A staggering 20% of senior management positions remain empty in the NHS – a figure that goes up to 37% in mental health. As demand for health and social care services go up in a context of recession and an ageing population, it appears that nobody wants to take the lead when it comes to jobs in health and social care.
One cause is the brutality of the bullying culture that goes right to the top – reflected in highly publicised cases of senior management turned NHS whistleblowers. Leadership vacancies are in part due to the fear of “double jeopardy” when clinicians take up senior management positions and find themselves with often conflicting organisational and clinical duties of care.
Set productivity targets combined with austerity cuts have increasingly put clinical best practice in direct conflict with financial targets and encouraged gaming the system – parking patients on trolleys in hospital corridors to avoid falling foul of waiting time targets and early discharge of patients followed by quick and unreported re-admission.
One of the problems is that targets are politically motivated, passed down from ministerial to management level without due consideration of local needs and resources. It was therefore surprising that health secretary Jeremy Hunt recently called for more transparency and fewer targets in the NHS. Although the principle is welcome, unless the dominant culture is addressed then this just becomes another ministerial dictate with more than the usual hint of irony.
Research indicates that managers under pressure to deliver targets typically default to a command-and-control management style which is unresponsive to both patients and staff – “do this now” rather than “what is the best we can do?” This, in turn, is linked to workplace cultures where staff are reluctant to raise concerns, and become disengaged and dysfunctional, a long way from best practice and patient safety.
What we know from the research is that inclusive teams – which promote diversity, working across disciplines and democratic practices – are significantly better at capturing knowledge and promoting organisational learning. Where teams are inclusive they have a tendency to widen the pool of experience and knowledge they have and to encourage dialogue and the exchange of ideas.
Democratic and emotional leadership
At policy level this inclusive model is a no-brainer and gaining widespread support but the difficulty remains in actually doing it. This is in part because for people to participate at work they have to be allowed to speak their minds, make decisions about their work and challenge their own leadership without penalty.
Within this tradition of democratic leadership, teams are the primary unit of management and hold the collective responsibility for performance. This model was developed in the manufacturing sector in the 1980s, using a Japanese model of team building – a “support and stretch” as opposed to a “control and constrain” culture which emphasises interdisciplinary and experiential learning and importantly is linked to high clinical results.
All well and good, but how do managers create democratic cultures in an NHS where most people manage work by keeping their mouths shut and doing what they’re told?
One characteristic of inclusive leadership, whether at senior or frontline level, is to show some emotion. This is not a call for tears in the boardroom or team hugs, rather it’s the argument that delivering democracy at work requires managers to address the deep and often destructive emotions that we all carry in our jobs. From getting to the bottom of bullying to addressing racism in the NHS, working life requires both emotional intelligence as well as bravery.
Emotional intelligence can be defined as the capacity for self-reflection and self-regulation, empathetic qualities which allow us to understand the situation of the people around us, and social skills which allow people to hear and observe reality as it is. In the case of health and social care this inevitably involves experiences of trauma, pain, distress and - not wishing to burst any Human Resources Management bubbles - death.
Inclusive leadership prioritises practices of listening, observing, auditing, self-awareness, social awareness, and emotional management. It is through this emotional capacity that leaders become effective at building teams that are both realistic and resilient rather than grandiose and unresponsive to patient needs.
It also requires a demanding regime of this from executives to frontline managers. This involves a radical departure from the current “pervasive culture of fear” that operates in the NHS and creating workplaces that are structurally, politically and emotionally open to the people that work within them. A workplace where I can say what’s on my mind and you can bear to listen to me.
This column looks at the reality of our health and care systems from the perspective of those working to deliver services. Please send us your anonymous stories from the frontline.