A staggering 20% of senior management positions remain empty in the NHS– a figure that goes up to 37% in mental health, flagging up a crisis in leadership. As demand for health and social care services go up in a context of recession and an ageing population it appears that nobody wants the leadership jobs in health and social care.
Whatever your politics, we should be worried that our leaders are feeling so vulnerable at work because it silences them over the now evident financial and leadership crisis in health and social care.
One cause is the brutality of the bullying culture that goes right to the top – reflected in the highly publicised cases of senior management turned into NHS whistleblowers. Leadership vacancies are in part due to the fear of ‘double jeopardy’ when clinicians take up senior management positions. Nationally set productivity targets combined with austerity cuts have increasingly put clinical best practice in direct conflict with financial targets and encourages gaming – such as patients being parked 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 levels without any consideration of local needs and resources. It is therefore with some surprise that Jeremy Hunt recently called for more transparency and less targets in the NHS. Although the principle is welcome, unless the dominant leadership 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 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.
Studies of knowledge creation and performance management have shown innovation and knowledge transfer happen more often in non-hierarchical teams. Where teams are inclusive they have a tendency to widen the pool of experience and knowledge they have and encourage dialogue and exchange of ideas. This allows for deeper levels of organisational learning which can be linked to increased public sector productivity and patient safety.
At policy level this inclusive model is a no-brainer and gaining widespread support but the difficulty remains in the doing-it-bit.
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. That is, a model of what used to be called industrial democracy.
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 actually create democratic cultures when the NHS is operating within a ‘pervasive culture of fear’ 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 levels, is to show some emotion. This is not a call for tears in the boardroom or team hugs, rather it’s the argument that to deliver democracy at work requires managers to address the deep and often destructive emotions that we all carry to work. From getting to the bottom of bullying to addressing racism in the NHS, this is the stuff of blood and guts that requires both emotional intelligence as well as utter bravery.
Emotional intelligence can be defined as the capacity for self-reflection and self-regulation, empathic 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 HRM bubbles – death.
It means that leadership has to have the capacity to address authentically their own and other people’s states of mind and to bear being in contact with uncomfortable feelings of vulnerability and anxiety.
In order to do this inclusive leadership prioritises practices of listening, observing, auditing, self-awareness, social-awareness, and emotional management techniques. 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.
Inclusive leadership requires a demanding regime of democratic practice and emotional intelligence 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 blog was produced for theconversation.com for our column Battles on the NHS frontline: Stories from the vanguard of health and social care. Please help us build up a picture of what is happening in health and social care by sending us your Stories from the Frontline here.
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