Leaders are always in the spotlight, whether they are in charge of the country, the banks or the NHS. The people at the top of organisations are rightly held to account for the performance, productivity or profit of the public services or corporations they run.
The ongoing debate about leadership in the NHS following the publication of the Francis report last month, highlights how patients and the general public assume that the ‘top person’ determines what happens in an organisation.
The Daily Mail continues to bay for the blood of Sir David Nicholson, responding to the understandable need expressed by relatives of patients so badly treated at Mid-Staffs for some kind of retribution. The more balanced and specialist press, as well as senior managers in the NHS find themselves uncomfortable in wanting to defend Nicholson without appearing to challenge the righteous indignation expressed by the relatives.
As someone coming to the end of a six year tenure as a Non Executive Director in the NHS my perception is that the NHS itself has subscribed to an autocratic style of management which can only ever be partially successful. The perception and reality of political interference in the day to day running of the NHS has led to its separation from the Department of Health in the new reforms, with Nicholson at its head. This both clarifies and intensifies the ‘chain of command’ felt by all senior management within Sir David’s sight line. For many of us who serve as Non-Executives who are not from within the NHS, his personal influence is overwhelming, and it doesn’t feel that healthy.
There is no doubt that a top down performance driven culture can achieve results. It is true that many people have been better treated, more quickly, for less cost in recent years as a result of the ‘grip’ on the ‘system’ which is the everyday parlance of NHS management. As someone who is very keen to see people enjoying better health and experience excellent services, this evidence is welcome. But it often feels hard won, and difficult to hang on to.
The NHS is an extremely complicated business, demand is growing as the population ages and technology offers more possibility for treatment and cure. We expect more, faster and we don’t really want to pay for it. The pressure is intense, and it is felt every day in every hospital, clinic and GP surgery. Strong management is only one aspect of the kind of leadership needed to deliver an excellent NHS, and on its own is not only insufficient, but as Francis has demonstrated it is very, very risky.
As in all organisations, the NHS needs good leadership to run through everything it does, like 'Blackpool' through a stick of rock. Strong management is not the same as good leadership. Strong management can be prescriptive, telling people what to do, encouraging them to wait for orders. Good leadership is empowering, encourages people to generate ideas and to respond appropriately to changing situations.
In a National Health Service we are looking for consistency, fairness and access for all, so there have to be national policies, guidance and sometimes rules. But health varies from person to person and from community to community, influenced by lifestyle, economic and social circumstances and genetic inheritance. A public service needs to respond to what it finds at the point that people ask for it, and our NHS needs to enable the doctors and nurses that we train so well to practice their clinical and caring skills in a wise and sensitive way.
I am disappointed that the NHS reforms seem to have resulted in more managerial and bureaucratic layers than they were designed to replace, but I hope that there will be more opportunity at a local level to determine excellent quality services within a national health context. I hope that leadership at the top of the NHS will recognise that it is a service, not a system and will empower those locally to serve people well.
At The Open Channel our commitment to building on the strengths in people and organisations recognises that leadership exists at every level and in public service we fulfil our purpose if we support one another to achieve our best. We are all accountable. And we have the power to succeed, if we share that power.