Hatching a new breed of NHS executive

It is remarkable how many of the leaders of top international companies are grown from within; nurturing talent is clearly a major activity for any successful business. Perhaps it is unsurprising then that some commentators bemoan the lack of widespread and high quality leadership in the NHS. As a near monopoly employer it has not always given sufficient attention to developing people with the greatest leadership potential.

This is why NHS chief executive David Nicholson and health minister Lord Darzi have given such a high priority to leadership development. In no uncertain terms they have told the NHS to up its game. With prime responsibility for overseeing the work handed to the strategic health authorities, a reported£80m is being invested to make sure it happens.

But if the NHS is being told to get on with it, we might reasonably ask: "Get on with what?"

Emotional leaders

What the NHS needs, first and foremost, is leaders who have the highest level of emotional intelligence - the ability to perceive, understand and manage their own emotions and those of the people they lead - and use this to enable people to give their best. The challenge for leadership development in the NHS must be to select people who have this emotional intelligence and then to nurture and develop it.

How well are SHAs rising to the Nicholson and Darzi challenge? Over the last seven years at the Health Foundation we have been learning about leadership for improvement by designing and evaluating a range of leadership development schemes. Recently we also commissioned a rapid appraisal of SHA activity.

It is early days. Parts of the NHS have taken leadership development seriously for a long time and the NHS Institute for Innovation and Improvement and a small number of pioneering trusts have been running leadership schemes for several years. However, adopting a strategic approach is new territory for most SHAs. But they are taking on the role enthusiastically and experienced and respected NHS leaders are being appointed to head up their regional activities.

All the SHAs are doing what they were told, concentrating at least initially on the chief executives and senior directors of the future. Despite the apparent desire of the centre for a common leadership brand, there does not seem to be an agreed single guiding model. Instead, there seems to be a preference for more practical competency-based approaches over high level theoretical ones. Few SHAs saw a need for a single framework to guide their work.

There is also no common governance structure underpinning the delivery of the SHA programmes. NHS North West was the first to establish an "academy", independent of the SHA and hosted by a local trust. NHS London looks likely to adopt a similar model.

To do list

Others appear to want to be more hands on and are not willing to be just another stakeholder around the table. Most see themselves primarily as commissioners, contracting with established providers from the university, private and third sectors.

However, some, such as NHS South Central, are also involved at the provider end of the spectrum. These contracted providers are using widely recognised delivery methods for their courses - residential modules, workshops, learning sets, study tours and a small (possibly too small) amount of coaching.

At present there seems to be little interest in formal certification for those who complete the courses, though this might reflect the seniority of the current target audience.

So there has been a lot of progress, but the scoping exercise also identified a number of issues that the Health Foundation's work suggests are important but do not seem to be high on the SHAs' to do list.

Generic leaders

First, the purpose of all of these activities is not yet clear. If all the NHS wants is more generic leaders to deliver what the service has always delivered, then there is little need for new thinking. If, however, the prime purpose of leadership is to deliver better care for patients - "leadership for improvement" as Lord Darzi called it - then the new leadership development programmes must reflect this and do so explicitly.

As health management expert John Ovretveit, one of the gurus in the field, says, we need leaders who will influence others to focus on how they can make the service better for patients.

The science of quality improvement, with its emphasis on the end user, systems operating across traditional boundaries and improvement methods, should be central to leadership development in the future.

Rather than commissioning the same activity from the same providers, SHAs should be challenging current thinking and searching for new providers who push back the boundaries of our understanding of leadership for improvement.

Second, much of the current SHA activity still seems to be focused on developing individual leaders rather than developing shared leadership models.

There also seem to be few attempts at creating a cultural change that values leadership across the workforce. The focus on the highest level of organisational leaders, while important, risks missing out on other areas of great importance to the NHS, such as developing those who will lead commissioning on the ground, or addressing the fast-growing crisis in leadership in public health.

In addition, there is still a strong focus on people learning within their own discipline, thereby missing the challenge that comes from learning across professional boundaries.

Developing sustainability

Third, with few exceptions, there seems to be little emphasis on the sustainability of current leadership development activity. Past experience tells us that the attrition rate is significant after one-off development opportunities. People with potential can be inspired by a course but sink back into the crowd when they are not given ongoing support by their organisations and through networks or alumni. SHAs need to ensure their investment in talent is maintained and built on in the longer term. This requires interventions not only with individuals but across the system.

Finally, while the SHA leads meet frequently and there is already some evidence of shared learning, few have so far commissioned a rigorous evaluation of their leadership activities. At a time when Lord Darzi is expounding the importance of evidence, it is a wasted opportunity not to look for new knowledge from such a large investment.

The NHS has a long way to go before it can say it is as committed to growing its own leaders as the Microsofts and AstraZenacas of this world. But there are encouraging signs that it is now taking its responsibilities seriously.

HSJ's Leadership Forum 2008 is in London on 1 December.