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Leadership and Organisational Performance Print E-mail
The Quarterly 2014

This article was written by Dr Susan Keam, derived from material presented by Professor Chris Ham on the 2nd of June 2013 for the WFMM Annual Conference. A recording of the conference can be found on the WFMM website here

Leadership and management in the NHS

Massive, complex organisations like the NHS require top class leadership and management. Managers and leaders in the NHS have a critical role supporting doctors, nurses and other clinicians to improve patient care. In 2011, in an environment where politicians of all parties called for cuts in management costs/bureaucracy in the NHS, The King’s Fund* set up a Leadership Commission to consider the future of leadership and management in the organisation. Their findings, summarised in the report “The future of leadership and management in the NHS: no more heroes”, were
  • No more heroes: the NHS needs to move beyond heroic leadership focused on the role chief executive
  • Leadership needs to be shared and collective: a property of teams and not individuals
  • Leadership needs to be distributed and present at all levels of the organisation, especially in clinical microsystems
  • Leadership needs to be developed alongside followership
  • Clinical leadership in the NHS remains variable and under developed
  • Clinical leaders need to work hand in hand with experienced managers
  • High performing health care organisation around the world exemplify the benefits of clinical leader/manager partnerships.
Building on the themes in the first report, in 2012 the Leadership Commission then considered  leadership and engagement in organisations  both within (at every level – links to distributed leadership) and across organisational and system boundaries, with the aim of  understanding and clarifying  the value of engaging leadership in the NHS leading to improvements in care and quality. As part of the review, the Commission also provided case studies and recommendations to support the further development of leadership and engagement for improvement in the NHS. The key findings of this report, “ Leadership and Engagement for Improvement in the NHS: together we can”,  were that there is the strong evidence that leaders who engage staff deliver better patient experience, stronger financial management, higher staff morale and less absenteeism and stress. West and Dawson (2012) have shown that there is a clear correlation between leaders who engage their staff and achieving better patient experience, stronger financial management, higher staff morale, less absenteeism and stress.
Absenteeism is lowest when overall engagement, motivation, involvement and advocacy is high, and the quality of services provided and financial performance is greatest when engagement is high (figures 1 & 2; figures are from the 2012 Leadership and Engagement report). How an organisation is performing in relation to leadership and engagement can be effectively assessed using staff surveys, and results can then be correlated with organisational performance measures.


The business case is compelling: there is a strong link also between medical engagement, improved organisational performance and better patient outcomes, and a strong correlation between levels of staff engagement and hospital mortality rates.  As noted by Angela Coulter in her research, ‘Happy staff makes happy patients’.
How do we engage staff?

Michael West, in his research over many years, has shown that simple changes can make a big difference e.g. doing effective appraisals, clear job design and providing a well-structured team environment. NHS organisations need to support leadership and engagement for improvement through good human resources practices to create a culture and  climate where staff feel valued and feel engaged, while NHS boards should value patient and staff engagement and pay attention to staff health and wellbeing e.g. by acting on the results of the NHS staff surveys.
Warning signals about potential problems in the organisation are often evident in staff survey responses. Within the NHS, the dominant leadership style is a “pace-setting” style (leaders leading from the front, setting demanding targets and pushing others to do the same, encouraging people to overachieve). Importantly, a pace-setting leadership style and engagement don’t naturally go hand-in-hand, and to achieve good engagement, this style needs to be complemented by other approaches, e.g. managers with a facilitation or coaching style and a more collective, team-based approach, such as that identified in “No more heroes”.
Leadership in microsystems

Gill Maben’s research on leadership in microsystems, published in 2012, is very important. This research underlines the critical role of team leaders in creating the right climate for high quality patient care. Within a clinical setting, the team leader is often a nurse, rather than a doctor. Effective team leaders value staff, create time to for staff to provide care, and provide support and feedback to staff. Unless we have great team leaders who are valuing and appreciating the members of the team, we will not see the quality of patient care that we want. Valuing and developing team leaders in the NHS, therefore, needs much more attention.

Medical engagement and organisational performance

Various studies have shown a relationship between medical engagement and organisational performance. The Medical Engagement Scale in the UK uses a tool to assess engagement and relates the results to routine performance measures. Research in Europe and the US by McKinsey and the LSE found that organisations with clinically qualified managers produced better results. Goodall has observed in the US that there is a correlation between hospital performance and whether or not the CEO is a physician (better performance is achieved with a physician CEO).

Key Assumptions of the Medical Engagement Scale

Improvement in healthcare needs the positive involvement and engagement of doctors who are highly influential in planning and delivering service change. Competence can be thought of as what someone “can do”, whereas engagement requires a “will do” attitude. Reliable and valid measurement and monitoring of medical engagement is critical, since this will inform and shape the effective management of change. Many definitions of engagement focus solely on individual aspect of engagement whereas the Medical Engagement Scale (MES) also incorporates organisational conditions.
The MES is a complex instrument that identifies whether participants feel they are working in an open culture, have purpose and direction and feel valued and empowered. Within these three meta scales, there are subscales around learning, relationships, performance and rewards, participation in decision making and change, professional development opportunities and commitment and work satisfaction.
The MES has been applied in a number of NHS sites and results show that, in general, higher levels of engagement (evidenced by a higher overall MES Index score) are associated with good or excellent overall quality and financial management scores, while lower levels of engagement are associated with lower quality and financial management scores (see www.institute.nhs.uk/medicalleadership for more detailed discussion of the implications of MES outcomes).

Level of Medical Engagement and the Care Quality Commission NHS Performance Ratings (2008/2009)
Trust ID Overall Medical Engagement Scale Index Overall Quality Score Financial Management Score
21 65.8 Good Excellent
12 65.2 Good Good
15 63.4 Excellent Good
5 62.0 Excellent Excellent
24 60.8 Good Excellent
1 60.4 Excellent Excellent
10 59.9 Good Excellent
16 59.8 Good Fair
14 59.7 Excellent Excellent
11 58.8 Excellent Excellent
25 56.8 Fair Fair
4 56.7 Fair Fair
22 55.7 Fair Fair
23 55.3 Fair Good
29 54.4 Good Excellent
3 54.3 Fair Excellent
26 53.1 Fair Fair
8 52.7 Good Good
18 52.1 Fair Fair
20 47.0 Poor Poor


Engaging and valuing all staff (not only medical staff) will bring benefits. Engaging doctors is especially important because of their ability to block change as well as make change happen. Health care organisations are complex adaptive systems that need leaders at all levels. Medical leaders must work within the team and organisational context: i.e. No more heroes.

Where next?

The business case is compelling but many obstacles remain. Engagement is as much about the development of followership as of leadership. Medical leadership roles are not always attractive compared with the alternatives. Leadership development needs to go hand in hand with work on valuing medical leadership, developing career structures, and providing financial and nonfinancial incentives.

Developing Followership

Developing leaders without simultaneously developing followers risks setting up leaders to fail. High performing health care organisations like Kaiser Permanente and Mayo Clinic focus on developing all staff. These organisations develop cultures of engagement and improvement at all levels. Other examples of high-performing organisations include Intermountain Healthcare and Jonkoping County Council, which invest heavily in-house in leadership for improvement.
Finally, let’s remember the many other influences on organisational performance. Medical engagement and leadership are certainly critical factors, but they are not the only ones. Other factors that are important are: organisational stability (frequent restructuring is distracting and gets in the way of having better patient care); having a clear vision, which is focused on quality and outcomes first and foremost, and being constant in pursuing that vision; the relentless use of measurement and data (converting the vision into specific measurable goals and objectives for quality and service improvement, then collecting the data routinely to track progress towards the successful delivery of those goals).

* The King’s Fund

The King’s Fund is an independent charitable foundation established in 1897. Since 1951, the Fund has been involved in leadership development within healthcare. Currently, the Fund works closely with NHS organisations to support leadership development and is also engaged in research and thought leadership on leadership in the NHS.

The Royal Australasian College of Medical Administrators
Professor Chris Ham, , p680
www.racma.edu.au /index.php?option=com_content&view=article&id=680&Itemid=400