of staff to deliver continually improving, high quality, compassionate care.

Michael West

In healthcare, discussion about the need for leadership that facilitates the right culture of care has now moved well beyond speeches and rhetoric.

Regulators – both the Care Quality Commission (which the King’s Fund has been working with) and Monitor – are looking at what being well led really means at all levels of an NHS organisation.

The snowball effect

We know that care is more likely to be high quality and compassionate when there are associated visions and values enacted from the board to the front line and translated into a small number of clear challenging objectives for the board, departments, directorates, teams and individual staff.

Where staff are treated with respect and afforded care, support and compassion, they reflect these qualities in their care of patients and treatment of each other.

‘To nurture compassionate care we have to ensure leadership capabilities, characteristics and attitudes produce a bright culture’

Positive, challenging environments focused on continual quality improvement in supportive organisations create high levels of staff engagement that lead to better quality care.

Collaborative ways of working produce more effective, integrated, innovative and higher quality care.

Research I published last year with colleagues for the Department of Health’s policy research programme suggests that across the NHS and inside the best organisations there are bright spots where cultures of compassionate care are the norm, as well as dark spots where change is needed.

To nurture compassionate care we have to ensure we have the leadership capabilities, characteristics and attitudes to produce a culture that creates brightness throughout the organisation.

Plan and pursue

This will not happen as a result of piecemeal interventions, sending sub sets of leaders on development courses or relying on a small number of semi-willing volunteers to fill leadership positions.

Leadership for high quality care must be planned and pursued. Yet many NHS organisations have no leadership strategy in place. They have not asked the questions: what leadership capabilities do we have now and what will we need in the future? How will we ensure we have leaders with the right capabilities in place next year and in five years?

To answer these questions, boards must initially take responsibility for developing a leadership strategy.

This must be planned, systematic and focused on the medium to long term.

‘We must focus on collective leadership, where it is shared, interdependent and extended to all in the organisation’

Crucially, it must focus on collective leadership, where leadership is shared, interdependent and extended to all in the organisation with expertise.

That is leadership of all, by all, underpinned by core values where leaders work across boundaries within and across organisations to deliver integrated care and support each other.

Where leaders make the success of the organisation as a whole, not just their individual areas, their priority, and leadership is the responsibility of everyone in the organisation.

Room for improvement

For such a leadership culture to emerge leaders must promote participation and involvement as their core leadership strategy; cultivate staff autonomy and accountability; ensure all staff “voices” are encouraged, heard and acted on; support staff in being responsibly proactive and innovative; avoid command and control except in crisis; take action to address systemic problems that hinder staff in providing high quality compassionate care; deal quickly, consistently and effectively with inappropriate behaviour and poor performance; and model compassion in dealing with patients and staff.

NHS organisations clearly have some way to go on this.

A recent King’s Fund survey of 2,000 NHS clinicians and managers found that 43 per cent do not believe that swift and effective action would be taken for inappropriate behaviour. Only 39 per cent believe their organisation is characterised by openness, honesty and challenge.

A starting point for building a new leadership strategy is to identify the number of leaders needed in each area of the organisation over the next five years - the qualities, competencies, diversity and knowledge (including clinical expertise) that are required.

‘It is no easy task for leaders facing unprecedented pressures but the prize is a significant one’

They should have a clear idea of the desired leadership culture, including skills, values and behaviours, and the collective leadership capabilities and strategies required.

Then the organisation must develop and sustain its collective leadership strategy. This will require the engagement and contribution of all staff and other stakeholders and recognition that courage, vision, persistence and management of uncertainty are required.

The prize is bright spots everywhere in the NHS and the lighting up of all the dark spots so that patient care is continually improving, of high quality and is compassionate.

This is no easy task for leaders facing unprecedented pressures but the prize is a significant one.

The argument for taking a new approach to transforming leadership and a culture based on what we know works and be sustained should be considered by every board committed to high quality care.

Professor Michael West is a senior fellow at the King’s Fund