Leadership in the NHS: does the Emperor have any clothes?

Introduction

After 30 years of working in the NHS, and 12 years spent researching it, the rise and rise of the concept of ‘leadership’ in policy rhetoric and within the Service has been striking. The earlier rise and subsequent decline in the perceived value of ‘management’ has been equally noticeable. What is perhaps less obvious is the difference between these concepts, and the extent to which those demanding an NHS full of leaders understand the limitations of the concept they have embraced so enthusiastically. This essay explores the rise of what has been called ‘leaderism’ in the English NHS ¹ and critically examines the claims made on its behalf. I start with a sketch of the current landscape of ‘leadership’ in the NHS. This is followed by an analysis of the claims made about the benefits that the NHS will obtain from an expansion of ‘clinical leadership’, and I conclude with a slightly more critical look at the function that such rhetorical claims might be playing.

Current landscape of ‘leadership’

Martin and Learmonth ² usefully explore the rise of ‘leadership’ as a rhetorical device in NHS documents from 1997 to 2008. They highlight a rhetorical shift from the concept of ‘administration’ to ‘management’, with the former identified as ‘old and bad’ whilst the latter became ‘new and good’. Elsewhere, Learmonth has critically examined the ‘chief executive as hero’ narrative, ³ exploring the discursive work being performed by the denigration of administration in contrast to management and the subsequent denigration of management in favour of leadership. There is an extensive literature on leadership, but definitions are slippery, and it is not always clear how the desirable attributes ascribed to ‘leaders’ differ from those historically labelled as ‘good management’. For example, the NHS Leadership Academy ⁴ lists ‘evaluating information’ and ‘sharing the vision’ as two of nine ‘leadership dimensions’, whilst the website of NHS Connecting for Health ⁵ lists ‘analytical, problem solving and decision making skills’ and ‘being a strategic/visionary thinker’ as key attributes of ‘good managers’.

Claims made about leadership

Much research in this field focuses upon ‘leadership behaviours’, attempting to test the impact of these in the real world. ⁶ However, there is a danger of circularity, as researchers first define desirable behaviours that they decide constitute ‘leadership’ and then test for effect, claiming any positive impact found as a benefit of good leadership. A critical reader might ask what the concept of ‘leadership’ adds to this analysis: it is the specified behaviours which have been shown to be beneficial, and labelling these as ‘leadership’ would only have explanatory value if it were possible to be confident that these behaviours were in fact necessary conditions for the existence of ‘leadership’. This takes the analyst back to the beginning: how can we know that specified behaviours define ‘leadership’?

Martin and Learmonth ² go on to identify a further rhetorical shift, moving away from a focus on leadership training for those in ‘leadership positions’ (i.e. at the higher levels in the hierarchy) towards what has been called a ‘distributed’ form of leadership, in which staff throughout the service are exhorted to exhibit ‘leadership behaviours’. ⁷ The Darzi report ⁸ consolidated this, claiming that:

For those in formal leadership roles, such as clinical directors, a majority of their time is spent as leaders. For many, clinical practice will continue to dominate – though they will still need to work with others as partners and show the necessary leadership to keep practice up-to-date and deliver the best possible care for their patients.

Thus, behaviours historically seen as the routine requirements for professional practice (i.e. keeping up-to-date and delivering the best quality care) have here been appropriated as showing ‘leadership’.

Logically, ‘leadership’ requires the concept of ‘followers’. Dansereau et al. ⁹ put it thus: ‘In most definitions, the basic elements of leadership usually include a leader, a follower, and their relational interactions’. Much scholarship in this field focuses upon the psychology of leaders and followers, exploring their behaviour and interactions. ¹⁰ However, it is perhaps instructive to take a more sociological perspective and examine the nature of the authority relationship within which this occurs. Weber ¹¹ identifies three potential forms of authority: rational-legal, invoking rules and hierarchies; traditional, such as that enjoyed by hereditary monarchs and (one might argue) the medical profession; and charismatic, whereby leaders use their personality to inspire. A leader relying on rules and hierarchy resembles a manager, whereas the heroic leader identified by Learmonth ³ would seem to fit within the category of ‘charismatic’. What remains unclear is how those calling for ‘distributed leadership’ throughout the NHS conceptualize the ‘followers’ who are logically necessary for ‘leadership’ to be meaningfully exercised. At best, this suggests an NHS peopled by staff oscillating their identities between that of ‘leader’ and ‘follower’; more cynically, one could argue that redefining routine elements of professional practice as ‘showing leadership’ represents a rhetorical device designed to flatter rather than inform.

Martin and Learmonth ² take a critical view, arguing that, rather than ‘empowerment’, the rhetoric of distributed leadership represents an attempt by those at the centre to persuade front-line staff to discipline their own behaviour and to enrol themselves in a particular political project. Ethnographic work undertaken by McDonald ¹² would seem to be consistent with this interpretation, highlighting the extent to which staff engaged in a ‘modernisation’ project were persuaded to discipline their discourse and act upon themselves in a Foucauldian attempt ¹³ to project a (management-defined) ‘desirable self’ to their colleagues.

Critical voices such as these have been little heard in the modern English NHS. Indeed, the industry associated with the promulgation of ‘leadership’ throughout the service has expanded, such that a Google search on ‘NHS leadership’ returns references to the Leadership Academy, Leadership Framework, leadership development programmes, leadership competencies and leadership trainees. A further rhetorical shift is also evident, away from an inclusive vision of desirable leadership behaviours exhibited by clinicians and managers alike, to a narrower view that ‘the problem’ of the NHS can be understood as driven by a lack of ‘clinical leadership’. The recent NHS reforms seek to solve this ‘problem’ by embedding ‘clinical leadership’ throughout the system. An analysis of documents published between 2010 and 2012 highlights the multiple and far-reaching benefits it is claimed that this process will yield. A crude count across 36 different documents (Table 1) reveals the tone is relentlessly positive, highlighting the almost magical powers ascribed to ‘clinical leadership’. For example, a briefing paper for nurses suggests: ‘systematic and comprehensive clinical leadership across England [will] drive up outcomes, tackle health inequalities and improve value for every pound spent on healthcare’. ¹⁴

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Table 1.

Benefits claimed for ‘clinical leadership’: count of claims made across 36 briefing and other documents issued by the Department of Health and NHS England between 2010 and 2012.

Benefits claimed for ‘clinical leadership’	Number of appearances
Improve efficiency	11
Improve quality	11
Improve patient care	9
Improve outcomes	8
Enable innovation	7
Unleash potential	7
Enable partnership working	4
Improve clinical behaviour  and decision making	3
Benefit communities	3
Reduce health inequalities	2
Increase integration of services	2
Reduce admissions	2
13 other claimed benefits including increasing accountability, accessibility, responsiveness, safety mentioned at least once

A critical look at the rhetorical claims

It is probably unfair to analyse words used in this way, as most of the documents are simply communicating one simple message: the NHS in England is now in the hands of ‘clinical leaders’, and this represents a desirable shift from the failure of ‘management’. This discourse is part of a wider discourse of crisis in the NHS, in which it is claimed that the problems faced are so significant that only some kind of paradigm shift will be good enough to save us all. ¹⁵ It is not hard to see an echo here of the historical discursive shift from ‘administration’ to ‘management’.

Buried within these discourses, discursive shifts and critical ripostes are a number of issues. First, I remain unconvinced that ‘leadership’ is a distinct thing which can be learnt. This scepticism is reinforced rather than quashed by the recent discursive shift towards a model of distributed leadership embracing all. Quite apart from the practical difficulties of running a unit full of ‘leaders’, ¹⁶ I remain unconvinced that the concept of ‘leadership’ carries within it analytical power over and above the impact of the desirable behaviours that are said to underlie it. Whilst I acknowledge the existence of truly inspirational and exceptional leaders, from Winston Churchill to Malala Yusuf, the magic ingredient these individuals share has not yet been clearly defined, and indeed may never be so. Furthermore, I am not sure that trying to distil an alchemy which is so context dependent and historically situated is of much value, and I wonder if our current mania for training all and sundry to be leaders may in fact detract from the exceptional life-affirming power of real leadership. In essence, I am asking if it might not be of value to tone down the rhetoric, leaving the word ‘leadership’ for exceptional cases and returning to an emphasis on sound and careful management. We could then, perhaps, ask what the presumed benefits of having major elements of the service managed by clinicians are, and focus on those areas where clinical expertise can be truly shown to add value.

Second, critical theorists claim that much of what is happening in the English NHS is designed to enrol front-line staff in enacting a particular political project, possibly in an attempt to avoid the well-known problems associated with change in complex organizations. It is possible to take this argument further, with some commentators concerned that the more recent emphasis upon leadership by clinicians simply places them in the front line to be blamed once the inevitable consequences of the 2008 financial crash are felt. ¹⁷ Furthermore, a sceptical view of the ‘leadership industry’ might suggest that those providing leadership training have a vested interest in perpetuating the discourse. Academics can also be challenged, with careers launched and grants obtained by those prepared to accept the existence of a thing called ‘leadership’ which can be identified, taught and researched. Those currently building careers in this field should be prepared to defend their scholarship, define their terms more clearly and engage with the arguments which are being made.

Finally, it has been claimed here that one of the conditions for the current rise of leadership rhetoric is the ‘crisis’ facing the NHS, a crisis so significant that only some major shift in the way that we work can save us. Is there really a crisis? Of course, the finances of the NHS will be under severe strain, and of course, the ageing population will require us to change our services and our behaviour, but is this something that could be weathered incrementally, using some of the old-fashioned values of public service? Is what is really needed sound and careful management of a service peopled by good ‘followers’, maintaining a relentless focus on care, quality and day-to-day efficiency?