It is nearly two years since High Quality Care for All announced the intention to “empower frontline staff to lead change that improves quality of care for patients”, suggesting an explicit link between leadership effectiveness and the quality of care.

This has been implicit in numerous inquiry reports over the last decade from the Bristol Inquiry through to the Francis report.

Since the Darzi review, the development of leadership effectiveness has been seen as a priority, and this has prompted various initiatives, including: the establishment of a National Leadership Council; SHA leadership development plans; various leadership development interventions, for example, relating to top leaders, board development, and clinical leadership. A major initiative has been the development of a leadership competency framework for doctors.

The Medical Leadership Competency Framework (MLCF) is the first strategic- level attempt to develop the leadership competencies required by doctors at various stages in their careers. Doctors are a part of the “front line staff” identified as a priority by Darzi. However, this is an essentially uni-disciplinary development: it can be argued that more needs to be done at the level of the multi-professional clinical team? It remains to be seen whether these policy initiatives will be pursued after the general election but, regardless of this, leadership effectiveness is always going to be important for a large complex organisation like the NHS as it is for other large organisations.

The question is: what is leadership effectiveness? How do you define effectiveness? Which leadership model or approach is best for the NHS?

There is no consensus about effectiveness because it is a subjective, socially-constructed, concept. It is open to interpretation and different meanings, and depends upon the perspective of key stakeholders. For example, effectiveness  may be results or outcomes- focused, or it may be related to inputs. It may be about improving performance by achieving clinical or financial targets, and standards; or it may be more about the process, in particular, how targets and standards are met. Moreover, the end results may be focused on staff and / or patients and the wider community.

Equally, there is no consensus about the most appropriate model or approach for an organisation like the NHS. There are many interpretations, definitions, and theoretical perspectives about leadership, each with a particular emphasis. Well known approaches include: the traits or personality-based approach, the behavioural/style approach; situational leadership and the contingency approach; and transformational leadership. Each one serves as an umbrella term for a variety of specific perspectives on leadership. They are usually presented chronologically but there is considerable overlap:

*Traits or personality based approaches - focus on identifying a set of traits associated with effective leadership; assumes leaders are “borne not made”, but effective leaders in the NHS may have differing personal qualities and still be effective?

*Behavioural/style approaches- identify the importance of adopting either a people-centred or task centred style: Beverly Alimo-Metcalf and Margaret Bradley have suggested that an “engaging style” in the NHS is associated with effective leadership?

*Contingency/ situational approaches- extend the concept of style to include the possibility of different styles for different situations; this may be related to different stages in the organisational or policy life cycle; to be effective, leaders in the NHS may need a range of different styles, post the general election?

*Transformational approaches- identify effectiveness as the process of engaging with followers, motivating and inspiring change; of clear relevance in the NHS over the past few years, but there is a need to deal with the problem of clinical engagement?

In addition, there are numerous specific approaches, for example, servant leadership, leadership substitutes, emergent leadership, distributed or shared leadership. There are approaches related to different aspects of leadership: spiritual leadership, cultural leadership, strategic leadership, leadership and power, values and leadership, leadership and emotional intelligence, or leadership competencies.

The latter has been utilised quite widely in the NHS, with examples such as the Key Skills Framework, the Leadership Qualities Framework, and the Medical Leadership Competency Framework.

Dulewicz and Higgs have noted that “a new stream of thinking is emerging which looks at the challenges faced by organisations and the need to think of the associated leadership requirements in less rational or analytic terms”. They suggest a new leadership paradigm may be necessary, taking more account of the emotional aspects of leadership, particularly in relation to leading change.

Given the variety and diversity of these approaches it is difficult to draw conclusions about the most effective approach in the NHS. Rather than searching for a particular solution, which probably does not exist, it may be better to take an eclectic approach. Each approach has some value and may be of use in either practical or theoretical terms, and in providing guidance on leadership development.

There is a need to ensure that development is underpinned by robust and reliable theory and evidence of effectiveness. Depending on the latter, there are various implications for leadership development, for example, a personality based approach is ultimately about recruitment and selection, whereas other approaches focus more on the development of leaders. The latter needs to be interpreted sensitively, to take account of differing contexts and cultural settings: there are no quick fixes or generic solutions. The competency approach, which remains fashionable in the NHS, may well be appropriate, but only in specific contexts?

So what is the way forward? Given the policy imperative to develop leadership capacity, alongside a period of financial constraint and limited funding, what are the priorities?

 If one looks at the link with quality identified above, it may be that the priority should be to focus on leadership within clinical teams, as opposed to leadership at the top. This is leadership which is more concerned with a vertical and lateral influence process as opposed to leadership by position. It is leadership exercised by all clinicians, regardless of level in the hierarchy.

Crucially, it is shared leadership; leadership that is shared within multi disciplinary clinical teams. This may be a greater priority because of the potential for direct impact on both quality of care, and on the development of effective clinical team working.

The latter is an important pre requisite in primary and secondary healthcare, and is, in itself, a key factor in bringing about both team member and patient well being.

In order to be effective as a leader of a clinical team, there are several inter-related aspects that need consideration. As noted above, there are no generic solutions, given the complexity of different organisations- or more precisely, different complex systems- within the NHS. It may be necessary, therefore, to adopt an eclectic approach as a focus for developing leadership effectiveness.  

There are at least five inter-related aspects to consider, influenced by the different approaches to leadership effectiveness outlined above:

* Effectiveness may be enhanced by developing core leadership competencies derived from contextually specific situations- currently popular in the NHS but they must be implemented with care to avoid “identikit” leaders or “tick box” development.

* The development of emotional competencies, such as empathy, sensitivity, and emotional resilience are of particular importance in relation to effectiveness ,and are said to be relevant to the specific needs of leaders in the NHS, given the emotional dimension in leading change. Dulewicz and Higgs have noted that “emotional intelligence (EI) is a critical factor in the effective leadership of twenty first century organisations”

 * In addition to the development of competencies,, effectiveness  is also about the readiness and motivation to assume a leadership role, depending upon the situation. This cannot be assumed as a given and will need appropriate support, particularly in the case of clinicians new to leadership. There is a need to provide both individual support in developing effectiveness, such as coaching, and mentoring, and system- wide support, such as career development and succession planning.

* Another important aspect of effectiveness  centres on a critical understanding of the various contextual variables, such as power and culture, structural components, individual and team differences. It is clear that no intervention in leadership can neglect either cultural diversity or the differing organisational and power structures within the NHS. Given this diversity, an understanding of a range of leadership styles is important; the flexibility to adopt an appropriate style in a given situation or specific setting. In times of change, flexibility is an important pre requisite for effective leadership

 * Effectiveness is also about making connections between leadership, clinical innovation and organisational change. There is a need to ensure that leadership is seen as being of direct relevance to changing clinical practice. This has been emphasised in High Quality Care for All, with particular emphasis on the expectation that clinicians will assume an entrepreneurial style of leadership in instigating clinical innovation and change. In order to do this it is important to ensure that leadership is underpinned by an appropriate set of values- of particular relevance, but not exclusively, to the motivation of clinical leaders.

These are all important in developing leadership effectiveness. However, it is important to bear in mind that effective leadership is essentially embedded in the culture of an organisation. As such, it will take time to develop and nurture: it is not something that can be imposed from the top without involving those working at the clinical interface. What is needed is a more emergent approach, taking into account the need to engage meaningfully with stakeholders and the context of leadership. It is suggested that a priority should be to focus on what Alimo-Metcalfe and Bradley describe as “nearby leadership”, ie clinical leadership, thus avoiding the tendency to concentrate too much on “distant” leadership, that is, leadership at the top.