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JMM
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Journal of Management in Medicine,
Vol. 16 No. 1, 2002, pp. 34-47.
#
MCB UP Limited, 0 268-9235
DOI 10.1108/02689230210428616
Lea dership dev elopme nt in
hea lth care: what do we
know?
John Edmonstone
Centre for the Development of Nursing Policy and Practice, University of
Leeds, Leeds, UK, and
Jane Western
NHSP, Barrow Hospital, Bristol, UK
Keywords National Health Service, Leadership, Health care, Model, Development
Abstract The NHS in England has developed a strong focus on clinical and managerial
leadership. The article describes both e merging ideas on leadership models and approaches to
developing leaders as a background to the description of two evaluation studies of leadership
programmes for executive directors and the lessons learned for the future.
The NHS plan for England stimulated the creation of the leadership centre for
health as part of the modernisation agency. The plan mentions a range of
proposed new leadership d evelopment priorities and the leadership cen tre also
inherits a ``suite’’ of existing leadership programmes. The plan states that:
``Leadership development in the NHS has always been ad hoc and incoheren t
. . . That will now change’’ (DoH , 2000).
Recent commentary on this initiative (Goodwin, 2000) noted that th e NHS
has already spent millions of pounds on leadership development, although the
precise amount was unknown. Evaluation of such programmes had, until
recently, been non-robust and at best anecdotal. Historically the NHS had
focused primarily on individual skill development with managers (and
increasingly clinicians) learning about leadership ideas and skills, invariably
delivered by externally-provided programmes and offering little which was
specific to the local challenges facing individuals. Goodwin suggested that it
was increasingly inappropriate to concentrate on the individual’s ability to lead
and that instead there was a need to dev elop a ``local leadership mindset’’. He
suggested that leadership development should be:
mandatory ± not ad hoc or optional;
locally-focused;
based around action learning approaches;
concentrated on inter-organisational and shared leadership b etween
organisations, rather than ``leader/follower’’ relationships within
organisations.
This article seeks to describe a number of emerging leadership models and
development approaches as a context to describing the methodology, process
T he cu rre n t iss u e a n d fu ll t e x t a r ch iv e o f th is jo u rn a l is a v a ila b le a t
http://www.emeraldinsight.com/0268-9235.htm
Leadership
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35
and results of two evaluation studies conducted on leadership development
programmes for executive directors within the NHS and the lessons learned
from that experience for the future.
Emerging leadership models
As a large public bureaucracy the NHS has historically been marked by an
emphasis on management rather than leadership. Management can be defined
as the application of learning already in ha nd to address situations in which
that learning is sufficient to meet the challenges. Leadership, by contrast,
enables people and organisations to face adaptive challenges where new
learning is required.
This emphasis on management has gone hand in hand with a set of seldom-
questioned assumptions regarding the legitimacy and pervasiveness of
hierarchy and with so-called ``heroic’’ leadership located withi n the upper
echelon s of the organisation. This approach risks ignoring both the vast
majority of middle and ju nior managers and clinical professionals who (in this
world view) are seen to be simply dependent ``followers’’ rather than leaders in
any sense themselves.
A second underlying assu mption of this app roach is that by equipping
individuals with the means of developing their personal power and influence,
more effective leadership will be created, rather than preparing people for a
future in which task s are increasingly complex and ``messy’’ and which will
involve typically working collaboratively with o ther professions and agencies,
often with no direct (hierarchical) management control ± only the capacity to
foster collective identity, interdependence and collaborative accountability to
diverse stakeholders. It may therefore be an entirely inappropriate approach
(Hunter, 1998).
This transactional leadership approach (Alimo-Metcalfe, 1999) with its’
``command-and-control’’ or ``engineering’’ assumptions ± based on notions of
legitimate power and control; a task-orientation focused o n short-term targets;
an emphasis on resource use and com fort with the rational and quantifiable ±
is an indication of how far many organisations (and particularly public sector
organisations) in the UK are wedded to the machine m etaphor (Morgan, 1986)
in thinking and acting . The transactional approach is als o heavily gendered
(Rosener, 1990), with research suggesting tha t male preferences tend to equate
power with formal authority an d the guarding of information, while female
preferences are more in favour of an interactive style, the sharing of power and
information, an d an emphasis on personal influence and the enhancement of
self-worth. A UK study (Alimo-Metcalfe, 1995) expressed it, as shown in
Table I.
A powerful and emerging alternative view (Bate, 1994) is that leaders cannot
control or manipulate the culture of their organisation, but can only influence
and shape that direction as it emerges. This is because leadership is not an
individual but a collective activity ± there are limitations on what any one
person can achieve because organisational culture is a social, not an individual,
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phenomenon. This view o f leadership as a collective cultural activity is
consistent with the notion of transformational leadership which argues (Kouzes
and Posner, 1995) that leadership potential exists at all levels of an
organisation, is shared across large numbers of people and is ``everyone’s
business’’. This approach is based upon empowerment and change, challenging
the status quo, creating a new vision and exciting the creative and emotional
drives of individuals to ``st rive beyond the ordinary to deliver the exceptional’’.
The notion of shared or distributed leadership (Brown and Beech, 2000) sits
comfortably with recent developments among clinical professionals in health
care. For example, both shared governance (Edmonstone, 2000) in acute
hospital services and the creation of self-managed teams in community nursing
services (Baileff, 2000) both emphasise the significance of ``nearby’’ as opposed
to ``distant’’ leaders ± the former being mor e typical of the transformational
approach and the latter being more typical of the transactional approach
(Shamir, 1995), as shown in more detail in Table II.
The dangers of dualistic approaches such as transactional/transformational
or distant/nearby is, of course, that they suggest a simplistic either/or choice.
This is not the case in practice and Kotter (1990) suggests a model (shown in
Figure 1) showing those situations when transactional and transformational
leadership are needed.
In the emerging NHS, where both the amount of change needed a nd the
complexity of the organisation are likely to be high, there will be a need for both
transactional and transformational leaders, but as has been pointed out
(Hunter, 1998) previous NHS management development activity developed the
former at the expense of the latter, of whom there is now a dearth.
Table I.
Gender and leadership:
UK research
Male constructs Female constructs
Gives clear directions Relates to others on an equal level
Confident Strong and supportive
Career driven Concerned to take people with them
Clarity of purpose Recognises that delivery r elies on others
Organised Self-aware
Cerebral Honest with own values
Table II.
Differences between
``nearby’’ and ``distant’’
leaders
Nearby leaders Distant leaders
Dynamic, active, sociable Have rhetorical skills, an ideological orientation and a
sense of mission
Open and considerate Persistent and consistent in pursuing their vision
Expert and intelligent Courageous in expressing opinions without fearing
criticism
Original and unconventional
Set high standards
Leadership
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37
Leadership development
Much previous leadership development in the NHS (Goodwin, 2000) has been
conducted through off-the-job development programmes run by external
providers. There are a number of problems associated with such an approach.
In addition to the focus (highlighted above) on individual skill development and
on learning about, rather than learning to:
It has often been patchy in provision with less than full coverage, as some
health care organisations opted out due to task pressures or local
alternative arrangements and as some individual participants put local task
accomplishment before programme-based leadership development activity.
There are problems associate d with contractual working, chiefly the
slow-moving and cumbersome means of providers responding
adequately to a rapidly-changing health care environment and the
problem of ``up-to-dateness’’ of external staff.
As a result of the NHS modernisation agenda embodied in the NHS plan, work-
based development activity has become increasingly popular. This includes
those approaches which are based on learning from:
(1) Another person:
coaching;
mentoring;
role models.
(2) Tasks:
special projects;
job rotation;
attachments;
secondment;
shadowing;
acting up/across.
Figure 1.
When different types of
leadership are needed
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(3) Others:
task forces/working parties;
action learning;
networking.
Yet recent commentators (Woodall and Winstanley, 1998) suggest that there
are also dangers with work-based approaches, including:
Skilled mentors being few in number, in great demand, and subject to
career movement.
Performance management systems not being development-focused, at
both individual and organisational levels.
Immediate line managers being invariably task focused, rather than
development orientated.
Work-based development often being an informal and incidental
activity, and the time and support needed by learners to ``tease out’’ the
learning not bein g recognised.
The conclusion was that there existed ``fashion swings’’ between work-based
and off-the-job d evelopment activities and that added value lay in recognising
that they can be complementary and mutually reinforcing.
Evaluating executive leadership development: context and
methodology
Between 1997 and 2 000 the authors undertook th e evaluation of two regionally
based leadership development programmes for executive directors of NHS
trusts and health authorities. They were the Trent Leadership Development
Programme (TLDP), which ran from 1997 to 1999, and the Northern and
Yorkshire Board-Level Development Programme (NYBLDP), which spanned
the 1998 to 2000 period.
TLDP
TLDP was run in three cohorts b etween June 1997 and Ma y 1999, and was
delivered by the Centre for Leadership Development at York University. Just
under 200 board-level directors within Trent region took part in a programme
which was largely funded by em ployer subscription, with ab out two-thirds of
NHS employers in the region taking part ± plus financial support from the NHS
Executive’s Development Unit. The programme had been debated for some
years prior to it being commissioned through a process of competitive
tendering. It took place against the context of a new Government, trust
mergers, the appointment of a new generation of non-executives and the
creation of a significa nt change agenda, particularly in primary care. During
this period a national NHS leadership programme for chief executives was also
launched and the importance of clinical as well as managerial leadership was
increasingly being recognised.
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There was a major emphasis on the fact that TLDP was a ``programme’’
rather than a course, with the latter being regarded as fragmentary and
piecemeal, while the former was seen as more integrated and cohesive . The aim
was to encourage a self-development approach for executive directors and the
programme structure was made up of:
Development groups. T hese were action learning sets of seven people
meeting with a facilitator bi-monthly on five occasions, basing their
work on each participant’s personal development plan.
Personal mentoring. A m entoring ``pool’’ wa s created, mentors t rained
and each participant offered this facility.
Learning network. T hrough whole-group conferences and single-issue
workshops p articipants were expected to enrich their personal and
professional networks across professions and organisations.
The programme represented a complex and sophisticated approach to the
development of senior managers, and the number of stakeholders with an
interest in the outcomes of the programme was wide and varied. It was
therefore deemed too simplistic to evaluat e only the provider’s delivery of the
programme and the participants’ immediate experience of it as the sole basis
for determining its success. Moreover, there was a need to provide early
feedback to the provider and the stakeholders to enable them to make
``steering’’ adjustments for each programme ``cohort’’. The distinction between
formative evaluation (providing feedback to peo ple who are trying to improve
something) and summative evaluation (providing information for decision
makers who are considering whether to fund, ter minate or continue to support
something) (Scriven, 1980) was seen to be a useful one and the evaluation team
adopted an approach which was:
Holistic. It took into account the views of chief executive sponsors, the
programme steering group, programme participants and the provider
organisation, as well as a number of key variables with an influence on
the participants’ experience.
Based on the degree to which the expectations and planned outcomes were
achieved.
Thus the evaluators based t heir approach round that of impact evaluation
(Harper and Beacham, 1991) and the intention was to be:
Focused enough to identify and demonstrate the benefits of the
programme to the subscribing organisations and the return they
received on their financial investment, based upon their expectations
and objectives.
Wide-ranging enough to provide an objective analysis and assessment
of the progress of the programme in producing the desired and expected
outcomes.
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Rich enough in terms of the number of people involved to demonstrate
the extent to which individual and organisational aspirations had been
met.
In order to gain the broadest possible view of the expectations and planned
outcomes of the programme, a series of one-to-one and telephone interviews
were held in the autumn of 1997 with the provider, sponsors, participants and
steering group members. This produced a vast amount of information which
shaped the evaluation framework adopted.
The evaluation subsequently involved:
(1) Cohort 1.
The administration and analysis of a structured questionnaire to all
programme participants.
Ten one-to-one interviews with participants and sponsors.
Fifteen structured telephone interviews with participants and
sponsors.
This took place in March-April 1998 and the formative evaluation
report was published in May 1998.
(2) Cohort 2. As for Cohort 1. The evaluation work took place in November-
December, 1998 and the report was published in January, 1999.
(3) Cohort 3. Due to a degree of repetition in the findings to that point a
revised format was adopted of:
Eight one-to-one interviews with participants only.
Two one-to-one interviews with steering group members.
Administration and analysis of the structured questionnaire to all
cohort participants.
Focus group discussions with participants and facilitators on the
final session of cohort 3.
An invitation to facilitators to write to the evaluators in response to a
number of ``trigger questions’’ derived from the evaluation work thus
far.
Discussions with the NHS Executive Development Unit.
This evaluation work was undertaken in May-June 1999 and the third
formative report published in July 1999. The final summative report,
drawing upon the sources outlined above, was published in August,
1999.
NYBLDP
In or der to meet a similar identified need for leadership development for people
working at board level, the Northern and Yorkshire region decided to create a
programme aimed at the same target group. However, there were important
Leadership
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differences between this experience and that of Trent. Northern and Yorkshire
had been formed in 1996 out of a merger between the Northern region and the
Yorkshire region. The former had based leadership and management
development around the annual funding of a quantum of places on the Durham
University Business S chool MBA programme, while the latter had developed a
suite of leadership programmes for managerial and clinical staff provided by
the Centre for Leadership Development at York University. Following a
competitive tendering exercise, the contract was awarded to a partnership
between these two HE institutions.
NYBLDP ran over two years (1998-2000) with a maximum intake of 100
participants a year in two cohorts. The design comprised:
A one-day launch event.
A development centre event based on agreed competences, the outcome
of which was a personal development plan for each participant.
A core taught programme, made up of short (one or two-day)
modules on such topics as leadership, new public s ector
management, managing information and managing organisations
and alliances.
Optional modules, to meet specific needs.
Action learning sets.
A ``graduation day’’ to review th e programme.
The programme was funded on the basis of 75 per cent top-slicing out of health
authority budgets and 25 per cent directly from employing organisations. The
evaluation study was asked to cover the same ground as TLDP, but specifically
to assess:
How far and how efficiently the stated aims of the programme had been
achieved.
What the individual learning from the programme was.
Whether learning had been applied in the workplace, resulting in
performance improvement.
What lessons were to be learned from running such a programme.
The evaluation therefore involved:
(1) Cohort 1:
A structured questionnaire was designed, administered to all cohort
members and analysed.
One-to-one interviews were conducted with three stakeholders, four
participants, a facilitator and a sponsor.
A telephone interview was conducted with the steering group chair.
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The universities’ own evaluations of the mo dules were shared with
the evaluators.
A formative report was published in January 2000.
(2) Cohort 2:
The questionnaire was used again with all cohort members.
Telephone inverviews were conducted with four participants, a
facilitator, the steering group chair and representatives of the two
universities.
The universities’ module ev aluation results wer e again shared.
The participation levels in the pr ogramme of all employers in the
region were analysed.
The second formative report was published in September 2000 and a
final summative report in October 2 000.
The two programmes thus had some impo rtant similarities and some
important differences:
In both the self-development of executive directors was a major
emphasis.
Action learning sets featured prominently in both programmes
Both programmes were delivered by higher education institutions.
Both programmes were largely employer funded.
In bo th cases there was partial take-up of available places by employers
and participants.
Both programmes took place at a time of intense change.
However:
Only one of th e two programmes began with a diagnostic development
centre.
One programme featured mentoring prominently, the other did not.
Taught material featured strongly in only one of the two programmes.
One programme was d elivered by a consortium of tw o HE institutions,
while th e other was delivered by one.
One region had a hig h degree of continuity, while another was newly
created as a result of a merger.
Learning from the evaluation studies
Rather than concentrating on the local learning specific to each of the
programmes, this article focuses on the generic findings from the ev aluation
process, under seven headings:
Leadership
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(1) The need for a common vision of leader ship.
(2) Design issues.
(3) The need to lead leadership development effectively.
(4) The need to ensure a ``multiplier effect’’ by ``dovetailing’’ activity.
(5) The problems of contractual working.
(6) Geography.
(7) The question of individual or organisational benefit.
A common vision of leadership
The results of both evaluation studies suggested that there was high a degree
of ``conceptual fuzziness’’ among all stakeholders on such matters as the
difference between leadership and management, the distinctions between
managerial and clinical leadership a nd the relationship between them,
understanding of transactional and transformational leadership approaches
and the contrast between command-and-control and shared/distributed
leadership. There appeared to be a strong need for much greater definition,
coherence and calibration ± for ``joined-up’’ thinking and action in the
leadership field over such matters as:
The overall purpose of leadership development ± what is it for?
The underlying conceptual framework.
Where the balance should lie between developing existing and future
leaders.
What the balance should be between transactional an d transformational
leaders.
The differences and similarities between leadership in clinical and
managerial settings.
Issues of ``equivalence’’ between leadership in smaller a nd larger
organisations in the context of a generic programme.
Design
Due in part to this conceptual fuzziness, the underlying conceptual framework
and assumptions both programmes were not alway s clear and often seemed
confused. Fo r example, one programme combined b oth action learning sets
with taught modules, yet the former are based upon assumptions about adult
learning processes which at the very least are highly sceptical about the value
of the ``programmed knowledge’’ embodied in taught courses (Edmonstone,
forthcoming).
There seemed to be an intent (perhaps unintentional) by the providers and
by other stakeholders (including some participants) to adopt an atheoretical
``technical-rational’’ (Fish and Coles, 1998), one-size-fits-all approach to
leadership development which ignored such matters as basic assumptions
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(about human behaviour at work, how adults learn, etc), conceptual models of
leadership and the previous experience of programme participants (of prior
development activity, personal learning style and role model offered by their
chief executive).
Whether programmes are work based or programme based there seems to
be a strong n eed to make explicit the underlying conceptual framework of
leadership being adopted (not least to aid the evaluation process). This seems to
point to a need for diagnosis to be a feature of development activity; fo r
disaggregation of cohorts of staff around work themes or local health
communities, and for a high degree of ``bespokeness’’ in ter ms of the
development activity devised.
Leading leadership development
There was some evidence in both programmes of some employers and whole
professional groups opting out of the region-wide arrangements. In some
instances it was claimed that this was due to (su perior) local development
schemes, but often it seemed that whole professional groupings, after some of
their members had ``sampled’’ the programme in an early cohort, had decided
that it was ``not for us’’. This clearly runs counter to Goodwin’s aim of
mandatory lea dership development and makes for difficulties in building up a
local leadership ``mind-set’’.
The earlier history of management dev elopment in the NHS was essentially
``tribal’’, with each profession addressing its own perceived needs. This
changed significantly with the advent of general management, but the tribal
nature of current leadership development may be reflected to a degree in
current programmes, existing or proposed (in such areas as the allied health
professions (AHP), mental health nurses, etc). While not arguing for ``generic’’
leadership development, there would seem to be a need to recognise the realities
of a profession-based organisation such as the NHS and to accommodate and
reflect the diverse interests and concerns of the various interested
``constituencies’’ through repesentative steering arrangements which embody a
degree of stability in membership and an element of challenging independent
input.
Creating a ``multiplier effect’’
The evaluation studies revealed a wide range of existing leadership
development programmes, into which TLDP and NYBLDP fitted. These
included:
National programmes (centrally funded). Including the Chief Executive
Development Programme, the NHS Management Training Scheme,
Nursing and AHP leadership programmes, etc.
National programmes (self-financing). These include programmes
offered by the King’s Fund or offic e for public management ±
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45
esseentially prestigious national programmes run on a cost-recovery or
income generation basis.
Regional programmes, such as the two p rogrammes which were
evaluated. Additionally, the work-based modernisation programmes
(such as Trent Ex cellence and Northern and Yorkshire Excellence) are
funded and directed under regional arrangements.
Local programmes. These have been organised on a sub-regional basis
and funded by a variety of means on a one-year basis ± often through
non-medical education and training monies.
Employer programmes. Many employing or ganisations have d iagnosed
leadership development needs themselves and have take local action to
meet them.
Individual initiative. NHS staff continue to fund or part-fund their own
development through postgraduate Diplom a and MBA programmes.
There was a high degree of confusion among both programme participants and
NHS employers over the appropriateness of particular programmes to
particular individuals or groups of staff. Programmes had been create d by local
initiative, central direction, commercial consideration and individual interest
and simply did not ``hang together’’. There was t hus a powerful desire
expressed for the coordination and ``dovetailing’’ of this wide range of activity,
so that there was mutual reinforcement bet ween levels, professions and issues,
thus creatin g a ``multiplier effect’’.
Problems of contractual working
Both the programmes evaluated were run as the result of a competitive
tendering exercise which led to a contract between higher education
institutions and th e NHS. These contracts left little scope for variation or
``flexing’’ in provision as new data emerged from the formative evaluation
feedback. To vary the contract in any significant way would have meant the
NHS committing further in-year expenditure and this had not been budgeted
for and thus was deemed impossible ± while (as perceived by the NHS) the
slow-moving speed and inflexibility of response of HE was also problematic.
This seems to be the downside of the more adversarial contractual culture
which has emerged in recent years (NAO, 2001).
There was a strength of feeling among programme participants that
alternatives to such contractual arrangements, such as ``mixed-model’’
partnership agreements, combined in-house/external working, HE working
closely with consultancy agencies, etc. would bring greater flexibility and
responsiveness to the needs of individuals and employers in the NHS.
Geography
Geography was an important and continuing consideration. Whether
development activity was programme based or work based, geographically-
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distant locations often felt disenfranchised where travel was time consuming or
difficult. Sensitivity by both HE institutions and by NHS employers was
needed in handling such issues, but was not always perceived as existing.
Individual and organisational benefit
Ascribing organisational benefits from the programmes (in the short term at
least) was impossible. It is notoriously difficult to ascribe cause-and-effect
relationships between specific development experiences an d individual and
organisational change ± an d particularly problematic where the focu s is largely
on self-development (Lee, 1994). In the evaluation studies there were no
attempts made prior to the programmes to establish any b aseline measures; no
specifically-sought organisational benefits were identified and there was no
consensus over what organisational benefits might be anticipated.
However, it was much easier to ascribe individual benefits ± the opportunity
to stop, take stock, reflect an d plan ahead was highly valued by programme
participants. It has been suggested (Lee, 1994) th at it may be inappropriate to
attempt to quantify su ch personal development in the short term and that if the
programme is truly successful and the learning fully integrated, then it is
unlikely that the participant will fully credit the programme with effecting the
change!
Conclusion: what lessons have been learned?
The need for effective lead ership in the NHS has never been more clearly
recognised at national, regional and local levels. With the advent of the
leadership centre as part of the Modernisation Agency, a focus for future
development now exists. Yet many questions remain. For example:
The future NHS will need both transactional and transformational
leaders, but where, in what numbers and how they should be developed
are all open questions.
Both work-based and programme-based leadership development have
much to offer, but how to move beyond the current eith er/or ``fashion
swings’’ and to ensure that careful and judicious use of both approaches
contributes to leadership development is a major problem.
Debate on such matters is urgently needed ± leadership development itself
needs to be well led if added value is to be achieved from the many activities
already in existence or plann ed. Wide-ranging discussion is needed to explore
many of the assumptions relating to leadership in health care.
Finally , there are a variety of ways of delivering leadership development (in-
house provision, external provider, mixed models) and there is no reason why
these should also be the subject of evaluation. In other words, the whole field of
leadership development in the NHS needs to move up a gear to face the
challenges of the future.
Leadership
development
47
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