A study of healthcare leadership training needs is contributing to new locally led, patient centred and clinically driven development plans, write Tim Bryson and colleagues
The Francis inquiry and other recent national reports have highlighted the role of leadership in the NHS to bring about cultural change.
In Cambridgeshire, stakeholders were concerned about understanding the health system’s leadership development needs and formulated a comprehensive and locally owned approach.
An analysis of leadership training needs across all of the NHS organisations in the health system followed, and the results are now being used to guide a leadership development strategy.
The project was led by the academic health science centre Cambridge University Health Partners and commissioned by the Cambridgeshire and Peterborough Workforce Partnership Group. All local NHS organisations were involved including the clinical commissioning group and the five provider trusts.
The analysis included a questionnaire for frontline clinical and managerial staff, focus groups and interviews. Local leadership activities were mapped.
‘It is not PC to say this but I felt like if you don’t know how to sell yourself, you won’t go far in this place’
Based on the analysis, an “accelerated design event” was held to develop the proposed leadership approach. Key principles were used to ensure the programme design “added value” to the existing activities of NHS organisations; maximised the benefits of collaboration between trusts; and was sustainable.
The analysis highlighted the sobering but not surprising conclusions that leadership development was seen as “stop start”, difficult to access and was often poorly supported.
Respondents prioritised their preferred leadership development topics. The top three preferred leadership development topics were:
- team leadership and people management skills;
- influencing and negotiating skills; and
- managing performance.
In contrast, the bottom three topics were:
- the quality, innovation, productivity and prevention programme;
- integrated care; and
Leadership questionnaire results
- The electronic questionnaire was developed collaboratively, piloted and implemented.
- The sample of 631 respondents was considered representative of frontline leadership, with just under half (294) nurses and 62 per cent (397) at bands 7 and 8. Consultants made up 14 per cent (90) of the sample.
- Two thirds of the sample did not currently access leadership development but 80 per cent had accessed some aspect of leadership development in the last five years.
- In terms of preference of uniprofessional or multiprofessional methods of delivery, 80 per cent preferred multiprofessional or had no preference.
- Among medical staff, 30 per cent preferred uniprofessional programmes.
- Access was identified as a significant issue, with 49 per cent of the sample rating leadership development as “difficult” or “very difficult” to access.
- Rating the leadership development support from their organisations, 23 per cent of respondents said it was “poor” and 45.2 per cent rated it as “adequate”.
- The finding that only a small number of NHS clinicians and managers were undertaking leadership development activities echoes research from employers more widely.
The preferred topics indicate a strong feeling that leadership programmes should target skills that help leaders in their day to day roles. The least preferred topics might be associated with national policy directives and be seen as remote or top-down.
Qualitative comments provided additional insights into questions about organisational support and access. These themed comments and indicated that:
- Leadership development programmes were seen as episodic, patchy or not sustained.
- While there were courses available, sometimes they were difficult to attend as maintaining clinical services or mandatory training took precedence.
- There was a lack of information about opportunities.
- Support from managers was variable and sometimes felt like managerial favouritism.
- At times courses were fully booked or there were long waiting lists, or the programmes were run at unhelpful times.
Talking about leadership
A range of interviews and focus groups were held in each organisation. Some staff had experienced helpful leadership development including participation in activities external to their trust, coaching and mentoring opportunities and leadership development that could be undertaken flexibly.
‘Leadership support is erratic; at times it has been embraced enthusiastically and then just dropped’
In contrast, some colleagues reported less helpful leadership development experiences such as a lack of support or follow-up from line managers, or being placed in a leadership role without training.
Some participants reported learning leadership skills but having no opportunity to use them.
Perhaps most worryingly, colleagues thought leadership development was insufficiently focused on promoting diversity and equality. Health Education East of England has recently developed a “leadership conversation guide” to promote an inclusive nomination process for leadership programmes.
Participants contributed ideas for future leadership development. There was a consistent plea for organisations to view leadership development as essential and to ensure clear, fair and robust processes for allocating and resourcing leadership development activities.
There was also a strong call for leadership development to be multiprofessional and matched to the needs of different leadership levels.
View from the top
Chief executives expressed a strong, consistent view that leadership development should be seen as a shared service, provided by and for the local health system, building on the potential to scale up from current local leadership development offerings.
‘If there is a single thing we should be investing in across the health system, it is leadership’
There was a concern that leadership development should include commissioning leadership and should embrace health and social care leadership. The chief executives group saw a collaborative approach to leadership development as a significant opportunity to strengthen clinical engagement and create a common focus on quality improvement.
Mapping the gap
Programmes such as mapping of trust leadership provision and those run by the NHS Leadership Academy provide further evidence of the variations between NHS organisations in their leadership development targeting and investment.
While there was reasonable local provision for first line leaders, provision was patchy in other areas, especially for service level leaders and experienced senior leaders.
When local activities were examined further, heavy reliance on internal mentoring and coaching, and on external (non-NHS) provision for specific leadership initiatives were found. Some organisations were doing very little leadership development at all.
Design for the future
The accelerated design event involved a good cross section of clinical and managerial leaders from across the patch. A proposal for a health system approach to leadership development was produced through the establishment of the Cambridgeshire and Peterborough Leadership Hub.
The hub aims to provide the capacity to progress leadership development in an integrated, collaborative and sustainable way, building on local leadership development activity within trusts. The coordinating hub would also support an ongoing “return on investment” evaluation and analysis of the benefits to the individual, their service and the organisations.
The overall leadership offering was designed to include three linked development strands:
- A leadership development opportunities programme supporting experiential leadership activities tailored to the individual’s development needs, including multiprofessional coaching and mentoring, shadowing, job swaps, secondments and project involvement.
- A continuous leadership programme offering a varied and accessible range of skills workshops, master classes and discussion forums throughout the year.
- A formal leadership programme targeted at existing or aspiring leaders, focused on equipping them with skills and behaviours for working across boundaries and leading transformational change.
Cambridge University Health Partners has provided a “chief resident” leadership programme that has delivered benefits from GPs and hospital doctors learning locally together. Our next step is to provide an “aspiring health leaders programme” for new consultants and non-medical equivalent roles which will help address some of the local gaps identified, and improve system leadership capacity.
The project has informed the leadership development strategy of the Cambridgeshire and Peterborough Workforce Partnership Group. Nationally the NHS Leadership Academy and its regional delivery partners have energetically taken up leadership development. However, these programmes will only reach a percentage of busy frontline clinical leaders.
Once back in the workplace these leaders will need further access to leadership development and support. The High Quality Care For All report proposed that “change should be ‘locally led, patient centred and clinically driven’”. The local leadership development model was shaped as a result of this leadership training needs analysis to support that ethos and complement national initiatives.
Ultimately, creating real and lasting change requires experienced healthcare professionals leading services, supported in an inclusive and sustained way with the acquisition of leadership skills, behaviours and practices.
Tim Bryson is education services lead at Cambridge University Health Partners; Jessica Watts is programme director of the clinical leadership and management development programme at Cambridge University Hospitals Foundation Trust and the Judge Business School; Janet Martin is a human resources consultant