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Follow the leader

30 August 2013

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Following the publication of the Francis Report earlier this year, what can practice managers take from the findings?

Thanks to the Francis Report, issues of culture and leadership in the NHS are high on the agenda. As part of The King’s Fund’s response to Francis we published Patient-centred leadership – rediscovering our purpose.1 Drawing on external research and our own expertise, we attempted to summarise the main findings of Francis in relation to leadership and culture, and set out what needs to be done to avoid similar failures in future.  

An unhealthy and dangerous culture was identified by Francis as a pervading cause of failures, with a clear statement that organisational culture is informed by the nature of its leadership. His report drew attention to a top-down, command and control leadership style that has given rise to a tendency to ‘shame and blame’ within the NHS.  

The challenge that faces the health service is significant. Nothing less than the transformation of systems, leadership and organisational culture across the NHS is needed if lessons are to be learned and acted upon.

To understand how we can change culture and leadership within the NHS, it is important to understand what they are and how they relate to each other. An organisation’s culture is made up of the basic values, shared beliefs, deep-seated assumptions and working practices that underpin how its staff behave – encapsulated in the phrase ‘the way things are done around here’. Leadership is key to changing the culture of any organisation. Consciously or unconsciously, leaders set the tone of their organisations through what they say and do. 

NHS staff are intrinsically motivated to help patients when they are vulnerable, and failures more often than not occur when the systems in which staff work let them down. These systems emanate from senior NHS leadership at national level as well as the systems and leadership in place in each and every local NHS organisation. We define the three lines of defence against poor quality care as:

 – Frontline clinical teams.

 – Boards of NHS organisations.

– National organisations overseeing commissioning, and regulation and provision of care. 

The challenge facing the NHS is how to create a culture that puts patients’ needs first at all of these levels.

To understand the current state of play, we recently conducted a survey of more than 900 NHS professionals (a mix of clinical and non-clinical staff) asking them about their views on leadership and quality of care. The results revealed that almost three-quarters (73%) of them do not think that quality of care is given enough priority. The percentage was even higher among nurses at 80%.

Care quality in NHS organisations is first and foremost a corporate responsibility under the leadership of boards. However, when asked who has the biggest impact on quality of care, NHS professionals ranked them sixth out of eight, behind clinicians, managers, government, regulators and patients. This suggests that boards should be doing much more to exercise clear and visible leadership by demonstrating that they give sufficient priority to quality and patient safety; for example, by seeking and acting on patient feedback, hearing patient stories, reviewing and learning from complaints, taking time to listen to patients and their relatives or acting on the results of staff surveys.

Only 14% of those surveyed thought the quality of leadership in the NHS was ‘good’ or ‘very good’. Time and resources were seen as the biggest obstacles to improving patient care by 40% of all NHS professionals, and more than half (51%) of nurses. Organisational culture was the second biggest barrier identified by 28% of respondents. Interestingly, NHS executive directors identified organisational culture as the most significant challenge, with 48% viewing it as the biggest barrier.

We should not underestimate the challenge. Changes to cultures and behaviours take many years to make an impact. As such, it is important that leaders begin to start this process now and that the issue remains high on their agenda.

Nowhere is leadership more critical to improving care quality than in wards, clinics and general practices. Leadership at the front line is best performed by clinicians in partnership with general managers. Clinical teams perform best when their leaders value and support staff, enable them to work as a team, ensure the main focus is on patient care and create time to care. 

High quality leadership is key to changing the nature of any organisation, and the challenge is how to develop and sustain a different culture that always puts patients first: ‘How should things be done around here?’

Leaders must work on several fronts simultaneously to deliver success. They need to be:

 – Seeing quality as an organising principle.

 – Building capabilities and skills for improvement.

 – Engaging patients in their care.

 – Promoting professional cultures that support teamwork.

 – Providing consistent leadership themselves.

 – Most importantly leaders must create the systems in which staff are supported to do the right thing.

In our report we highlighted the importance of the emerging concept of patients as leaders. It is a concept worth paying attention to – enabling patients to help frontline teams to redesign services according to patients needs and moving towards true co-production to improve services and patient experience. 

NHS leaders should encourage and nurture patient leaders to help build collaborative relationships and ensure they have access to support and development.

So, what are the implications of Francis for training and development of leaders working in healthcare? The King’s Fund has been delivering leadership development in the NHS since 1951 – we,  like any part the health sector, should reflect on what part we have played in the system and culture we now have and what part we might play in improving leadership in future. 

In recent years, many millions of taxpayer pounds have been invested in NHS leadership development, with relatively little evaluation and therefore very limited evidence about what works best. What is clear, particularly given the current financial climate, is that we must now make sure that resources are directed where they will have the greatest impact.  

Leadership development should focus on developing individual performance in order to improve the performance of the team, organisation or system they work in. 

We should focus on supporting the networks of people practising leadership throughout an organisation or system and on how skills and behaviours can be honed and applied in the real situations in which leaders find themselves, whatever their level or professional background. Working with real relationships and problems makes sense – it is unlikely that much organisational change will be achieved by the development of unconnected individuals. While there will always be a need for individual skills development, we think that development with others in context is the way to ensure organisational values, goals and culture are aligned and the way to get the most ‘bang for our buck’ for the money invested. 

One thing is clear; there is no quick fix. A sustained effort is needed at all levels to learn the lessons of the Francis Inquiry and to bring about the difficult but essential changes in leadership and culture that are needed to prevent those failures happening again. As we say in our report – the journey of improvement and rediscovering our purpose starts here. l



1. The King’s Fund. Patient-centred leadership – rediscovering our purpose. 2012.