The need for an NHS Staff College

What is the nature of the issue?

‘Our lives begin to end the day we become silent about things that matter.’ – Martin Luther King

As we head into the most severe financial cuts yet experienced by the NHS, there can be no doubt, no matter what the rhetoric, that a drive to cut costs will inevitably impact on the duty of care to patients. Rather than a disaster for patient care, the timely emergence of a new cadre of clinical leaders could allow this challenge to become the NHS' finest hour.

‘A recognized but extremely rare complication results in an avoidable patient fatality. A structured debrief surfaces inadequate team safety training. Of the seven consultants in the specialty, five recognize the need for standardizing technique and implementing team training. Two of the consultants do not, and claim that the complication is just one of those things.’ (Author's experiences of anonymized NHS situations)

It is extraordinarily difficult to measure the results of leadership and yet the results of leadership seem extraordinarily important. Healthcare is dominated by the extreme, the unknown and the very improbable, conditions that demand leadership, and, yet, we spend our time focusing on what we know and what we can control. Doctors and nurses are not managed into patient care, they are led. Behaviours and values are the lynchpin of sustainable performance. People measure their behaviours and beliefs by those around them. You get the behaviours you train for. You get the behaviours you reward. Behaviours need example. Teams need leaders. Every doctor and nurse in the NHS is part of a team. The importance of effective leadership is widely recognized and yet, to date, despite numerous attempts to address concerns about leadership development, there has been limited visible evidence of success. Undeniable characteristics of a well-led, open culture are easy to recognize but deceptively difficult to implement. Chief among those characteristics are staff speaking well of each other and an understanding and acceptance of the need to tell the truth to power. These hard to measure characteristics cannot be taught or imposed, they are the consequence of enabling trust, encouraging challenge and creating commitment. They are the consequence of leadership. Organizational reputation is about promises kept by doctors and nurses in the moment of patient care versus bold and principled mission statements.

In 2001, West found strong associations between the number of staff trained to work in teams and lower patient mortality rates.¹ In a study of 61 hospitals in England, strong associations with lower mortality were found between the quality and sophistication of training, the number of staff trained to work in teams and the extent and sophistication of appraisal systems. And yet, this overwhelming evidence does not appear to have filtered into NHS boardrooms.

We propose to establish an NHS Staff College where selected leaders will be taught to express themselves, to challenge assumptions, to be innovative, to take risks, to try out new ways of doing things, to confront vested interests, to win over sceptics, to disagree openly and honestly, to manage their careers, to circumnavigate NHS politics, to do what is right, to lead. These leaders will be taught to communicate effectively and deliver organizational values, and beyond that, to performance manage expectations with a clear focus on what is right for each and every patient. In addition, these leaders will be taught to review organizational performance and capabilities, and to translate performance review findings intopriorities for improvement.

‘There are widely held, substantive concerns about a colleague's clinical performance and safety. He is nearing retirement and has a big private practice. He is generally recognized as a bully. Management seem content to do nothing and HR is ineffective.’ (Author's experiences of anonymized NHS situations)

Since the inception of the NHS, more than 30 public inquiries have been conducted to address catastrophic failures in patient care. The same common themes emerge from each inquiry: professional isolation, disempowerment of staff, poor communication, ineffective systems and processes and inadequate leadership – the most recent example being Mid Staffordshire Foundation Trust.^2,3 These recurrent lessons centred on people and relationships, poor collaboration, poor team working and a poor sense of patient-centredness.^4,5 It is almost as if a clinical conspiracy of silence prevailed at the heart of such failing organizations. It seems as if progress is elusive because culture in healthcare has not changed.

In a role defined by the unintended consequence, medical leadership rails at the limitations of straight line thinking. Reality emphasizes the folly of valuing scientific knowledge or management diktats above all else, when hard evidence so often turns to thin ice on the wards or in theatre. The seductive simplicity of a P value or a management target provides no answer to what patients actually present with – their complicated lives, their experience of suffering and their personal styles.

‘A highly performing, technically excellent, long established surgeon is systematically disrespectful, aggressively condescending and routinely abrasive and intimidating to colleagues. His behaviour undermines morale and saps enthusiasm. Medical line management and HR feel they can do nothing.’ (Author's experiences of anonymized NHS situations)

The focus must be on how doctors, nurses and other frontline staff can work together in well-led teams, rather than organizational restructuring.⁶ The recent National Audit Office Stroke Report⁷ emphasized the criticality of effective joint team working both within the specialist stroke unit and with social care to support discharge and then ongoing rehabilitation. One of the features identified as having led to a relatively successful implementation of the National Stroke Strategy was national and local leadership. Similarly, in another recent report by the National Audit Office on dementia,⁸ a similar conclusion was reached. Leadership, team working, good communication and collaboration are words that slip so easily onto the page. They are so effortlessly written and so comfortably accepted. And yet, the gap between the rhetoric of well-led teams versus the reality of the dominance of custom, practice and tradition is a consequence of confusing ease of understanding with ease of implementation. This gap reflects a values deficit where values are the moral underlying principles, the intangible character and spirit that should guide and develop the health service. Bridging that gap can only be built on leadership. The image of the medical profession continues in large part to be an idealization that reflects our medical student aspirations rather than our actual experiences. We appear to have slept-walked into a situation where salaried GPs feel less stressed than GP partners and where consultants, rather than trainees, are delivering direct patient care. This manages the known in the short term, while self-reliance and duty have been replaced by regulation and bureaucracy. And, we, as a profession, in the large scheme of things, have stood by almost, arguably, paralysed and watched this happen.

‘Patient falls, despite numerous management interventions, continue to rise.’ (Author's experiences of anonymized NHS situations)

The real obstacles to quality and safety improvement in the health service are often found in unmeasurable patient care moments and include complacency, a lack of urgency, denial, averting the gaze, arrogance, institutional blindness and an acceptance of passive learning from mistakes made. Leadership for quality and safety improvement can influence each of these obstacles by reaching into the far recesses of individual discretional energy. There is a clear resonance with the current quality, innovation, productivity and prevention programme (QIPP), which would support the concept that effective leadership provides safer services that reduces activity and makes for better and more cost-effective care.

Faced with an unyielding bureaucracy and inevitable budget constraints, organizations will tend to do what they have always done, but faster. To achieve effective integrated care, culture management is as results-critical as performancemanagement. The realities of patient experience and patient safety are less about bold and principled words than about the prevailing culture and promises kept by staff.

‘Medical record documentation is appalling and a common theme in severe untoward incidents.’ (Author's experiences of anonymized NHS situations)

Since 2000, when To Err is Human⁹ stimulated action to eliminate errors and mitigate the resultant harm in the United States and An Organisation with a Memory¹⁰ initiated similar efforts in the United Kingdom, healthcare systems worldwide have devoted considerable attention to the safety of patients. Yet, despite attempts to reduce adverse events through multilevel interventions, there has been little substantial change in the critical area of healthcare culture – an area that has the greatest potential to produce sustainable improvements in patient experience and safety.¹¹

‘Twenty two percent of ward medications do not reach patients.’ (Author's experiences of anonymized NHS situations)

Frontline staff represent what is best about our NHS. Day in and day out, on weekends, bank holidays, 24/7, 365, they do whatever needs to be done, whenever and wherever patient need arises. They deserve the very best leadership – leaders of compassion who are clearly vocationally motivated and who are transparently accountable. Leaders of character and competence who act to achieve excellence. Character is the product of our best and worst experiences. It is who we are. It is our compass and the model for our values. Real leaders know themselves and the more we know ourselves, the better we will lead. Typically, however, the job description specification to run a leadership course in the NHS doesn't include any management or leadership experience. Imagine being taught to fly by someone whose credibility was based wholly on study and analysis of flying, together with experience of education models, but had never actually flown? It is for this very reason that MBA schools are often so weak on leadership development. If ever there was a need to systematically develop NHS leadership, now is the time.

NHS organizations have countless stories about real doctors and nurses who faced excruciatingly tough decisions, where the conditions were not supportive and action needed to be taken, and often was, but more often was not.

What could we do even better?

There is an abundance of high-flown rhetoric, jargon and management-speak written around leadership. There is simply no easy way to develop those critical leadership skills. No matter how able you are, it is a set of skills that you can only acquire by doing. Leaders liberate others to be honest with themselves so that they can find the inner strength to do what they would rather not do. Medical leadership is no different. All too often the development programmes that exist do not achieve these desired results.

How, as a doctor or nurse, do you make your caring relevant? Good care, badly delivered, is always diminished. What is the point in keeping your head low, because you feel you can't influence, when at some point in the future, that ‘averting of your gaze’ will come back to haunt you?

Leadership lifts people above their ordinary, personal wants and self-interest. It moves them beyond the material considerations of reward and coercion. It is leadership which motivates others to do more than they originally intended and often even more than they thought possible. Leadership comes to the fore in times of turbulence and change when people need to be shown a new way ahead even if their instinct is to stick with the familiarity of the old, whatever its cost.

In every organization there are hidden barriers to individuals doing their best. People are not contributing fully because they are unconsciously or consciously sidelined by others. These barriers are derived from the organization's culture, the team dynamics and personal and interpersonal experiences. An effective leader would clearly understand the culture that they are operating in and be able to navigate and influence it through behaviour. It has often been said that culture eats strategy for breakfast – it doesn't matter what wonderful and seemingly inspirational documents are produced to inspire and motivate frontline staff, if ‘the way things are done around here’ isn't aligned to the objectives of those documents, then whatever improvement programmes are planned, they are designed to fail. If patient safety and quality are not seen as an excellence to be achieved, then they will be seen as a standard to be complied with. Aptitude for leadership is not synonymous with the ability to lead – there are many individuals who have, on paper, everything that a leader should have to be successful. What they often don't have is that inner strength from which they derive the courage and the will to act as they would wish to, particularly in adverse circumstances. Leadership programmes, more than anything else, should identify truths that help us cope with life as a leader. Many so-called leadership programmes are, in fact, management programmes, which can be defined as courses that provide the tools required to manage money, resources and people. Such courses are essential, but of limited value if not coordinated and directed by a leader.

Leadership is energizing people through motivation and inspiration – not by pushing them but by pulling them through satisfying basic human needs for achievement, a sense of belonging, recognition, self-esteem, a feeling of control over one's life and the ability to live up to one's ideals. Such feelings touch us deeply and elicit a powerful response. They are not the product of an MBA. They are not the product of a clever 10-module syllabus. They are the product of leadership training and, crucially, experience that is delivered by leaders for leaders. The NHS Staff College can respond to this significant unmet need.

The NHS has had a massive increase in funding over the last decade but has failed to deliver better services proportionate to that investment. The question arises as to whether this is because that investment has primarily gone into the physical component of health delivery. It is accepted in the military that the best tanks in the world are useless if the soldiers manning them have no will to fight and are poorly led. An NHS Staff College, properly developing leadership and ethos and directly addressing the conceptual and morale components of health delivery, would accrue returns for the NHS out of all proportion to the investment required to run it. If the individuals, who by nature of our organizations are our greatest resource, are neglected, the cost incurred will be a lost battle or a Mid Staffordshire debacle. If we develop our staff, they will regularly exceed all expectations.

Practicalities of the Staff College solution

The NHS Staff College will aspire to encourage and equip the present and future leadership of the NHS to continually put the best possible care for the patients, staff and the public we serve at the very centre of their personal and corporate endeavour. They will be leaders who care passionately about the development of their own leadership skills and of those with whom they work and have responsibility for.

What will differentiate the Staff College leadership development from other leadership initiatives will be taking people out of their comfort zone and then building them back up with the fundamental blocks in place. This leadership development programme will also be different in that it will deploy the well-tried technique of teaching the fundamentals of leadership by those they will be leading. This programme will recognize that making tough decisions is often a lonely place and will seek to improve the sense of isolation that some people find themselves in when making those difficult decisions.

This will be an elite course, drawing students, directing staff, visiting contributors and key-note speakers from among the very best. There will be a strong commitment to learning from the experience of those who have excelled in the past; while developing skills that will be fit for purpose in the future.

The critical objectives of the NHS Staff College will be to equip individuals, within an NHS leadership framework, with both personal and institutional leadership skills.¹² At the heart of the taught modules and curriculum will be four fundamental strands of leadership development:

1. Self-awareness: A series of exercises, immersive simulations and observations, which will allow delegates to get to know themselves through personal insights and relate these insights to how others see them. They will learn to recognize their recklessness, timidity, ego, emotions and their need for popularity.

2. Self-management: Among the most challenging hurdles for leaders to overcome is their ability to manage their own egos. These challenges come upon us in the most unlikely moments. This module will build on their self-awareness and employ that understanding to manage stressful and often uncertain moments, with targeted acquisition of skills to overcome the usual blocks of status quo inertia, limited resource, demotivated staff and opposition from powerful vested interests. The foundation methodology underpinning the self-management module is immersive simulation with structured feedback through expert facilitators, filmed scenarios and peer review.

3. Leading the team: To achieve effective integration, the philosophy within teams must be team-centred, not self-centred. The culture has to move towards task conflict good, personal conflict bad. Once the beliefs and energies of a critical mass of people are engaged, conversion to a new idea will spread like wildfire. This module will combine self-awareness and the ability to manage moments of personal challenge to deliver team-leading capability.

4. Big leadership: This final module will combine the self-awareness, self-management and the delegate's ability to lead a team across a wider scope. This will allow them to explore how a combination of all they have experienced can support their ability to work outside of their normal environment, to influence policy, to see opportunity and to manage upwards.

Delivery of these objectives will be through a combination of personal development as leaders and development of the skill-set required to deliver consistent, sustainable performance. Personal development will be reinforced by mental attributes including the will to persevere, self-discipline, initiative, sound judgement and self-confidence. Core leadership values and ethics will be a consistent theme throughout.

The initial phase of the Staff College programme will comprise an off-site introductory briefing with, subsequently, a modular programme with an experiential theme underpinning throughout, with performance, simulations and role play exercises assessed not just against results, but against leadership performance (the ‘how’ will be measured as well as the ‘what’). There is an opportunity in this NHS Staff College initiative to set a new global standard in the development of healthcare leaders.

Recently, the Institute for Health Improvement, the American Joint Commission and the Rand Corporation concluded from three separate surveys across the NHS that there was a damaging rift between doctors and managers, i.e. that general practitioners and consultant contracts had de-professionalized and have had the peculiar effect of simultaneously demoralizing and enriching doctors. It was suggested that vocation is being managed out of healthcare professionals and that there is a tendency towards working to rule. These reports concluded that there was a culture of fear and slavish compliance. Inadequate leadership is a relentlessly recurring theme. If we always do what we always did, we will always get what we always got. The time is ripe to introduce an NHS Staff College.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor AH

Contributorship AH is the sole contributor