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The best leadership is inclusive, is very much a team sport that doesn't always lead to excellence in leadership, and I.
Think the system is sometimes defaulted to that.
So I think leadership in those days was almost synonymous with management.
This is the national health executive podcast, bringing you views, insights and conversation from leaders across the health sector, presented by Louis risks.
Today I'm delighted to be joined by Steve Gallarti, associate professor and director of healthcare leadership for the Health Services Management center, at the University of Birmingham. But to start with, I want to ask you about when you started in the NHS and how would you describe leadership then?
Well, I joined the NHS in around the mid 1990s, and in lots of.
Ways, there were many parallels today to.
What we saw then, significant service pressures.
Creaking infrastructure, long waits, et cetera.
So I think leadership in those days.
Was almost synonymous with management.
It certainly wasn't more of the sort.
Of nuanced distinctions that you get today.
And I think allied to that, there was a concept that was more prominent.
Of what I'd called stewardship rather than leadership, looking after resources, distributing resources, deploying them, rather than leadership as we describe it today.
So I think it was quite patchy. I think there wasn't very much.
Attempt in those days to identify best practice and, to disseminate it in the way that we would today.
there was probably some tensions as.
Well, I think, between management and clinicians.
And, clinical leadership, I think, was.
Very much in its infancy in those days.
So, in summary, I think there was a strong top down culture, when.
I joined the NHS 30 or so years ago.
and, there were quite strong.
Concepts of heroic leadership, and of.
Trait based ideas that leaders were born and not made.
And there was strong macho culture around it.
Having said all of that, I think there was, a great deal of enthusiasm, a very strong ethos of commitment.
To service, a real sense of mission.
and very much values driven behaviors. So I think that's something that hasn't.
Changed and I think that's something which is staying the same today as well.
You mentioned stewardship there. Would you characterize stewardship then as more of just managing current practice rather than leadership, as driving forward practice in that respect?
I think that's an accurate summary. and that's certainly, I think, what the NHS experienced for quite a long time, which was, the role of leaders being much more what we.
Would describe now as managing resources rather than leading.
And if there is a single point.
Of difference, I think it's around this concept of leading for improvement, which we try and work to today, compared to the sort of ideas of stewardship.
Which was, efficient administration rather than.
What we would today call leadership.
You've already mentioned some of the changes in the following years. What would you say the main changes are in leadership and the main levers follows changes?
I think there's definitely a trend to recognize that leadership and management, are.
Important and don't just happen.
I think that's something which is.
Quite an important distinction to make, but.
Also that management and leadership are different.
And leadership and management education has much more of a recognized concept today,
Than I think it was some years ago.
Allied to that, there's attempts to move.
Towards a more evidence based approach, accepting that in a field as complex and dynamic, and as dependent on.
People as leadership and management is, there's always going to be significant elements of nuance. So constructing leadership development opportunities or learning opportunities which are people centric has been quite a big change over the past couple of decades, and that probably compares to being very sort of task centric.
before, and then we move.
Into something which is a lot more relational now, I think probably thirdly, my.
Thinking, there's a move towards a more diversified approach as well. firstly an acceptance of and then.
A slowly valuing difference.
Perhaps I can give you an example that sums that up. the NHS Institute for Improvement, used to develop a series of publications.
this is probably going back 20 years, and they developed a sort of series of interventions around ten high impact changes. And that was in a variety of fields and there was something about ten high impact changes for human resources, I think, and around leadership, around people management. And that was really useful in spreading good practice. It was a good thing, but it.
Was also quite prescriptive. and I think what we've got now is a realization that objective interventions.
Which are evidence based, are, ah, very useful, but they're always implemented in a subjective way, they're always implemented by people. And therefore, if people are being authentic to their leadership, the implementation of evidence based practice is going to be nuanced.
So I think that's as much a.
Driver today as, any input output model that we used to see.
which I can probably summarize as.
Some of these changes being recognizing the importance of evidence, but recognizing as well that it's not going to be implemented in the same way, perhaps in Cornwall than it would be in Cumbria.
You describe in the journey of NHS leadership there, how would you sum up the state of NHS leadership now, are we in a good place?
I think it's pressured. I have to be very honest about that.
I think the state of NHS leadership today is under pressure.
the demands are more complex than ever.
We're seeing lots of burnout.
and I think in those circumstances of pressure, some of the relational behaviors are the first things that go.
when people feel pressured or stressed. There's an understandable tendency, I think, in.
Leadership in the NHS today to cleave.
To task the need to get things.
Done, and the people's side is often in those circumstances, ah, either not.
Considered or if there's pressures around those relational, dynamics, that's accepted as collateral damage. I think sometimes the best leaders know this and know how to attend to it, rather than seeing some of the softer skills as a nice to have or an optional extra. On the other hand, I think there.
Is more recognition and appreciation of the.
Value that leaders bring than ever before.
and that leadership exists in so.
Many different levels and in so many different spaces. There's fewer stereotypes of leaders and leadership today.
I think, certainly in terms of.
classifying types of people or, types of behavior, there's more of the old trait based ideas.
I think we've made really good progress.
In leadership in the NHS around that.
there being a much greater recognition.
That leadership is practiced at so many.
Different levels and by so many different people. So I think there are far more.
Flavors of leadership which were accepted today.
than there have been in the past. But I think it's accurate to say.
That leadership is perhaps just like any other part of the NHS, is under pressure.
How much of these changes to leadership would you put down to the NHS in itself, rather than just general changing society and changing values, changing opinions?
I don't think we can separate the two. thinking around leadership and leadership practices.
Evolves as society evolves.
and using diversity as an example.
thinking around diversity has moved on a lot in the last 20 or 30 years from those original ideas around equal opportunities of that. If we treat everybody the same, that's fair. That thinking has moved on to recognizing that people come with different needs, this.
Concept of diversity, and that systems.
And individual leaders need to respond to those needs, rather than just treating everybody the same.
So I think the ideas around leadership evolve as society evolves.
And I don't think we can dislocate.
The NHS from it being a societal construct as well.
It exists in a context, and I.
Think that's very similar to the ideas.
Around situational leadership, contingent leadership, which is about maintaining a set of principles and authenticity. But they're applied in very distinct ways, which recognizes the context.
Now, this conversation sprouted from a separate conversation we had about the Anderson program at the University of Birmingham. and we'll get onto that shortly. You mentioned in that conversation there are some well known truths about NHS leadership that are seldom voiced. Would you be able to share what they are from your perspective?
Yeah, I'll try not to be controversial here. and this is based as much on my time in the NHS as my experience now working with the NHS.
I think there's probably three things that I would say in response to that question. The first of which is this concept.
Of an accidental leader, that as people.
Do well in their jobs in the NHS, they tend to get promoted and.
They often end up in management or leadership positions, but often without training or without support. I think it relates back to the, question we discussed about state.
Of NHS leadership today. I think it's much improved in terms.
Of people are supported when they're put into leadership positions. but this concept, of being really excellent at your profession or being really effective in your operation, will lead to promotion, that doesn't always.
Lead to excellence in leadership, and I think the system is sometimes defaulted to that. I think secondly, a very serious.
Point, I think, around, leaders being attracted to, or being, in a system which is really avoidant of conflict, to a degree.
I think that efficiency and sometimes, possibly even patient safety can be compromised. I think it was, Roger Klein who talked about false harmony, which.
In turn can sometimes lead to this idea of protective hesitancy, all of which is about stifling healthy debate in systems.
And I think the best leaders know both how to sensitively explore these topics. Sensitive topics open up debate, sometimes have some quite vigorous debate about it, but then also to close it down safely. Now, I think because of the pressures that I've talked about already, and I think because of systems and culture, leaders in the NHS sometimes find that difficult.
And avoiding, conflict is easier, but in the long run, it.
Doesn'T bring any benefits. I think we know from discourse in every other way, the longer one avoids or puts these things off, sometimes the worse it becomes.
And thirdly, I think everybody is so busy, we know that in broad terms.
That sort of environment leads to a propensity to action, by which I mean that time for thinking and for.
Reflecting, is sometimes viewed with suspicion.
And it certainly isn't always facilitated.
and although cleaving to task and having a propensity to action, I. E.
Just get on and do things that can make for really successful task completion in the short term. But it doesn't always make for reflective or even compassionate leadership.
And I think it relates back to something we talked about a bit earlier.
About the importance of the best leaders, recognizing that time spent on relational soft skills is a real investment, it's not a waste of time.
And on that second point about conflict avoidance, which has the need not for confrontation, but at least measures in place to ensure accountability, and maybe hard conversations are taken when they need to, and.
It'S a key skill. Again, I think we need to recognize.
That people aren't necessarily born with us.
And it doesn't happen by accident.
It takes skill to be able to have difficult conversations, but to be.
Able to do them in a way that's constructive, that doesn't lead to.
Relationships being damaged, which can be easily.
Done, and some people are more naturally inclined to do that. But I think that's also then dependent upon a system which facilitates it as well. And I think that was a real.
Challenge for leaders in the NHS, especially given the complexity of what leaders do in the NHS, but also the sort of critical importance of the work they do in terms of, for example, I use the example of patient safety.
but it relates to all spheres of operation. So it is critically important, this ability.
To have difficult conversations, to explore sensitive topics, to be able to manage the outcome of that.
and that's certainly something that we actually focus on, on programs like the.
Elizabeth Gat Anderson programme that you've mentioned, and the work that we do, with the NHS Leadership Academy, a lot of that is about relational dynamics, people skills, rather than, I think, the.
More traditional management development input of times.
Gone by, which was very much about knowledge transfer.
so I think it is critical, but it's something we need to.
Recognize, doesn't just happen.
You've mentioned the program, though, helpfully, because it was going to be my next question. Could you tell the listeners a bit about the program, what it aims to do, what it's hoping to do, how it works, just the real machinations behind the program.
Yes, the Elizabeth Garrett Anderson program, is a master's lovely program, it's been running for ten years now,
And commissioned by the NHS Leech Academy.
Delivered by ourselves here at the University of Birmingham in partnership with the University of Manchester.
I think the best way to summarize.
The whole program is this fundamental credo or ethos that we use, which is.
We challenge leaders from day one on the program, right through to the end of the program, to think about what's it like to be on the receiving end of me. And the first time I heard that.
Phrase, I think it's a very simple.
Phrase, but I thought it was exceptional in challenging people to think about the impacts they have. So the program works in terms of.
Structure, works at three levels.
it looks at individual practice, team dynamics, organizational effectiveness and impact.
But running through that is a set of what we call golden threads,
Which focus on things like equality, diversity, inclusion.
but the credo running through all.
Of that is thinking about and giving people the confidence and the skills and the ability to have the courage, I.
Think, to have the ability to ask the question, what's it like to be on the receiving end of me?
What's it like working for me?
The theoretical basis of the program is the growing evidence around the impact,
On patient clinic clinical outcomes and patient.
Experience of well led organizations.
Well led teams, make for better clinical outcomes and for better patient experience. That's a really important concept.
But from day one on the program.
We'Ve recognized that this isn't a knowledge transfer environment.
we do that through a virtual learning environment.
The key learning that takes place through.
The program is, what we call social learning.
And it is about working in groups towards a common goal, but always having.
This level of what we call reflexivity.
Of thinking about what it's like for people who are receiving my leadership.
And on that, this is, an off cuff question. Based on what you just said, how important is it for, do you think, leaders to be embedded within their community? Talk about social leadership there. For me, leadership strikes me as a word where you do it on your own, you do it from the top. And you mentioned top down before and back in the day, how important would you say it is for the NHS leaders to be really embedded within their teams, be on the front lines, as it were?
I think it's a, ah, really interesting question and I think it's really interesting concept because we emphasize from again, throughout.
The programme of the Elizabeth Anderson programme, but also the other work that we do at the health services Management Centre.
At the University of Birmingham. It is about that, leadership is a team sport. I think if there's one difference that sums up, modern leadership practice and thinking from what we used, to do, and certainly what I experienced when.
I joined the NHS, was leadership. Was seen as an individual, heroic thing to be undertaken by people who were.
Born with certain traits, and they.
Know, sometimes inaccessible, quite macho in lots of ways.
and the big change that's happened.
In terms of thinking, and again, this is based on evidence and research, is.
That, the best leadership is inclusive.
Is very much a team sport.
So that is a fundamental part of what we do.
And it's one of the reasons that we've not just structured the Elizabeth Clarence Anderson program the way we have, but the approach that we encourage with people.
Who go through the programs, is.
To think about, as I've mentioned, what it's like to be on the receiving end of me, to think about, the context in which they're, performing.
So I think, to answer your question.
As directly as I can, I think.
That context is critical.
I don't think we can separate out, people from their organizational culture. I don't think we can separate out organizations from their societal, context. all of these things are connected.
And I think that's one of the.
Reasons in terms of management development, education, in the NHS, is this movement's very welcome movement towards being a lot more holistic. Rather than thinking that if we teach a set curriculum, we will get a particular outcome, we know that doesn't happen. We've got years of evidence that that doesn't happen.
and recognizing that development takes place.
In a highly contextualized place, and that we can't separate our personality at work from the people that we are at.
Home, I think they're really critical.
Concepts and it's something which I'd like to see more of.
You mentioned evidence and research, though. How much can be taken. How much is taken from other sectors in the public sector, and how much can be taken from other, healthcare systems across the world.
And it's something I'd like to see.
More of in the future, actually.
it's something which, people have heard me speak before will recognize me, saying, I would like us in the.
NHS leadership community to lift our gaze.
and look outwards, both to other sectors, but also to Europe and the.
Global context as well.
I think sometimes there's a feeling in the NHS that because of our, unusual, relatively unique, funding structure and.
The fact that it's very much a treasured part of british society, that we're.
Somehow unique and that we don't have learning that we can gain from other sectors or from other systems. And I don't think that's the case at all, this is a very.
Live debate to think about leadership in healthcare being distinct from leadership in other sectors.
And of course, there are some things.
Which are, separate, and which are highly contextualized and there isn't a read across.
But if we look at the evidence.
For example, I've talked about patient safety, but if we look at the evidence around safety practices in industries such as aviation, as often quoted, there are so.
Many things that we can learn from.
Aviation, in fact, have learned from aviation.
in the NHS. So I'm a great advocate of,
Elevating our gaze and having the courage.
to look around us, and.
Not be a passive recipient of learning.
But also to be a bit more.
Confident that we do some things really well in the NHS. I think we are world leading in lots of ways.
but I don't think we talk.
About that very much.
And I think there's as much that.
We can teach as we can learn.
Is there a reluctance, do you think, with everything that's going on in HS and around the world? Of course, every health system is under huge pressure after Covid. Is there reluctance, do you think, on the NHS to not shout from the rooftops about what it is good at doing, but really sharing best practice and being proud of what it's done?
I think that's improving.
I think it's probably a fair summary, but I think it's improving. The NHS is getting better at, realizing that. In fact, we've got very rich sets of data, from the services that we provide, but that we can.
Disseminate best practice as well. So I'm seeing an improvement in that.
I, think sometimes there certainly was.
A reluctance, if we look back to.
Thinking that we were, sort of.
Almost classified or stereotyped as being a public sector service.
but I think there's much more awareness now that there's as much that we can teach, as we can learn.
And certainly when I talk to people from other health systems, from other countries.
they're very keen to see both.
Clinical practice, but also leadership and management practice and how it's expressed in a system such as ours.
because as I've mentioned already, the.
System that we use is very heavily values driven and values based. Now, that is very different to a profit driven system. But the relational skills that people need.
To be effective in their systems,
I won't say they're generic because I think that downplays the element of skill and nuance.
but there's certainly a read across.
Yes.
With all this being said, what changes would you like to see in NHS leadership in the near future?
I think the system would be improved.
If we had, greater curiosity about not just what works, which evidence can show us, but some of the softer things around that.
So how it works and why it works. And seeing a more integrated approach is a real strength of leaders and the leadership community.
the best leaders recognize that there.
Are many pieces to the jigsaw of a particular issue or a particular problem, and that they can be held by many different stakeholders. So the role of leaders is to identify, unlock and facilitate those discussions, rather than perhaps what we used to see.
Which was thinking that all of the.
Answers reside in a very small number of people and that they can heroically solve an issue.
I think something that's quite topical and that I'd like to see is,
Adopting a more inclusive approach to the debate about the regulation of NHS managers and leaders. I think that could easily slip into something that's quite adversarial or something that's quite, critical. So I would like that debate to be inclusive because I think if we go back to this idea of values.
one of the great pleasures of.
Working in the NHS is the sort of combining values, set of values that people bring. So I think an inclusive approach to debates about things, rather than adversarial approach would be useful.
Developing an attitude of inquiry is something.
We'Ve already talked about.
I think that will be something.
That will be very useful to, I think does exist in NHS leadership and healthcare leadership, but I think it's something which we could do more of.
having an attitude of inquiry about.
The evidence that underpins effective leadership approaches and interventions in healthcare leadership. I've already mentioned lifting our gaze to.
Look at our european friends and even a global perspective.
I think that's really important.
I think that's happening.
but it would be good to see that continuing. One of the other changes, I think, which is important to think about is recognizing, this distinction between skills based.
Management development, which contains a lot.
Of knowledge transfer and a lot of.
Practice based learning, and leadership development.
Which focuses more on ideas of reflexivity, which I've already talked about, but also about humility in some ways, and thinking about impact of self.
And that's something, again, which is a.
Trend, which is there.
Some of the work that I do locally with, Birmingham Health Partners, in the West Midlands, is really recognizing.
The interdependencies between management development and leadership development.
I think sometimes there's a bit.
Of a seesaw in terms of what gets most attention. Getting a better balance there, I think will be really important.
And if I can summarize, I think continuing to see leadership development as a.
Process rather than an event or a.
Series of events is going to be really important.
This isn't something which we can plug into people and then they'll have it for the rest of their lives.
it's something which we need to keep working at.
So we need to keep working that.
As a system, more, than.
Just one institution or one trust.
For those of our listeners who are interested in carrying on this conversation with people like yourself and with the Anderson programme, how can they do that? Where can they find you? Where can they find more information about that?
I think the first port of call.
Would be, the website around the.
Anderson programme that's a passive source of.
information for people.
But equally, people are welcome to contact.
Me here at the University of Birmingham. I'd be happy to talk to them about the program. the NHS Leadership Academy and the local NHS leadership academies as well.
are always happy to talk about the Elizabeth Kath Anderson programme, but also.
The other programs that the NHS Leadership Academy have in their suite of management development.
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