‘New’ and distributed leadership in quality and safety in health care,or ‘old’ and hierarchical? An interview study with strategic stakeholders

Introduction

Despite sustained effort over the last decade, health systems worldwide, including the UK National Health Service (NHS), are faced with evidence of serious deficits in the quality and safety of care delivered to patients. ¹ Investigations into high-profile failures – including those of Mid-Staffordshire NHS trust – have repeatedly emphasized the importance of leadership in securing and improving quality and safety. ² It is one thing to identify the importance of leadership; it is quite another to achieve clarity and consensus on the ideal forms of leadership and to put them into practice.^3–5 The academic literature on leadership is extensive, but different studies use different definitions that may compete, conflict or overlap (for example, in the way they distinguish management from leadership) ⁴ and many terms are used loosely or in different ways in different contexts. ⁶ The field is further complicated by lack of a high-quality evidence base. ⁷

Despite the fierceness with which some of the debates in the academic literature are fought, remarkably little is known about the views of those in senior positions in relation to quality and safety in the NHS on the precise form leadership for improvement in health care should take, who the leaders should be, and how they should enact their leadership role, nor is it clear the extent to which their views conform to or contest the features of academic debates. This is not a trivial problem of interest only to scholarship, but one with real practical implications. Clarity about leadership in an era of large-scale institutional reform and associated uncertainties has important implications for who commits to leading quality and safety, how direction is set and what gets prioritized by whom. In this article, we report an empirical study of the views of stakeholders in senior positions. We explore how they talk about leadership for quality and safety, including how far their views align with or oppose prominent debates in the academic literature.

We begin by outlining some of these debates, including the tension between ‘old leadership’ and ‘new leadership’. Old leadership is typically constructed as the heroic acts of single individuals usually in powerful positions at the tops of organizations, who exercise skillful and creative managerial techniques. ⁸ Newer conceptualizations of leadership, by contrast, see leadership as a property shared by multiple individuals, who may or may not be positioned at the top of a hierarchy. ⁸ Here, leadership is not a direct product of positional authority or use of particular methods, but rather of skills, character traits and relationships that can be deployed contingently by a breadth of individuals, depending on the task in hand. ⁹ Leadership may thus be ‘distributed’ through multiple levels of organizations rather than hierarchically ‘concentrated’ in a small number of hands. Distributed leadership is achieved through a wide variety of individuals and is conceptualized in terms of the act of leading rather than role positioning.^3,10

New and distributed leadership is claimed to have several advantages in the pursuit of improvement, especially in public service fields characterized by complex problems that cross the boundaries of organizational responsibility, multiple professional groups with divergent identities, norms and accountabilities, and ambiguous or multifaceted aims. ¹¹ An overreliance on older, concentrated leadership is argued to limit the scope and impact of efforts to lead, perhaps by failing to cross institutionalized boundaries between professions, clinical areas and organizational units. ¹² This can be especially problematic in fields such as quality and safety, where improvement relies crucially on the conjoint effort of multiple parties separated by such boundaries.^13,14 Thus, an influential account argues that efforts at improvement in health care are especially prone to failure when they rely too heavily on old leadership rather than recognizing, valuing and mobilizing new forms of leadership that are distributed throughout organizations.^8,15–19

The reasons why leadership may need to be distributed across multiple groups and multiple levels lie in the range of stakeholder groups, both professional and managerial, who occupy the institutional territory of health care and have a stake in issues of quality and safety. ²⁰ All may have an important role to play in modern, multidisciplinary health care organizations. ¹⁴ However, distributing leadership in order to improve quality and safety is far from straightforward. Different professional and managerial groups often endure an uneasy co-existence, their interests competing amid messy power relations.^10,15 Unless carefully managed, distributed leadership may give rise to a ‘nobody in charge’ model ¹⁰ or the mere re-badging of activities and roles as leadership. Either may result in the dissonance and disenfranchisement of those drawn into leadership, but without possessing any power to lead. ³

Given the risks of a descent into disorganized and rivalrous tensions or inauthentic rebranding exercises, how far it may be possible to distribute leadership in order to engage, value and give respect to the contributions of those who seek to secure patient safety and quality of care is not clear. However, few studies have invited people closely engaged with health care delivery in the UK to talk directly about their interpretations of leadership in relation to quality. As Jackson and Parry ²¹ point out, ‘everyone wants to talk about leadership’, but less is known about what is being said and interpreted and what implicit models of leadership are current or potent. Leadership may be a pervasive discourse among policy makers, ³ but how far the notions of new, ‘post-heroic’ or distributed leadership have salience among those involved in managing and delivering services is unknown. ²¹ Indeed, some studies identify a discernible gap between normative notions of leadership and roles as they are enacted. ²² These are important and current problems, given that remedial prescriptions for leadership as the solution to problems of quality and safety are often vague and aspirational, and have been criticized for failing to take account of contextual contingencies and institutionalized constraints on the possibility of leadership.^22,23

In this article, we take the view that ‘talk’ about leadership among those given the mantle has been under-described, even though the accounts of people charged with improving quality may allow a more realistic picture of the possibilities and limitations of leadership to emerge. We sought to investigate, through a large-scale interview study, how strategic-level stakeholders across the NHS talk about leadership, including, in particular, the extent to which such talk reflects or contests the ideas that feature in the academic debates around old, new, concentrated and distributed leadership.

Methods

This study was conducted as part of a large multi-level, mixed-method research project funded by the Policy Research Programme for the UK Department of Health. For this study, interviews were conducted with 107 NHS stakeholders in England and Wales and other experts across the UK with a strategic-level interest in patient safety and quality of care. Individuals were purposively sampled from public sources (including websites and conference brochures) and through extensive snowballing. All were selected as a result of close involvement in quality and safety either through their posts, specific initiatives – either local or national – or through their involvement in research and commentary. We asked respondents questions about aspects of delivering quality and safety improvement in health care, including what they understood a vision of the delivery of high-quality, safe care to comprise; what was required to make it happen; and what theories of change and quality improvement they are deploying. We also asked about how improvements could be secured and what stands in the way. Though issues of leadership permeated many responses, two specific questions honed in on leadership and governance: first, who was leading the initiative for quality and safety in the NHS and second, who should be doing so?

An interview topic guide was developed through literature review and discussions within the project team and was customized to capture the diverse stakeholders. We grouped participants broadly into stakeholder types (Table 1) though many had composite roles. Interview participants included senior NHS executives, for example chief executives, medical and nursing directors, executive and non-executive directors, trust chairs, front-line staff, clinical directors, directors of clinical governance, Strategic Health Authority managers, quality and patient safety managers and NHS commissioners. We also interviewed individuals from UK public and independent policy bodies and senior university health care researchers (described here as commentators). NHS respondents came from across England and a range of trusts. Many held combined positions as clinician managers. Several who were involved in commissioning had also had lengthy clinical careers and some academics had held NHS posts. All the commentators had specific research knowledge of quality, patient safety and health care management. Interviews took place over a period of 12 months from January until December 2011.

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Table 1.

Participant profile.

Stakeholder role	Number of participants	%
Managers who were also Clinicians	47	44
Managers	18	17
Clinicians	15	14
Commentator (e.g. from academic  and charity sectors)	13	12
Commissioner	7	7
Manager/Commentator	4	3
Commentator/Clinician	3	3
Total	107	100

Interviews were transcribed verbatim. Analysis was based on the constant comparative method. ²⁴ We worked collaboratively to agree an interpretative framework, making use of some sensitizing concepts ²⁵ drawn from the literature on leadership quality and safety to supplement our interpretations. We conducted close and systematic reading of the transcripts and independent coding by two researchers to extract themes and patterns of responses across all interviews – first, following the order of the interview schedule and questions, and second, by reading within as well as across cases, to appreciate responses by each respondent as well as across the group. Given constraints of space, for this article, the analysis is mainly at the broader level of typical or dominant aggregated thematic responses across all participants and is not further broken down by categories of respondents. Coding was supported by NVIVO 8 software.

Research ethics committee approval was received for this study. Participants’ identities have been anonymized.

Results

We discuss our findings in three sections. First, we give an overview of the accounts of leadership and its place in improving quality and safety given by participants, noting the primacy given to leadership and the value of working to distribute leadership. Second, we show that participants reported that spreading of leadership responsibilities at national level risked creating a vacuum of authority, leaving some confusion. Third, we suggest that enthusiasm for distributing leadership at organizational level was tempered, with participants arguing for the enduring importance of old, concentrated forms of leadership alongside newer forms.

Discussion

By listening to senior stakeholders’ talk about leadership, we have been able to identify the implicit concepts and views of leadership that people in the NHS use to guide practice and make sense of reality in complex health care contexts. Our analysis shows that a shift to ‘new’ leadership needs, in the view of these stakeholders, to be balanced and complemented by direction-setting at a national and unit level; hierarchical approaches most commonly characterized as ‘old’ leadership are thus seen as having an enduring and useful role. We have also been able to assess how far these understandings are consistent with current academic debates around leadership for quality and safety in the NHS. We have identified participants’ sophisticated arguments for combining the best aspects of old and new, concentrated and distributed leadership in ways that are situationally specific and contextually sensitive. Participants were clear and explicit that all staff in the NHS needed to have responsibility for patient safety and quality, and that staff at the sharp end of care have important leadership roles. But they were equally clear that distribution of leadership could go too far, and that retaining a clear focus and priority for patient safety and quality required visible, coherent leadership and an ongoing role for top-level, visionary leadership with positional managerial authority founded in hierarchical structures. Furthermore, they emphasized that clarity and coherence needed to be reproduced at every level of the health service. Thus, from the ‘blunt end’ ²⁶ of regulation through every level to the sharp end of practice, participants stressed that staff should not be expected to answer to competing, conflicting or duplicative requirements or information requests. In this context, the lack of clarity that participants reported about who leads and who should lead quality and safety, which national organizations hold responsibility, and who is accountable and at which organizational levels, is troubling.

The multiple notions of leadership devolution and pluralization suggest a nuanced, advanced and practically grounded conceptualization leadership on the part of study participants, showing awareness of the operation of power, hierarchy, medical hegemony, context and systems. ²⁷ Participants mainly avoided giving naïve or simplistic answers about any single, preferred type of leadership. Of particular note in this context are the nuanced examples given of how old and new leadership could best interact to create a culture that both valued quality and safety and could take the practical action needed to secure improvement.

Thus, though participants acknowledged the benefits and value of distributed leadership, they also suggested that it risked neutralizing the focus for getting things done: ‘everybody’s business becomes ‘nobody’s business’. They saw interaction between leadership based on (managerial) authority and leadership distributed to individuals as crucial. Sometimes – as in the example given by a senior nurse – a managerial role could be made more ‘leaderly’ by embracing different styles of direction and instruction that emphasized learning and leading by example. At other times, it was clear that new forms of leadership, involving devolution to distributed leaders who lacked positional authority but possessed contextual knowledge and local credibility needed to be backed up, underwritten and occasionally enforced by old forms of leadership. There was expansive talk about, and considerable endorsement for, the empowerment of a wide cadre of leaders, especially clinical leaders. Particularly evident was a valuing of managerial–clinical partnerships and shared leadership rather than toleration of historical conflict or division, consistent with analyses identifying that increasing clinical engagement in leadership is an important device for minimizing conflict.^8,17

Thus, rather than the progressive linear shift implied by notions of ‘old’ and ‘new’ leadership, these stakeholders’ experiences suggested to them that while distributed, ordinary leadership was vital, so too was tying it into managerial authority and hierarchical infrastructure. Rather than romanticizing ordinary leaders, ¹⁰ leadership of complex systems was seen to require managerial clout and administrative nous.^28,29 These participants’ experiences had, perhaps, sensitized them to the institutional context ¹⁰ for leadership and led to the view that distribution of leadership responsibility, on its own, could have adverse or even perverse unintended consequences. For participants in our study, what was required was an approach to leadership that blended elements of old and new. This suggests that terms ‘old’ and ‘new’ in themselves may be perverse, disguising the complexity of the need for the co-existence and exercise of multiple and simultaneous forms of leadership.

This study has a number of limitations. It was based mainly on the accounts of senior level stakeholders and thus had few frontline line or junior representatives and no patients. The study sample used snowballing with its attendant risks of self-selection of ‘like-minded’ or of highly informed and engaged individuals in the network of respondents. The accounts are time-bounded and collected between January and December 2011, in a time of heightened organizational uncertainty (before the passage of the new Health and Social Care Act). We have not collected empirical data on leadership performance and have focused only on accounts. Given the focus of our study, we did not collect any data on the leadership training and development backgrounds of our respondents and thus cannot directly trace the influences of formal exposure to leadership models and theories. ³⁰

The value of our interviews is that they span a diverse set of NHS contexts and different types of NHS organizations. In a system characterized by shifting services, intense reconfiguration of organizations and movement of key people, questions of who should be doing what kind of leadership, and what helps and hinders, become all the more pressing. With the fast pace of structural reform and redesign occurring in health systems, ensuring that improvement efforts are not damaged by a leadership collapse or dilution is a key goal. The story from this research is that the participants welcome the distribution of leadership but it is not without risks. A clearer national steer – including perhaps a concentration of leadership – and pragmatic local use of a combination of ‘old’ and ‘new’ leadership styles are seen as important. Above all, the testimony of these stakeholders shows how the enactment of policy and academic prescriptions for new forms of leadership must be informed by the sophisticated and pragmatic know-how of insiders who are aware of to make them work in organizations that remain permeated by traditional structures, cleavages and power relationships. Such knowledge will have increasing relevance in the search to find the forms of leadership influence that can drive improvement in quality and safety in such an uncertain context. ³¹