A critical account of the rise and spread of leadership in the NHS

1. A critical account of the rise and spread of leadership in the NHS Graham Martin, University of Leicester Mark Learmonth, Durham University Full paper published in Social Science & Medicine 74(3)281-288.

2. The growth and spread of leadership • ‘Leadership’ increasingly prominent in talk about organizational life • Organizational elites now typically get called leaders • New phenomenon; previously preferred terms: • managers (60s-90s) • administrators (pre-60s) • Rapid growth in academic attention to leadership, too: WoS citations increased from 498 in 1979 to 3,537 in 2009

3. Leadership in Health Care • NHS Leadership Centre established in 2004; NHS Institute publishes Leadership Qualities Framework 2005; leadership discourse prominent in many recent NHS initiatives • Similar in other countries: e.g. www.nchl.org • Today, term “leadership” deployed to cover a whole host of quite disparate NHS activities, carried out by a diverse range of actors: not just elites

4. The discursive evolution of “leadership”: Research questions • How has the range of NHS activities and actors called leadership/leaders changed in the last 10-15 years? • What are the consequences of calling these activities ‘leadership’ and these actors ‘leaders’? • Key concern: not with what leadership “is” but what (calling things) leadership “does”.

5. Our study • Re-analysis of interviews with NHS chief executives from 1998-1999 • performative aspects of their language • ‘administration’, ‘management’, ‘leadership’ • Discourse analysis of DH command papers since 1997 (n=10) • excluding social care and discipline-specific • including High Quality Care for All (2008) • discursive function of leadership; chronology

6. Late 1990s’ NHS chief executives • Management the dominant term for chief executives’ activity • administration denigrated • leadership not yet prominent – casual synonym for management “There [had been] no radical or strategic thinking enough to do that sort of work; [name of trust] used to be peopled by a bunch of administrators, basically.” “The emergence of clinical governance was an opportunity to refocus the doctors’ role on clinical management, leadership and the management increasingly of clinical practice informed by evidence.”

7. The rise of leadership in policy discourse Three analytical (to some extent chronological) themes: • Theme I: The importance of senior-level leadership • Theme II: The distribution of leadership to frontline practitioners—and beyond • Theme III: Heterogeneous groups leading policy, not just its implementation

8. I. Senior-level leadership • Early (c.1997-2000) documents focus on leadership capacity at the top • Health Authorities “leading and shaping” NHS, “freed from unnecessary administrative activities” (The New NHS, 1997) • New senior roles outside management (e.g. nurse/AHP consultants, modern matrons) “NHS organizations should be led by the brightest and the best of public sector management. Leadership development in the NHS has always been ad hoc and incoherent with too few clinicians in leadership roles and too little opportunity for board members to develop leadership skills.” (The NHS Plan, 2000)

9. II. The distribution of leadership • From c.2002 onward, increasing focus on giving “frontline staff greater control,” displacing “the traditional top-down management approach” (Delivering the NHS Plan, 2002) • e.g. nurses to play “a lead role in improving the experience of patients in both the hospital and the community” (NHS Improvement Plan, 2004) “Real change will happen at the front line, with support from the centre, fuelled by encouragement and expectation from patients and drawing on the experience of partner organisations and other experts. Change will need: a clear shared vision and values, owned by national and local leaders; supported by continued investment and capacity growth; delivered by empowered staff, with support from peers and experts.” (Building on the Best, 2003)

10. II. The distribution of leadership (cont.) • Beyond frontline staff, patients and the public also now to play leadership roles • E.g. health improvement and promotion: need for “new forms of community leadership” and “a new approach to unlocking the energy that lies within communities themselves” (Choosing Health, 2004)

11. III. Leading the direction of policy • c.2006 onward: these leaders are (constructed as) leading policy, not just its implementation • e.g. contributions to HQCfA from 2000 NHS staff “who have shown tremendous leadership in creating, shaping and forming the conclusions”

12. Discussion • Expansion of leadership discourse: more leadership, more leaders • senior managers, frontline clinicians, patients and the public • leading not just implementation but policy • And yet… • an increasingly centralised NHS? (e.g. Greener et al., 2009) • an increasingly consumerist NHS, undesired by the public? (e.g. Clarke et al., 2007)

13. Leadership as subjectification? • Constituting particular identities • “Discourses of leadership in the public sector, depicted within the broader modernization discourse, provide managers with a means of self-monitoring, in which managers are ‘cultivated’ to become ‘autonomous, self-regulating, productive individuals’” (Ford, 2006) • But not just (former) “managers” – clinicians find a leadership identity attractive, but would have rejected being a manager

14. Leadership as identity, and as fig-leaf? • A means of aligning diffuse agents with policy aims? • Top-down direction an insufficient model of governance in contemporary, fragmented NHS • Need for a critical mass of actors to identify with the aims of policy? • Many people want to be leaders – but discourse hides traditional managerial imperatives necessarily involved in being a leader.