Ruth J. Boaden, Manchester Business School, University of Manchester, Manchester, UK
The author would like to thank the team providing the programme in Manchester, both academic and administrative staff, and in particular Claire Harris for her perceptive and effective data analysis and Amanda Shephard for the analysis of the second and third intakes. Thanks to all the programme contracts within PricewaterhouseCoopers and the NHS Leadership Centre. However, it is the participants in the programme who have made this paper possible and it is to them that thanks are mostly due.
Purpose – This paper seeks to examine the impact of a leadership development programme provided for, and funded by, the NHS.
Design/methodology/approach – It analyses the context, process of delivery and outcomes of the programme in the light of relevant leadership research. The programme itself is described after some consideration of the literature. Although the programme was originally commissioned by the NHS Leadership Centre for Human Resource (HR) professionals from the NHS, it is now offered to any aspiring or newly-appointed director, and aims (amongst other things) to enable NHS staff to manage people more effectively within the context of change.
Findings – The paper concludes that the programme has, to date, been successful in impacting on personal and organisational contribution, as far as individual participants, commissioners and providers are concerned, and as far as can be measured within current understanding.
Originality/value – The programme fits well with the most recent typologies of leadership development.
National Health Service; Leadership; Development; Self development.
Leadership & Organization Development Journal
Emerald Group Publishing Limited
The formation of the NHS Leadership Centre in April 2001 enabled a number of leadership development programmes previously commissioned by a variety of areas within the NHS to be brought together. It also fulfilled the commitment within the NHS plan that:
To deliver a step change in the calibre of NHS leadership, the government will establish a new Leadership Centre for Health (Department of Health, 2000).
This paper describes the impact of a leadership development programme originally commissioned by the human resource (HR) directorate of the Department of Health in mid-2000, for HR professionals, which is now run under the auspices of the NHS Leadership Centre and offered to any professional within the NHS who aspires to a director post, or who has recently been appointed to one.
Leadership itself has long been a popular and widely-used term and yet one that defies an agreed definition (Alimo-Metcalfe and Lawler, 2001). The increasing body of evidence that leadership makes a difference to organisational effectiveness, e.g. (Bass, 1998), has prompted those who commission and fund leadership programmes, particularly within the public sector, to focus on organisational outcomes and improvements as a tangible benefit from investment in such programmes. Other initiatives within the public sector, e.g. the modernisation initiatives co-ordinated by the NHS Modernisation Agency, are also increasingly identifying effective leadership as a key “success factor” in the long-term sustainability of organisational change (NHS Modernisation Agency, 2002):
Effective leadership is a key ingredient in modernising today's health services. Better leadership means better patient care and improved working practices for NHS staff (NHS Modernisation Agency, 2004a).
This paper provides a critical analysis of a leadership development intervention (programme) within the NHS, and focuses on its effect on both individuals and the organisation. It discusses the context of the programme, its structure and the process by which it is provided, and its outcomes. The conclusions show that there is an inextricable link between personal development and service change and that it is probably not possible to achieve long-term improvement in one without affecting the other.
The author of the paper was, at the time, one of the directors of the programme and had designed the programme jointly with another colleague. However, she did not lead the evaluation process, which was designed by PricewaterhouseCoopers, and data analysis was carried out by another academic colleague.
It is not possible, or appropriate, to review the whole area of leadership and leadership development here, particularly when there are a number of excellent such reviews already available (e.g. Vance and Larson, 2002; Alimo-Metcalfe and Alban-Metcalfe, 2002; Van Wart, 2003). For the purposes of this paper, the areas of leadership, leadership development, and leadership within the NHS will be considered.
There was a large and significant shift in terms of the study of leadership in the 1980s when the paradigm moved from “transactional” to “transformational” (Alimo-Metcalfe and Alban-Metcalfe, 2001). Previous models of leadership such as contingency models (Vroom and Yetton, 1973) focused on behaviours and styles as being predictors of effective outcomes, depending on the situation. The increasing pace of change during the 1980s led to transformational models being developed, which focussed on charisma and vision (Bass, 1985).
This is included here because the implications of this distinction in terms of leadership development will be returned to later in the paper. It is argued (Alimo-Metcalfe and Alban-Metcalfe, 2002) that “transformational leadership is coming to be equated with leadership per se; transactional with closed-ended, relatively static, management”. This distinction has been clearly taken on board by the NHS, which argues that both aspects are needed within single individuals in the NHS:
We need leadership in setting out the vision and working with and through people to achieve it. We need excellent management in systematic and tested approaches to secure delivery and improvement. Many people, of course, take on both roles (Department of Health, 2002b).
Although some academic authors have pursued the notion that the two different aspects of leadership require different psychological types (Zaleznik, 1977), the view of the NHS is that leadership is everyone's job:
Everyone in the NHS has a leadership role. The very way we behave is a demonstration of our leadership skills (NHS Modernisation Agency, 2003).
Another view on the same issue describes splitting the job of an individual into “management” and “leadership” components, with the leadership element being regarded as discretionary (i.e. a matter of choice) and predominant amongst the roles of senior managers (Kakabadse et al., 1996). This distinction is described by these authors as being pertinent where there are substantial conflicting priorities – as in the public sector at a senior level. It is argued that the choices made will impact on the performance of the organisation. This notion of choice is one that will be returned to later in the paper.
Not only is the “business” of leadership development a growth area for many providers, including universities, there is also an acknowledgement that there is gradual evolution of a paradigm to locate this activity (Fulmer, 1997; Conger, 1993). It is argued (Conger, 1993) that as our understanding and definitions of leadership have changed, so the approach taken to leadership development also needs to change. This evolution can be summarised as shown in Table II (Fulmer, 1997).
Although this model was developed in the US and describes activity there, it is also applicable to the UK that may be more advanced in this respect:
British business schools have been much more innovative than their American counterparts in designing programs that take the learning out of the classroom and into the real world (Fulmer, 1997, p. 68).
It is argued that many approaches to leadership development are not innovative (Conger, 1993) and are based around four areas which have been used for many years: skill-building (e.g. decision-making), concepts (e.g. what makes leaders different from managers), outdoor adventures (to build teamwork) and feedback (ranking on a scale of leadership dimensions). A review of leadership development in context (Day, 2000) concludes that there is a difference between developing leaders – using a “traditional, individualistic conceptualisation of leadership” – and leadership development which “has its origins in a more contemporary, relational model”, although he claims that organisations need both approaches. This need for a more contemporary approach is also reflected in a model of competency (Doh, 2003) that will require significantly different approaches to leadership development, focusing on strategic and global issues in a decentralised environment, within the context of sensitivity to diversity, interpersonal skills and communities, and with a focus on anticipating the future and mobilising their organisation to shape it. This need for leadership development to reflect the context is also highlighted by (Hartley and Hinksman, 2003) in another significant review of the literature on leadership development.
There is also a significant literature on learning, at both an individual and organisational level, and its relationship to training (Antonacopoulou, 2001) and this area is continuing to develop. Modes of learning may include (Akin, 1987) emulation of a mentor, role learning, learning through doing, validation, learning of concepts and personal growth. Some of these are more suited to formal development programmes than others. Action learning is regularly cited as a key tool in leadership development (Bowerman, 2003; Watkins and Marsick, 1993); and the literature gives examples of such programmes (Bowerman, 2003). A review of the difficulties encountered when using action learning for leadership development (Conger and Toegel, 2002) describes inadequate opportunities for reflection, poor facilitation and a failure to follow up on project outcomes as ways in which the potential of this technique is not fulfilled.
Whilst there is some debate over the extent to which leadership can be “taught” (Doh, 2003), and what might constitute such teaching, there is agreement that “leadership clearly requires personal commitments on the part of the learner” (Doh, 2003) and this may challenge the traditional role of educators. This new paradigm puts new demands on those termed “traditional educators” – respect is “earned by what the teacher is able to stimulate others to know” (Fulmer, 1997). The new paradigm is summarised by the author as “focused on learning as an action-oriented, lifelong process where global partners work together to produce a positive, profitable future for all” (p. 70).
An assessment of the state of leadership development in the UK and its implications for the NHS, was published in 2001 (Alimo-Metcalfe and Lawler, 2001), about the time that the programme discussed in this paper commenced. Its conclusions were different from those expected, because the findings showed that “leadership development in both the private and not-for-profit sectors is sporadic, haphazard and illogical” although the authors do acknowledge that the concepts and practices of leadership development are in an “early stage of evolution”, a view in line with those from the US (Conger, 1993; Fulmer, 1997).
There are also some observations about the role of organisational politics in leadership development (Alimo-Metcalfe and Lawler, 2001), which conclude that “there is a huge gap between aspiration and achievement [in terms of a logical process of identifying potential leaders], a gap filled by politics”. An additional perspective on this issue is provided by the concept of fair process (Chan Kim and Mauborgne, 2003) – where employees will commit to a manager's decision (even one they disagree with) if they believe that the process used was fair. It is argued that this concept can be applied to leadership development (Bowerman, 2003); although organisations say they want to develop leadership, they fail to understand the implications and do not create an environment in which such leadership can thrive. Proponents of action learning approaches make similar points (Revans, 1998).
Literature is also developing on why leadership development efforts may fail (Ready and Conger, 2003). These authors cite the “ownership is power” mind-set (where the focus from senior levels is more about traditional models of command, control and power rather than shared accountability). They also describe programmes that are “products”, rather than being designed around the issues within the organisation that need to be addressed as tending to fail. They argue that the metrics used to assess the effectiveness of leadership development may be inappropriate since they focus on activity rather than capability, a view that is shared by other authors.
Does leadership make a difference?
There have been a number of reviews (Bass, 1998; Gasper, 1992; Lowe et al., 1996; Patterson et al., 1995) demonstrating that transformational leadership has a strong positive relationship with objective measures of organisational productivity as well as subjective measures (e.g. job satisfaction). Most of these meta-analyses have been performed within the US. There is also a growing body of literature looking at various aspects of leadership and their relationship with performance (Moshavi et al., 2003); for example, consider leader self-awareness and performance. The impact of leadership can be considered on either workplace colleagues, or by some measure of organisational “success” (Alimo-Metcalfe and Alban-Metcalfe, 2002), or perhaps on both.
Whether leadership development programmes have a positive measurable outcome in organisational terms is something that is much more difficult to demonstrate, although it is regarded as important. A review of research in this area (Vance and Larson, 2002) concludes that “although work in the social sciences indicates that leadership styles can have a major influence on performance and outcomes, minimal transfer of this work to the healthcare system is evident”. Whilst acknowledging that it is difficult to conduct, these authors call for more research in this area, in the light of the move to evidence-based practice in healthcare. They also raise the issue that much of the research to date has utilised qualitative research methods, and they argue for more quantitative work, although this is not a universal view (Conger, 1998; Burgoyne and Williams, 2004). Another review (Collins, 2001) concludes that while approaches to evaluation are focusing more on performance issues, the results are mixed and there are inherent difficulties in doing this (Burgoyne and Williams, 2004). The lack of scholarly knowledge about leadership development is again cited here, but it is also pointed out that most leadership models were developed for a more stable and predictable environment than now, highlighting the need for further understanding of the relationship between leadership and change.
Leadership within the NHS
Leadership and leadership development within the NHS has come to increasing prominence in recent years, not only with the formal establishment of the NHS Leadership Centre, but also with the publication of a document which “sets out the new management task for the next three years and addresses how, together, we are going to create a coherent core of values and systems and build a management and leadership community in the NHS of international standing … combined with specific national initiatives that will help managers and leaders in practical ways” (Department of Health, 2002b). At the same time the “code of conduct” for NHS managers was published (Department of Health, 2002a), in response to the Kennedy report, and this code draws heavily on the NHS leadership qualities framework (Department of Health, 2002c), which is itself now heavily promoted within the NHS.
The NHS, like many other public sector organisations, is keen to learn lessons on leadership from other sectors and from an international base, and this is reflected in the new programmes that are being commissioned (e.g. the Gateway to Leadership programme which recruits managers from other sectors to work in the NHS (NHS Modernisation Agency Leadership Centre, 2003). There is also an emphasis on leadership development for groups currently underrepresented in terms of leadership positions (e.g. the “Breaking through” programme (NHS Modernisation Agency, 2004a).
The work of the Leadership Centre was categorised into three areas (NHS Modernisation Agency, 2004b): strategic leadership, front-line leadership and building capacity. All these work streams include programmes for both clinical and non-clinical staff, from a variety of professions from chairs and chief executives to social care and staff from learning disabilities organisations. The NHS plan states that “leadership development in the NHS has always been ad hoc and incoherent … that will now change” (Department of Health, 2000) and the recent work plan shows evidence of this starting to be achieved. The Leadership Centre has commissioned a number of formal programmes and taken on board others that were previously provided by particular functions (NHS Modernisation Agency, 2004b), although this was not without some concern from certain professional groups, where a lot of work on leadership in some areas had already been developed (Moiden, 2002).
The Leadership Centre has indicated its intention to move away from “mainly focussing on providing leadership development programmes and products” to exploring how to “contribute to leadership policy, ensuring best practice at local level, promoting diversity in leadership and research the results of effective leadership” (NHS Modernisation Agency, 2003) and its role in the NHS Institute for Innovation and Improvement reinforces this, although the detail is still evolving. It is clear that the establishment and development of the NHS Leadership Centre has increased the profile of leadership, and its effective development, within the NHS.
History and objectives of the programme
The Leadership Through Effective Human Resource Management (LTEHRM) programme (“the programme”) was commissioned to prepare both human resource (HR) professionals and other leaders as experts in the management and development of people and as full members of the team charged with building capability and delivering change in the NHS (Harris, 2000). The programme is open to people aspiring to be directors and those already at director level in the NHS, initially from England, although subsequent funding has provided places for participants from both Wales and Northern Ireland too. Three intakes of participants have completed the programme with the fourth due to finish the core part of the programme in autumn 2005, and the fifth intake having started in April 2005.
The aims of the programme are to enable both HR professionals and other NHS leaders to become experts in the management and development of people by:
- raising the profile of HR within the NHS by developing HR professionals as full members of the team charged with building capability and delivering change;
- embedding a consistently high level of managerial skill across the NHS, taking into account the demands of the NHS plan on HR professionals in radical restructuring and reorganisation;
- to combine academic knowledge with practical insights that can be applied in the workplace; and
- to develop an understanding of the needs and development of the NHS.
And to enable participants to identify and address their own development needs – in particular:
- to enable participants to develop understanding and skills in building organisational and individual capability for change; and
- to enable participants to develop understanding and skills in delivering change in organisations.
There are very few published accounts of other similar programmes, although one that has received attention was commissioned by the Office for Health Management in Ireland and found on evaluation to be effective from the point of view of both participants and line managers (Gavin et al., 2001; Hardacre and Keep, 2003).
Initially the LTEHRM programme was aimed at HR professionals:
Those charged with the management of human resources are key members of each executive team, both as experts in the management and development of people, but equally important as full members of the team charged with building capability and delivering change. This programme is concerned with developing the skills which this group of HR professionals will need (quotation from tender document).
Subsequently, intake one of the LTEHRM programme attracted predominately professionals from the HR function. However, this focus has lessened in subsequent intakes as other funding was attracted, the reputation of the programme developed and its applicability to a wider range of people was recognised. It was not designed to teach or enable learning of detailed technical HR/personnel practice. This development of emphasis on “people” management rather than HR as a profession is reflected in the fact that the programme's title has changed to “Leadership through effective people management” for the fourth and fifth intakes.
Structure and content of the programme
The core part of the programme was developed and is provided by the Manchester School of Management (MSM), UMIST (in partnership with the Manchester Centre for Healthcare Management (MCHM), Victoria University of Manchester), and the (then) HR Consulting group of PricewaterhouseCoopers (PwC). There are also two international partners (Erasmus School of Management and Harvard School of Public Health) providing optional parts of the programme. Table III shows the responsibilities of the various partners.
The core programme incorporates half-week blocks of teaching every two to four months (residentials), service improvement projects (SIPs) to work on in between, learning sets facilitated by university and PwC staff and a support website. The residential part of the core programme is delivered by academic staff from MSM and MCHM, by invited speakers from other universities and employers, and by experts from within PwC. The service improvement projects are written up and assessed throughout the programme, if academic accreditation of any form is desired. There are two learning set days between each residential module – the first is facilitated by MSM and focuses on the service impact of the programme to date (including support for SIPs if required) and the second day is facilitated by PwC and focuses on personal development. A brief indication of some of the benefits of this approach can be found in (Trapp, 2002).
Whilst the content of the programme is not the main focus of this paper, a summary of the key areas covered is given in Table IV for information.
In intakes 1 and 3 the number of participants were such that two groups were run – one consisting of deputy directors (the “accelerated” group) and one consisting of directors (the “advanced” group), each with 45 participants. Both groups covered the same material and had broadly the same input with some minor variations where speakers were not available to come to both groups. In intake 2 there were fewer participants so accelerated and advanced groups were taught together in the residential modules (a total of 45 participants) although their learning sets were separate to enable them to discuss work and personal development issues with their peers.
Evaluation of the programme
The evaluation process is regarded as a key part of the programme and assesses the value of the programme to participants and the NHS, as well as ensuring that experience from the programme is being built into future provision, enabling continuous improvement. The evaluation is therefore both formative (during the programme – contracted for five years – as a whole) and summative (after one complete cycle of the programme) (Burgoyne and Williams, 2004).
The process, based around Kirkpatrick's model (Kirkpatrick, 1994), was designed to:
- ensure the programme met the agreed needs of the NHS;
- demonstrate the impact of the programme on personal development, organisational development and service/patient improvement;
- provide a systematic means of evaluating and continuously improving the programme; and
- help participants cement their learning and support on-going professional development.
The model (see Figure 1) was used to enable evaluation of the programme at all four levels through a range of mechanisms.
Data on reaction at level 1 is gathered throughout the programme in the form of feedback questionnaires completed at the end of each residential, and through verbal reports at the following learning set meeting. At the end of the core programme participants are also asked to re-assess the residentials, so that a comparison of immediate and delayed reaction can be made. Details of achievements at level 2 are gathered through marks for assessed work throughout the programme, and in the work required for module 6 of the core programme. Participants are required to produce a project detailing their developments in knowledge (level 2) and how these have translated into changed behaviours (level 3), and how they relate to the structure of the programme. They are also required to provide a presentation on their assessment of the benefits of the programme for the NHS and its value for money (level 4). In both the report and presentation they are encouraged to use external sources of evidence – tangible benefits, the view of peers and superiors, as well as their own views. In addition, benefits described in the SIP reports are analysed independently and key themes drawn out.
However, in light of the evaluation breaking down the programme into its constituent parts as part of this process, it must be emphasised that the programme is a “total” experience, as illustrated by the following quote from a participant on the first intake:
It is still early days to evaluate impact on targets as the change is still underway and will be for some time. Additionally, I do not feel that it is a specific project that has had the most impact, but rather the whole experience of being part of the programme and all its component parts – it is hard to separate out what specific benefit has come from what aspect of the programme when so much of it has been inter-linked and holistic in approach.
Outcomes from the programme
The evaluation process described in the previous section shows that outcomes are at a variety of levels and in a variety of areas.
For the individual participant there are a variety of academic accreditation options; a Certificate of Attendance, Postgraduate Certificate, Diploma (participants must produce a management report) or MSc (participants must produce a dissertation). To date between 30 and 40 participants have continued to the MSc stage of the programme each year and the first graduates finished in December 2003. However, as the objectives of the programme show, the programme aims to achieve far more than this.
This paper provides results from evaluation of the first three intakes of the programme – about 250 people in total. Reponses were analysed from 63 participants in intake 1 (62 per cent), 32 in intake 2 (80 per cent) and 57 from intake 3 (63 per cent). Detailed analysis of the outcomes for the first intake of participants, from the evaluation process, shows that all objectives have been achieved to a greater or lesser degree. The list of key benefits generated by analysis of participant reports from intake 1 (not by giving a list of factors and asking participants to rate them), and their link to the objectives is shown in Figure 2.
In particular, the following can be noted:
- The profile of HR within the NHS has been raised by development of the HR community and the movement of participants to new jobs, combined with their increased personal confidence and motivation.
- There is evidence of a variety of transactional skills and transformational leadership characteristics also having been improved, as shown by the data generated from the analysis of participant evaluation reports. It would be expected that this will also follow from personal development.
- There is clear evidence that practical insights have been applied in the workplace and tangible benefits obtained. Many participants pointed out that it was in their view too early to quantify the benefits but they had no doubt that more would be achieved in future.
- Most participants reported a greater understanding of the needs and development of the NHS, which is having knock on effects on the credibility of HR as well as delivering change and improving patient focus and (ultimately) patient care.
- There has been significant personal development, which is continuing to have an impact on participants' roles and influence, as well as their career paths.
In terms of leadership, this was one the factors that emerged from the analysis of the SIPs, although participants were not asked explicitly to comment on it, because it is not explicit as an objective. However, there is clear evidence that leadership skills and self-awareness (Moshavi et al., 2003) have improved, as shown by the quotations below. It should be borne in mind that these quotations were also supported by tangible evidence as part of the overall evaluation process. It should also be noted that there were many other examples of personal and organisational change that could be classed as “leadership” developments – this comes down to the definition of leadership used – for the purposes of this paper the participants' own definitions have been used.
Leadership in general
The learning both personally and professionally has been phenomenal. I am more capable as a leader.
The programme has also highlighted my own contribution to successfully managing change in terms of my own personal approach and leadership style.
Greater competence in influencing others whose support I need.
I am taking a more proactive leadership role.
The quality of my leadership contribution within the trust and the local health community has been significantly influenced.
The increased knowledge and understanding gained from the programme has enabled me to be able to display leadership and vision across the Trust
I have been able to call on leadership qualities developed through the programme to deliver two important roles for the service.
I believe that this (staff feedback) provides some evidence of my successful leadership of the organisation and am aware that this has been a key area of development.
The various exercises and questionnaires completed during the programme have enabled me to assess where I sit personally on the leadership ladder.
The understanding of leadership competencies and the self knowledge about my own leadership competencies gained has been critical in maintaining my ability to cope with the current context.
The need for strong leadership was emphasised on all modules and I think now that I have a better insight into my leadership capabilities and of the possibilities for HR to lead in areas, which historically, the function has been peripheral.
The learning set has provided me with opportunities as well as frameworks to develop a greater understanding about my preferred leadership style.
The programme made me think about my own qualities in leading effective services
What about the patient?
It can be argued that outcomes from any type of leadership development within the NHS should lead to improved patient care, although most of the empirical work on this appears to have come from the nursing profession to date (e.g. Gantz et al., 2003). The structure and content of the programme were designed to enable participants to think this aspect through, something which HR professionals in particular had not always considered in detail, unlike those in more “front-line” roles. Each SIP report had to include a section on the impact of the findings and analysis for the organisation, the patient and for the participant. This is illustrated by the following quotations from SIP reports:
Increased awareness of the impact on patients
My awareness of linkage to patient care has increased dramatically over the last 18 months.
I have worked with the management team … on how I undertake my role … and we have become more patient focused.
I am now fully committed to leading transformational change to improve patient care and to ensure that these changes are embedded and become the norm so that there can be no going back to type
Changes in behaviour and/or practice related to patient care
Completing projects, and having to assess the impact on patient care as part of the process, have helped me to maintain a focus on patients which is not always apparent in a primary and community care environment. I often remind staff within the HR Directorate that we are about improving the patient experience.
I will challenge the views of others in situations when I would not have done previously, to ensure that the impact on patient care is priority.
I have found a new way of working which demonstrates the value of my knowledge, my ability to achieve results both personally and through others, my ability to take personal ownership of my actions and their consequences and relate all that I do to the patient.
A very direct result of the programme has been HR participation in user involvement in the trust
The impact of the programme
The commissioners and their context
This programme was already running when the NHS Leadership Centre was formally established, having been commissioned by one of the functional directorates of the (then) NHS Executive. However it has developed to fit within the overall portfolio of leadership programmes funded by the NHS and has just been commissioned for a further two intakes of up to 100 participants each. During the time that the programme has been running it is clear that the understanding of leadership within the NHS, as well as the ways by which it can be developed, has evolved considerably. What is clear from informal feedback to the providers is that the focus of this programme on translating learning into behaviour and into changes in the workplace and improvements in patient care is in line with this evolution and the current focus of leadership development activity within the NHS.
The NHS Leadership Centre does not appear to have an “agreed” definition of leadership – it could be argued that this is a strength rather than a weakness, given the diversity of definitions available. Although a “clear vision of what leadership means” is recommended (Alimo-Metcalfe and Lawler, 2001), it is in practice difficult to see how this can be done within the NHS when there is no central agreement, and possibly the adoption of a single definition would only restrict the potential for development. However, perhaps the leadership qualities framework is a tight enough definition, without being too restrictive, although it has been developed from a very small and organisationally narrow sample – further more wide-ranging research is needed to validate it.
However, the lack of a central definition, and the lack of a formal definition within this programme too, has caused some consternation with participants. The popularity of the US charismatic leader philosophy led to some participants initially being reluctant to consider more detailed aspects of organisations, which they felt to be about “management” not “leadership”. However, by the end of the programme, this understanding of both the transactional and transformation aspects of leadership had developed and was acknowledged by participants to be influential and important.
The contextual model of leadership (Alimo-Metcalfe and Lawler, 2001) was not a major focus of this programme – although participants often believed that there was something “different” about the NHS context that made the translation of ideas and models from other sectors problematical. The view from the programme commissioners was supportive of both learning from other sectors and also from other countries (as evidenced by the inclusion of two international modules in the programme). However, participants who had previously worked in other sectors did note that the NHS was more complex than many other types of organisation, an observation supported by other evidence (Alimo-Metcalfe and Alban-Metcalfe, 2001). Models of transformational and situational leadership were explored within the programme.
Structure and mode of delivery
This programme appears to fit very well with the characteristics of effective development programmes (Alimo-Metcalfe and Lawler, 2001): a strong action learning approach, using direct personal and business issues as the focus of activity, encouraging and expecting participants to implement changes in their work environments, and having the strong support of senior management and the support of line managers. This last point is perhaps the one that, in practice, was most difficult to achieve. It was not that managers did not want to provide support, but that day-to-day pressures, especially those around the achievement of targets, including financial issues, took priority at times. The significant organisational and structural changes resulting from “Shifting the balance of power” (Department of Health, 2001) affected a number of participants and the extent to which they were able to give time and energy to the programme and to their own development. This appears not to be a unique feature of the NHS (Alimo-Metcalfe and Lawler, 2001).
There was evidence from the staff involved with the programme that this type of programme required a change in their role – with much more emphasis on facilitation than in other types of teaching. All the university staff teaching on the programme were research active (in line with the overall philosophy of the provider institutions) and involvement with the programme gave new opportunities for research, but also grounded research activity in “reality”. The use of action learning (albeit not in its purest sense, since all learning sets were facilitated) is in line with effective leadership development, as described in the literature, and is something that the providers have gone on to use in other programmes subsequently, with similar success.
In terms of the new paradigm of leadership development (Fulmer, 1997), this programme can be seen to be well within the “future” paradigm – with the focus on participants as learners, the design of the programme being flexible and responsive to changes in the context as well as participant and provider feedback, clearly designed for action and looking to the future in terms of preparedness for change. Not only did the programme take place in Manchester, but also all across the UK and in Europe and the US – one of the many benefits of the partnership between a management consultancy and a university as providers of the programme. The programme also covers the areas suggested by (Conger, 1993) as those required in effective leadership development programmes.
The evidence is clear that “best practice organisations” always assess the outcome of their leader (Fulmer and Wagner, 1999), and this programme is no exception in this. There is also evidence that focusing on behaviour change will lead to changes in results/tangible outcomes (Ulrich et al., 1999) and again there is evidence from this programme to support this. The focus of evaluation was on the impact of the programme, not whether the leadership characteristics of the individuals had altered per se. Although the participants were asked to make some attempt to link the various elements of the programme to the changes that had resulted, many pointed out that it was the overall effect that was important, not the individual elements. However, it was patient care where much of the impact would ultimately be felt.
Many participants pointed out that they were now much better placed to utilise evidence effectively which is a factor not often cited in the leadership literature, but appeared to be important within the NHS culture:
While I have always had reasonable credibility amongst my colleagues and peers I now experience greater involvement and respect from clinical academics than I have before.
This enthusiasm for gathering and analysing evidence was also apparent in the relatively large numbers choosing to carry out an MSc dissertation, which gave the opportunity to investigate a topic in much more detail than is possible within the core programme. Such research will enable both theoretical and empirical investigation. The dissertations (which are more substantial pieces of empirical research, up to 25,000 words in length) appear to be yielding similar service benefits, and a more comprehensive and rigorous analysis of this aspect will be carried out in due course. This increased use of evidence has enhanced the ability of the participants to exercise the discretionary element of leadership (Kakabadse et al., 1996) through more informed decision making.
The gap between aspiration and achievement (Alimo-Metcalfe and Lawler, 2001) was evident, as it seems to be in most leadership development programmes, in that at times participants had problems in putting their proposed changes into practice because of the context in which they were working. Not only was there organisational instability as the result of restructuring, but a preponderance of national initiatives and continued emphasis on performance measures made it difficult for some to find the space to make changes within the daily pressures of their relatively senior roles. This “political” aspect (Alimo-Metcalfe and Lawler, 2001) was also evident in those whose motivation for coming on the programme was more to be seen as participating in such a high-profile initiative – the gap between their aspirations and the reality of their involvement was large, and those whose motivation to implement change and commit time to the programme was overcome by other factors tended to gain less both individually and organisationally from their participation.
A number of participants moved jobs either during or after the programme (Harris et al., 2003) and although this was often for promotion as a result of the increased capabilities developed through participation on the programme, there were some cases where participants felt that their style no longer “fitted” with the context of the organisation and this was a factor in them moving to another role. Details of job changes and the factors that influenced them are reported elsewhere (Harris et al., 2003).
So can the programme be considered as a success? In the terms that are described independently it appears so (Ready and Conger, 2003). There was some evidence of the “ownership is power” mind-set, with the senior focus not always being as much on shared accountability as some participants would have liked, but never to the extent that the effects of the programme were negated. The programme was clearly designed around the needs of the NHS and has constantly evolved as the context has evolved. At the time the best available metrics for success were used – those generated by the participants themselves (see Figure 2), within the context of the large number of performance measures already used within the NHS, including some specific to the HR function (for those from that professional background). However, it is acknowledged that there is always more work to do in this area as performance measures evolve (Department of Health, 2004).
Conclusions and the future
The programme has benefited from the changes in organisation of, and emphasis on, leadership development within the NHS, by being designed in a way that meets the future requirements of the NHS and its leadership development. The popularity of the transformational leadership approach appears to have shifted the emphasis away from the transactional aspects of leadership/management despite clear research evidence that both are necessary. The evidence in this paper shows that the NHS can learn from other sectors (approaches taught were not exclusive to the NHS and speakers from other sectors were used in various parts of the programme) – although this is challenging for both thinking and behaviour for those who are learning.
The characteristics of this programme have been shown to be consistent with the evidence from literature concerned with effective leadership development, in as far as such qualitative evidence can be argued to support other evidence. In particular, the use of action learning and the application of knowledge in the workplace are recognised as important. The approach of this programme is consistent with the evolving paradigms of leadership development.
All programmes have their weaknesses, and this one is no exception. This paper has deliberately focused on the positive outcomes from this work that are without doubt the vast majority, and therefore it is not intended to describe or address the weaknesses in detail here. Many related to structural issues, which were addressed in subsequent intakes, or to the volume of work required for full participation in the programme, which was difficult for some participants to manage given the responsibilities of their NHS roles. This was not necessarily a weakness of the programme but certainly coloured some of the responses from participants during the evaluation. Although it could be argued that the lack of definition of leadership in the programme was a weakness, evidence has shown impact on a wide range of what could be termed leadership “behaviours”. Feedback and perceptions were gathered from a number of different perspectives at different points in the programme (Alimo-Metcalfe and Alban-Metcalfe, 2002)
The evaluation of this programme focused on learning at both personal and organisational levels. The increased awareness and utilisation of evidence has increased the discretionary leadership capabilities of participants.
It is inevitable that politics will influence implementation of change and the context of leadership development, and this programme is no exception. Despite the recommendations of the literature (Alimo-Metcalfe and Lawler, 2001) that leadership development is best over carried out over a period of time, rather than through a one-off course, this caused some difficulty for participants because it appears to be increasingly difficult to take time away from the workplace, the more senior the role in the organisation. Whilst there is always an element of personal organisation and work prioritisation in this, there were clear examples of pressures that could not be avoided (e.g. industrial tribunals, CHI reviews) which interfered with the ability of the participants to attend. Those who completed the programme are without exception positive about its effect on them as individuals and about its effect on their organisations and the patients who they serve, but acknowledge that participation was very hard work.
However, political issues have not in general or totality negated the positive impact of the programme. The process of evaluating the programme is continuing to develop, in line with broader changes in the environment, but the key ultimate focus is on the improvement of patient care within the NHS. The problems associated with developing appropriate performance metrics were to some extent minimised by using self-generated categories for the first intake – something that is being refined for future intakes, although we intend to retain some element of self-generated metrics since it provides a richer source of data than simply asking participants to rate pre-determined factors.
Issues that are continuing to develop in importance within the programme content and focus include the role of leadership and teams – something that is often raised as more collaborative initiatives are introduced within the NHS, and partnership working developed, as well as being considered by academics (Kakabadse, 2000). There is also continued scope to develop the link between effective leadership and patient care, both in terms of research and also within the programme. To date, no independent or patient-focused measures of effectiveness have been utilised; changes in patient care have been reported by participants but not independently verified.
Another potential research area that can be linked with the programme is that of context and culture; something that has come to increased prominence as primary care trusts seek to mature and fulfil their purpose within the overall health economy. This will in turn impact on the role of acute trusts and other healthcare providers. Much literature on leadership and culture appears to assume that there is one culture per organisation (Alimo-Metcalfe and Nyfield, 2002), but experience of the NHS shows that this is not the case and therefore leaders may have to be much more flexible about utilising styles appropriate to the particular sub-culture, once it is assessed (Scott et al., 2003). The issue of professional cultures is also increasing in importance as the modernisation agenda is developed (Degeling et al., 2003).
It is also hoped that further funding will be made available to track the career paths of participants on the programme, as was done for the first intake (Harris et al., 2003). Within this context there is also scope for gender-focused research and analysis, which has not to date been carried out in this context.
Lessons for others?
The issue of generalisability of results is always a factor in research, as well as in evaluation of programmes of this nature. Any study of this type will be limited by its nature as a self-reported study of a single group in a common context. There is also the issue of potentially different understanding by individuals of terms used and concepts identified. However, these limitations are balanced out to some degree by the depth of the study and the level of detail, particularly from qualitative data, which it has yielded.
However, there do appear to be some key lessons from this programme that are transferable to others. The main one is clearly that it is possible to design and implement leadership development programmes for/within the NHS that make a difference – both to the individual participants, to their organisations and then ultimately to the patients who the NHS serves.
Other lessons include:
- action learning is a useful method for this type of development;
- time available away from the workplace is key, but availability of this is not only a matter of personal motivation and organisation;
- providing participants with a variety of views and perspectives on leadership is key in enabling them to develop the discretionary aspects of leadership behaviour through the assessment of evidence, which increase in importance with the level of the participant within the organisation;
- measuring the impact of leadership development is an evolving process and one where it would be useful to share best practice and experience;
- taking part in such programmes is hard work for participants, but beneficial for individuals in terms of personal development but also career development, as well as benefiting organisations who sponsor participation; and
- developing and providing such programmes is a new challenge for some parts of the provider community but one that has proved to be beneficial from a variety of perspectives.
Figure 1The Kirkpatrick model
Figure 2Achievement of programme objectives
Table IComparison of leadership and management
Table IIThe evolving paradigm of leadership development
Table IIIResponsibilities of the programme partners
Table IVSummary of content of the programme
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About the author
Ruth J. Boaden is Senior Lecturer in Operations Management at Manchester Business School. Her research interests cover a wide range of areas within health services management and include work in electronic health records, reengineering, operating theatre management and scheduling, patient safety, the management of emergency admissions, bed management and chronic disease management. Her main areas of interest are in quality and improvement and the use of industrial methods within the NHS. She has published widely in these areas as well as in the areas of IT implementation and quality management. She set up and teaches on the “Leadership through effective people management” programme for the NHS Leadership Centre, which is run in partnership with PricewaterhouseCoopers and provided for directors and deputies from across the NHS. She is also a non-executive director of Pennine Acute Hospitals NHS Trust that she finds a challenging but rewarding opportunity to put theory into practice! Ruth J. Boaden can be contacted at: Ruth.Boaden@mbs.ac.uk