HSJ 'Managers make a difference' Campaign: Whether it's the art of fostering effective relationships with clinicians, non-executives and politicians or demonstrating empathy with staff, what does the next generation of high-quality managers need? HSJ brought together six chief executives to provide some answers

HSJ 'Managers make a difference' Campaign: Whether it's the art of fostering effective relationships with clinicians, non-executives and politicians or demonstrating empathy with staff, what does the next generation of high-quality managers need? HSJ brought together six chief executives to provide some answers

Preparing to be a director

Peter Homa: Choose the organisation far more carefully than they choose you. Assess how well the chief executive is doing and how long they're likely to be in the post. Make sure you have a mentor who understands the stresses and strains of demands on directors. And have a personal development plan.

Plan an entry strategy. Whether you like it or not the early days will imprint your personality more powerfully in the organisation than anything you do subsequently.

Get the think:do ratio right and make sure you get enough time to think about things in the long term rather than just responding to others' demands. At least weekly, assess how much impact you and your team are making on your agreed objectives.

Developing commercial acumen is increasingly important. This doesn't always mean competing. There are often opportunities to collaborate.

David Astley: There's also something important about the mastery of your brief. First and foremost you've got to be a top-class professional regarded by your peers, a very competent operator before you start adding on.

Sophia Christie: Mastery of the brief implies there's a clear brief and a shared understanding about how to approach it. There are elements of director roles that require specific skills, but the world is increasingly characterised by the content and context changing rapidly. I would be very wary of appointing anyone who thought they had mastered a brief because that would imply they weren't really aware of the sort of context that we're working in. I'm looking for someone who is very comfortable with uncertainty and having to learn on their feet.

Mary Burrows: A director needs to be politically astute and able to recognise they're in a political environment and be comfortable in it and to actually use that environment to achieve their aims instead of saying: 'No, we're not political.'

Barbara Kennedy: One of the complexities that's rarely discussed is the ability to influence across organisations and cultures. Primary care trusts are a natural partner of local authorities, where operating culture is vastly different to the culture of acute hospitals. At the same time you're trying to hold a bridge between all three in your negotiating stance. It's quite sophisticated and my recommendation to aspiring directors is to get used to thinking about it.

Directors need a strange combination of transactional and transformational skills. So know what your strengths are and play to them; are you a naturally logical, deductive person or are you somebody who's best on re-design, working across organisations and doing things in a slightly different way? Transformation is required in practice-based commissioning; transactional is required in acute contract renegotiation.

Neil Goodwin: I agree technical knowledge and expertise are very important ? but I think mastery of the brief is the basics. Credibility of managers today, much more than before, is largely built on their ability to deliver organisational and national objectives. For anybody who wants to progress a career in the NHS, the first thing I would look for is a track record of delivery and what they have learnt.

Barbara: Having a focus on the objectives you're trying to achieve and then demonstrating you've delivered sounds very simple but it's not always easy when you're in the kind of chaotic environment the NHS can sometimes be. What the health authority may want from you is overriding what at a local level you know to be urgent. So as a director you need to see the important in the midst of the urgent and focus on what you're trying to achieve, not just short-term but long-term.

Working with non-executives

Helen Walley: The thing I was least prepared for when I became a director was the relationship with the non-executive directors. It's a very different role. Frequently I see people not even asking non-executives what background they have or understanding what qualities they possess.

David: When an organisation moves towards foundation status the relationship between the executive and non-executive directors needs to change. Non-executives can be far more focused on the bottom line rather than process so they can

hold the executive directors accountable. And executives have to be far more challenging of each other. It's our duty to help people make that transition in order to work in a tougher world.

Mary: I'm lucky my non-executive directors have always had their debates in public and refused to have briefings beforehand, which has made quite interesting dynamics. Some directors find challenge difficult, but it's the only way to build accountability.

Sophia: There is a shifting in appointments towards the commercial and away from being representative of the local community. We had an interesting situation in one of my neighbouring organisations where one non-exec from a commercial background felt the local hospital should have made a lot more money from the local health economy. There were genuine tensions as people brought in very different aspirations. It raises issues around how executives and non-executives interact to build a corporate culture that can act entrepreneurially and seek best value for money, but also is very clear about core public service issues.

Peter: I think some of the toughest experiences for a newly appointed director is providing constructive challenge to non-execs because there's a stereotype that non-execs are seen to be the challenging force and often that's false. Newly appointed executives can feel disabled to challenge back and yet it's the combination of such constructive terminology that will actually get the best results.

Setting the tone

Neil: One of the things linked to the discussion is about the chief executive setting the tone ? the way that business is conducted ? both within the organisation and the way the organisation works with external stakeholders. Choosing the right chief executive you want to work for is very important. The other thing is about the chief executive creating space within which people can operate, both internally and externally.

My instinct is that one of the things that may emerge from this period is the need for a new relationship between NHS management and politicians, local authorities and MPs about the future direction for healthcare and how it's going to be provided. But equally importantly there must be some kind of new relationship about how business is going to be conducted to achieve the transformation that we are going to have to deliver. Because every time we want to change services we can't go through the sort of torturous processes we go through at the moment. I think NHS organisations could learn about collaborative approaches to change from other public service organisations like local authorities.

David: Management of change is crucial so I've got to give them the space, but also the confidence in how they constructed these arguments with an MP ? maybe a government minister ? as well as dealing with the agenda locally or the scrutiny committee of the local county council, who will have a very different view.

Sophia: It's about skills, but it's also about relationships. There's an issue about building a relationship with key stakeholders and public groups, too ? the ongoing relationships with politicians rather than only ever seeing them when there's a bad news story. Our whole interface with those different groups is changing radically and requires time and investment into relationship-building and trust-building.

Neil: Sophia [Christie]'s absolutely spot-on there. In the future the agenda that will have to be pursued will require a much more sophisticated approach. Work relationships are no different to those outside of work; the test is when things start to go wrong. Can you still have a dialogue, can you still reach some sort of agreement with the relationship more or less intact' In order to do that, you've got to invest in the basics of the relationship. One thing chief executives can do when things get difficult is not to immediately cut the training and development budget.

Helen: One of the things I learnt over time is that if you're that insular you don't achieve the big picture; it's much easier to be confrontational. It is much more difficult to agree a pathway and keep talking throughout the whole of some very difficult debates, as I have done with Peter [Homa].

Mary: One of the things I've learnt and tried to use when setting the tone for my team is about putting yourself in the other person's shoes. If you don't understand where they are coming from, it's difficult to get the outcome you're aiming to achieve. One of the things we started talking about a couple of years ago was 'respectful conversations'; it's easy to get into your own organisation and have a real go about what you think is incompetence.

Engaging clinicians

Barbara: One group we haven't talked about is clinicians. We look at the world through a different paradigm than clinicians. One way of building respectful relationships is to understand what concerns them. And actually that's tricky because it's putting yourself in the shoes of the clinicians without necessarily having the experience.

Mary: Respectful conversations actually came about because it was clinicians, not managers, who were being disrespectful about each other ? secondary versus primary. Even being an ex-clinician myself I had never experienced that level of vitriol.

Sophia: Much of our training as managers has been organised around hospitals and, however idiosyncratic some of the clinical leadership in hospitals is, there has been a much more sustained process. In primary care we are still at a much earlier stage.

David: We've had success using targets, sometimes in spite of clinical colleagues. Now I think the real challenge is how we actually add value to that transaction. How can we demonstrate not only that we hit targets, but we've given a patient a positive quality experience? Credible directors lead from the front.

Neil: I was asked to move to St Mary's Hospital in 1988 to sort out the financial and strategic problems. After I'd been there three or four months a consultant told me they were 'getting on' with me and I thought that in the context of previous chief executives that was positive.

He said he'd like to explain why that was, and I thought he was going to say because I was sorting out the money and offering grand strategic options for links with district general hospitals and so on and so forth. Instead he said it was really for two reasons. One was that I always replied to their letters and the other was that when I wanted to talk to them I always went to their offices or clinics.

Protecting your managers

Helen: Ask yourself how big the risk is and whether it is a calculated risk. If you take risks in an organisation that does not like risks they may not come off. But the real issue is have you really thought through what you're trying to achieve? I took a risk a while ago because I took on a project that was supposed to be for a short period on a private finance initiative.

It turned out to be 11 months. The minister at the time said we need more risk-takers in the NHS. I thought: 'You wouldn't have said that if I failed!' But actually it was a very calculated risk, as the board were behind me.

Sophia: There's something about strategic alliances. Can you get your colleague in social care or one of your GPs to raise the issue? Is everyone on the board averse to risk? Or can you nurture a relationship with a couple of them that begins to shift the culture?

David: Make sure that if you're in an organisation where the boss is not supportive there are places you can go for advice. Make sure there are development programmes. Develop your skills in having difficult conversations.

If you have good influencing skills you'll find a way of making sure your boss is aware. We expect clinicians to raise concerns, and I expect the same of my line management staff if they have concerns about how an organisation is being managed or governed.

Helen: One way to convince people is to draw on the evidence base. It's about not merely relying on your own instinct to push a particular way of doing things, but also looking at what other people have achieved in other places.

Mary: Some directors don't have the skill set around research and data analysis and evaluation. Not that you need to know the detail, but you need to know where to look.

Sophia: Sometimes we all need somewhere to just scream. One of the things we've done to help with that is every two weeks we have a director team meeting and the first hour is just a 'mad and glad' session. We go round the table and everyone says something that's made them mad in the last fortnight and something they're really pleased with.

Neil: We should never appoint people to senior management positions who do not have insight. They will struggle to understand the impact they have on other people. Particularly when their role is principally about delivery and influence and persuasion. I've seen lots of chief executives who do not have insight and they devastate organisations.

Barbara: I think part of that is being ready for your role. Do you know yourself well? That is incredibly important. You don't have to be there 24 hours a day. And you have to take your annual leave ? I've got a real issue about making sure my team take holiday and book it in advance.

Peter: I agree with that so much, having started my chief executive career at literally the opposite end of the continuum. And I didn't realise that I was setting an example that others then followed. It took me several years to understand that we set a role model. How do we make staff feel better about the organisation? I think part of it is operating or appearing to operate with confidence, even in the toughest of situations.

Sophia: Middle managers see us as better at hard skills than empathy. One of the reasons they choose not to take on director roles is we have a negative impact on staff. It's about being able to admit that things are not exactly spot on and that the hard skills are increasingly valued ? the transactional skills of activity, of finance and volume and bottom line.

Neil: Chief executives can help by distilling the national policy agenda and helping directors and aspiring directors to understand what it means locally and what opportunities that presents. That's an underrated leadership skill. Too often we slavishly accept national policy without completely understanding what it means, how we can use it and which bits are best to use locally.

A lot of managers look upwards and are put off by the relationship between government and NHS management. If we lose the opportunity to try to create a new relationship based more on listening to each other, then I don't think we will be able to get the management culture right.

It will be even more difficult to put together candidate shortlists for director and chief executive posts because they will think it's just not worth the aggravation. I'd quite like to see the NHS Confederation leading this issue, calling for a new relationship between NHS management and the government.

Valuing the job

Mary: We're not very good at standing up to talk about good NHS management and I feel we should be. It's a damned good career and it's a really good opportunity. I think a lot of people would step up to the plate if they thought it was worth it.

Barbara: I have heard of senior people and aspiring directors be put off by the kind of brutal processes we seem to put people through in times of change. I do think there's an opportunity to stop that happening and make sure we move forward in a positive way. What Neil [Goodwin] said is absolutely right ? if the most senior people in the NHS are not valued for what they've done, it must be very hard to understand what the organisation's values are.

Peter: There is an opportunity to draw a line under what has been the worst-handled human resources process in terms of primary care trust and strategic health authority appointments. It is by any standard a disgrace. And I think the system ? and particularly the Department of Health ? ought to be big enough to acknowledge that and commit to applying a consistent and explicit set of values that will respect staff and put the patients at the centre of the whole issue. This should avoid putting colleagues through the avoidable trauma they've been through.

David: The signals are being very badly handled, too, as chief executives and directors are having to change services in ways that go against some our judgements in terms of how to handle change. We're having to put staff at risk because in some organisations,£20m has disappeared because of payment by results.

Mary: That goes back to Neil [Goodwin]'s point about how you articulate what policy is and try to manage people through the process. We've done certain things as a result of policy. Maybe we haven't articulated it very well. And actually that's really quite difficult to have that dialogue with staff. But also it's really important to have that dialogue with the public because otherwise we just keep going round in the same circles.

Sophia: In times of crisis people the best managers will rise to the challenge and perhaps take more risks in terms of redesigning services, if they've got the time to research and look at the evidence and managing the resources available.

And we have a moral responsibility to get within our budget but also to only spend that money in terms of the best value we can get for it. Hopefully when they come out the other side they will be able to make reasoned arguments.

It's quite hard for them when they don't know where their job is going to be. I think to do both is complex. People don't know where they're going to be and they're having to manage through one of the most challenging years.

Helen: There's a real issue about the attractiveness of senior management, that people most vulnerable to change are the ones where there are the fewest positions available at the top of the tree.

It is perceived that everything will change every three years when you're in that kind of top two tiers and you're going to be the ones most devastated by it. It doesn't seem very attractive when you can stay a bit further down and leave yourself less vulnerable.

David: We can talk up the pressures and the challenges, but we do have the ability to influence a lot of patient care and also a lot of people working for us through the right kinds of leadership skills.

You need to hang on to that as a chief executive and encourage your directors to inspire thousands of staff. There are plenty of other places I'd rather not be.

We're here to lead, whatever the external environment; we have to keep a smile on our face to inspire our staff. And that's something that's non-negotiable.