Middle leaders – the chief executives of the future – must be taught the behaviours required for a successful stint at the top, says Lubna Haq.

How often in the last 12 months have you heard that the NHS is undergoing radical change and the landscape of the future will look very different? With new arrangements ranging from clinical commissioning groups and primary care trust clusters to the establishment of the new NHS Commissioning Board, all staff are being repeatedly told that wholesale cultural change needs to take place.

The message should be clear: the task-focused, individualistic, target-driven behaviours that have been successful over the past 10 years will not help us to deliver success in the future. Staff need to work in new ways to meet the challenges ahead.

But who is going to be responsible for delivering this change? While top teams are clearly setting the strategic direction and are responsible for highlighting the organisational priorities, it is middle managers who form a large chunk of the workforce and will have operational responsibility for achieving the shift. Yet £20bn of savings still needs to be found and the quality, innovation, productivity and prevention programme is still a key driver.

Daily constraints

At Hay Group we often hear middle leader programme participants complaining that they have to battle with significant daily constraints. They feel they do not have the authority to make decisions and describe themselves as being stuck between staff who think they do not understand the real pressures and senior managers who expect them to work miracles.

Middle leaders describe feeling like servants to influential medics, who have to be engaged for managers to have any chance of delivering the operational side of the strategy.

Despite these difficulties this group of middle managers are the future leaders of the “new” NHS and a critical group for achieving the tipping point for the service acting, behaving, and thinking differently.

We have discovered some interesting patterns and trends to shed some light on why middle managers feel overwhelmed by the weight of their responsibilities.

Restructuring, delayering, clustering arrangements, doing more for less, financial constraints and redundancies have played a notable part in the sense of paralysis some managers feel. While these should not be trivialised, there are other forces at play.

Take any typical high performer in any area of operational activity, for example, in finance, HR, general management or clinical roles such as moving from nurse to ward sister. These staff will usually have trained in their area of expertise. They are likely to operate as individual contributors focused on getting specific tasks done and being recognised for it.

They may also need to work in a team but will typically not see this as the priority. If they consistently do what is required of them well and on time they are likely to be rewarded by being promoted. Here, we would suggest, is where the problems start.

In the NHS, promotion will often come with responsibility for people. It is not unusual after promotion for a good finance officer or a competent nurse to suddenly be expected to operate as effectively in the role of team leader as they did as an individual contributor. Little time and consideration is given either by the organisation or the individuals themselves to adjusting their self-image to the new role.

Behavioural shift

Almost overnight they are expected to recognise the different requirements of the role they now inhabit. This is not easy for anyone. The finance officer will have been successful because they will have done what is expected of their role. They may have had very little training, guidance or support in making the behavioural shift from individual contributor to a manager of people.

So what happens? Typically, the individual will continue to operate in the way that has given them successful outcomes in the past – that is, focus on task and delivery. Our experience suggests that they can see the management role as an “add on” to do if they have time. And because there is no real acknowledgement that a new behaviour set is now required, individuals do not recognise what they need to stop doing, start doing or do differently. This is compounded if they rise from within the ranks and find themselves managing people who were only last week their peers.

Sometimes, middle managers recognise that they now need to behave differently but do not really know what this means. Very often they will tell us that the strategy they adopted was to behave like others around them in similar roles or the way they saw their manager behaving. This can be very powerful with good role models but otherwise simply perpetuates poor behaviours.

Five further themes and patterns emerge from this group of middle managers:

Commitment: From working with groups of managers at this level, one of the striking features is the overwhelming sense of loyalty, integrity and genuine commitment to the ethos and values of the NHS. Staff may feel that their jobs are very difficult, and may feel overwhelmed by the scale of change and challenges of delivery, yet they are prepared to invest time and energy because they are committed to patients.

Leadership styles: Successful leaders demonstrate a broad or extensive repertoire of leadership styles. To help measure these styles, we developed two diagnostic surveys based on 60 years of research, benchmarked globally. The first relates to the breadth of leadership styles used every day and the second measures leadership impact. In other words, the conditions a manager creates to enable their teams to do their best work. Research shows that performance can be enhanced by up to 30 per cent under the right conditions.

We surveyed 132 middle managers attending NHS leadership development programmes, highlighting some significant messages (see graphs, opposite): 38 per cent of leaders displayed a broad or extensive repertoire of styles demonstrating three or more leadership styles. However, 61 per cent displayed a limited range of leadership styles (two styles) or narrow range (one).

The implications are quite stark. Our aggregate data of these 132 leaders shows only 9 per cent were creating a high performance environment where teams are motivated and focused. A further 15 per cent were creating an energising climate where teams are motivated but may be confused about clarity.

However, 77 per cent were creating a tolerable or demotivating climate, meaning that teams were not consistently engaged and motivated by the leader. This can result in disengagement, minimal discretionary effort and underperformance.

Influencing: Many middle managers do not recognise the need to influence beyond logical persuasion techniques. This is understandable in an environment where people see themselves as experts in their areas. The strong belief is that they make recommendations and decisions based on rational argument. This behaviour may help to explain why there is often tension between managers and clinicians.

Many middle managers are surprised to learn that a range of sophisticated influencing styles are needed to gain buy-in, but once they see the need to put themselves in the shoes of the various stakeholders, they recognise the advantages.

Political astuteness: Often middle managers do not recognise that all organisations are complex political systems that require careful and thoughtful tactics. They can be naive about what can and cannot be done, which turns into frustration and they retreat into their own expertise area.

This silo thinking means managers do not always understand the climate and culture of their own organisation, let alone the wider health and social care environment. They also tend not to know who the main influencers are, both internally and externally, and how to get them engaged.

QIPP requirements mean it has never been more important to be attuned to health strategy and policy at a national and local level and able to plan in a way that takes account of these strategies. For middle managers, understanding their role as leaders is now broader than simply being responsible for their area of delivery.

Collaboration: Intellectually, most middle managers will say working with others is critical for successful outcomes. However, when challenged about why this is important or how they do it, often they are 
not sure. Many managers interpret collaboration and partnership as informing others what needs to be done, or working with others where it immediately benefits them or their organisation.

We do not see evidence of managers striving to create the future conditions for successful internal or external partnership, working with an eye on the greater gain. This means not enough thought is given to cohesive and “joined up” services as required by QIPP, or to understanding and being sensitive to diverse viewpoints.

Art or science?

Middle leaders face considerable challenges – and yet are the crucial ingredient to future success. They need to be encouraged and enabled to build their leadership capabilities beyond technical competence. Leadership is an art not a formula.

Successful leaders take into consideration the context within which they work, the skill and motivation of their team members and the support and coaching individuals need.

We believe it is critical for middle leaders, the chief executives and directors of the future, to have the opportunity to learn the behaviours needed for positive leadership impact.