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The BIG debate

Frontline has been asked by the Department of Health Workforce Directorate to take part in a high-profile series of debates on the vital topic of leadership within the NHS.

In this issue, and in our 17 March issue, we are presenting arguments for and against three central questions from leading members of the profession selected by Frontline.

The views expressed are theirs alone, not those of the CSP. The whole point of this initiative, however, is to get your views. So read the arguments, think about the questions and then log on to interactiveCSP, the Society’s member networking website, www.interactivecsp.org.uk and search qqq053 to take part in a debate that will have a major impact on the future development of the profession.

Should the NHS identify potential leaders for development to build representative talent pools or is this best left to individual aspiration?

The National Leadership Council’s approach to inclusion is based on creating a culture in the NHS that genuinely values difference. This is potentially more sustainable than taking particular action to support underrepresented groups. However, will this take too long to deliver real change in the profile of NHS senior management? Should we set targets, hold boards to account and pick out those with potential from under-represented groups? Or will positive action cause resentment and be counterproductive? Should all appointments be purely on merit? What do you think?

Sue Rees (1), an NHS member of CSP Council, argues for positive action

As I sit in CSP Council meetings, I am surrounded by talented, hardworking, committed professionals. They are also almost overwhelmingly white women.

As I look at the current intake of newly qualified physiotherapists, however, I see the profile changing, albeit slowly. More men and more people from minority ethnic backgrounds are coming into the profession. But where are their role models? Who will inspire them to stay in the NHS and to become leaders of tomorrow?

Setting targets and spotting talent from under-represented groups is one way to go.

It has been used successfully elsewhere, with the government targets for recruiting more women, more people from black and minority ethnic backgrounds and more disabled people to NHS trust boards now bearing fruit. As a result, the NHS is becoming more representative of the communities it serves and people from different backgrounds have a voice.

Should this be translated to developing physiotherapy leaders? Perhaps, although there are pitfalls. The experience of such

fast-track programmes for professional development in the NHS to date has not always been good, with people picked not for their qualities but for their background. The box gets ticked, but the professional is set up to fail.

However, there is another sort of diversity and it is highlighted by a quick Google search under three terms: leadership, NHS, development plus UK combined first with medical, then with nursing and then with physiotherapy. The medical search turns up 1.8 million returns; nursing gives just over 700,000 but physiotherapy finds a mere 20,100.

Yes, there are more nurses and doctors than physiotherapists, but these figures illustrate a wider picture than just the numerical gap. Physiotherapists are under-represented at senior management level.

The benefits of having diversity such as the problem-solving skills and abilities of a physiotherapist, or the analytical skills of a health scientist, to enrich the team are clear but the NHS is not making use of them. This is despite a massive investment in developing leadership skills through the various programmes that already exist in the NHS.

The question really is, are we making best use of the talent that we have already developed?  Do physiotherapists have

equality of access when it comes to the opportunity to use what they have learned?

I would argue that they do not. If we are going to set targets, it must be to increase the number of physiotherapists taking part

in high-level leadership programmes and to increase the number of generic leadership roles that are open to all professions. Appointments then can be made on merit – but the pool from which they are drawn will be bigger and more equitable.

The NHS should look to use its ‘talent pools’ and use them well.  Such role models not only make a difference now but will inspire the leaders of the future.  We have leadership talent pools; let’s start to use them.

Fiona Jenkins (2) is director of therapies and health sciences at Cardiff and Vale University Health Board, she argues for leaving leadership to individual aspiration

Leadership in the NHS has traditionally been perceived as hierarchical, defined by job title, position and grade or band. Though some of this remains true today there has been a growing acknowledgment that leadership is required at many levels and throughout the whole career of a healthcare professional.

The key to leadership is using ways of thinking and behaving that effect change and bring about positive improvements regardless of position or rank.

So, should we select a cross-section that represents the staff profile and nurture these to be new leaders, or should we leave this to personal aspiration? The answer is in the evidence base, which applies just as much to management as it does to clinical practice – are leaders born or made?

Studies in the 1920s argued that successful leaders possessed certain inherent qualities. This so-called ‘trait theory approach’ attempted to identify personality-based characteristics.

Subsequent research in the 1950s and 1960s looked at identifying leadership styles to see if one was ‘best’. The evidence demonstrated that success was often achieved despite the application of less desirable styles and behaviour.

These limitations led to the application of ‘contingency theory’ indicating that it was not leadership style as such that led to effective leadership but the ability of the leader to adapt their style to the needs of the followers. The balance between the needs of the team, it's members and the tasks to be undertaken all need to be weighed up to obtain the desired outcome. Therefore the desired models of leadership are both transactional and transformational.

The NHS of the 21st century requires a model that is ‘not based on heroism, but on enabling others to lead themselves, not about being an extraordinary person… but being open, accessible and transparent’ (Alimo-Metcalfe et al 1998). A liberal measure of emotional intelligence, with motivation, self-awareness, emotional resilience, integrity and consciousness is required to lead in the NHS at this time.

So how do we get this? Leadership cannot be taught through academic study alone or learned purely through experience; it requires a combination of the two, along with reflection, to develop future action. This therefore requires some inherent qualities, the desire to learn and the ability to adapt.

Leaders need to have come up through the ranks, experienced frontline practice, have first-hand experience of good and not-so-good leadership in order to develop. They must have a personal desire and commitment to develop into leadership roles, and undertake the training and development that this requires – rather than be selected due to their gender, race or age.

With the agenda for service improvement and continuous change, leaders need to be equipped for the long journey and armed with an array of ‘tools’ as well as their personal skills and attributes.

Spotting future talent is one of the roles of today’s leaders. Everyone should be valued and diversity should be embraced, but not everyone wants to be a leader or would make a good one so don’t ‘pluck’ them, but nurture them, encourage them and support them, and tomorrow’s leaders will develop to ensure we have truly world-class services.

Should NHS organisations develop leaders for the whole NHS collaboratively or focus their efforts on their own future leaders? 

The National Leadership Council is complementing the work on leadership development at a regional level by establishing national programmes and initiatives, for example on board development and top leaders, where there are economies of scale or added value in developing national cohorts. However, some organisations point to past weaknesses in national approaches, stress that subsidiarity is an important current principle and argue that organisations should focus on developing their own future leaders, many of whom will then move on to other organisations. Some say national programmes make it easier for organisations to opt out of their own responsibilities. Others suggest that we need to develop leaders who understand the whole system, and that those who have worked and trained only in one organisation or in one part of the sector offer far less to a potential employer. What do you think?

Dr Lesley Holdsworth (3), head of health services research effectiveness at NHS Quality Improvement Scotland, argues in favour of developing leaders for the whole NHS collaboratively

Providing a focus on developing leadership at a regional or national level has much to offer physiotherapists and the physiotherapy profession.

Traditionally, allied health professionals have not taken on high-level leadership roles, either within their own organisations or more widely at regional or national level. They have not been exposed to high-level decision-making and consequently neither contributed fully to those decisions nor had much influence on them.

I would suggest that this has been to the detriment of patient care as well as to the development of the profession and its scope of practice. Engaging the profession in national leadership programmes is one way to tackle it.

Participating in national programmes allows AHPs to develop leadership skills alongside a wide range of other professionals and stakeholders. It exposes them to a broader range of views, issues and positions than they might encounter at a local level.

Participants gain access to a diverse network of peers, allowing for greater sharing and learning. They can build personal relationships that support action learning in an environment that is remote from day-to-day work and potentially more open and more honest.

They provide a good forum for exploring the implications of policy from the perspective of the whole system, allowing participants to gain a greater understanding of the role of other professions and their interaction with physiotherapy in the wider scheme.

Conversely, such programmes allow the other professions and stakeholders to gain a greater understanding of physiotherapy, not just what we do with individual patients but how we can support modern policy initiatives.

I am best known for my work in self referral to physiotherapy and this is a good illustration of the points I am making here.

Patient self referral to physiotherapy has been possible since 1978 but, despite the potential benefits, it was not a mode of access embraced by the NHS until more recently.

I believe that I was able to articulate the evidence for self referral in relation to its benefits for patients, service providers and the physiotherapy profession using skills developed as a consequence of national level strategic leadership development. I learned how self referral could be played into a number of policy agendas such as waiting times, self management, primary care and improving the management of long-term conditions. 

I was able to stand back and assess the relevance of self referral in terms of these key policy objectives and frame the argument in terms that other decision makers could understand, as well as demonstrate pertinent outcomes.  Patient self referral to physiotherapy is now embedded in UK health policy.

Undoubtedly, there is an important role for local leadership development, but I would argue that this primarily benefits physiotherapists at the more junior end of the spectrum and can provide a foundation from which influential leaders can grow. When it comes to supporting the development of high-level leaders, national development is the way to go.

Catherine Pope (4), associate director of allied health professionals at Nottinghamshire Healthcare trust, says trusts need to develop their own future leaders.

There is a clear need for leaders at all levels of an organisation, and for me, leadership development must start at trust level and must start early in clinicians’ careers.

I say this for several reasons, but primarily because decisions that are made close to the patient are the most likely to be relevant and appropriate. Engaging clinicians in leadership development that enables and supports them to make decisions will result not only in good decisions for patients but help clinicians to identify whether they wish to become the leaders of the future.

A local approach is great for enabling a wide range of clinicians to engage with leadership development. Family commitments can make it difficult for some people to travel to nationally-led programmes while different cultural backgrounds mean others lack the confidence even to apply.

Leaders who are involved in trust-based development programmes have a wealth of resources on which to draw. Their role models and mentors are on hand. By learning alongside established leaders and managers in their own organisations, they can start not only to learn the subtle political and soft negotiating skills of a good leader but also to apply them in a supported environment.

Learning in your own organisation also means that your leadership development has an application to your day-to-day job rather than being theoretical. Working alongside service users and carers means you can have an immediate impact on service-user and staff experience.

This certainly has been my experience. Three years ago, I joined a programme at my trust for people interested in being directors of the future. It was a six-month, part-time secondment where I worked alongside the executive director of nursing and allied health professionals.

In this role, I had access to fantastic role models and support from mentors outside my own profession who were able to give me fresh insights while having an intimate knowledge of the trust.

I was also able to develop a project at the trust, moving our mental health services towards the more multidisciplinary approach of New Ways of Working. I learned a lot about project management, about what motivates different people and about internal politics.

This experience led directly to my current job where I am professional lead for all the AHPs in the trust. I line manage very few – they are mostly in multidisciplinary teams these days – and my main role is to argue the case for AHPs at board and executive level.

I am now involved in a trust-level programme called ‘Invest to Lead’, in which about 60 senior managers are learning alongside more junior colleagues in order to develop a leadership community. It brings together clinicians and managers, helping clinicians to understand that managers care about patients too while keeping managers in touch with the frontline. It is extremely cost effective and helps to develop our sense of ownership, loyalty, shared vision and corporate approach.

I have since taken part in a national programme – ‘The Athena Programme’ with health think tank the King’s Fund – and it certainly has its strengths. I was only able to access it through having completed local programmes. Home grown is where leadership development has to start and a wise organisation is one that recognises this.

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