Leader board

Dr Paul Zollinger-Read
GP Prinicipal, Braintree
Director of Commissioning Development, NHS Midlands and East
Medical Adviser and Clinical Lead on Primary Care,
The King’s Fund

Leadership: mysterious, illusive, yet fundamental. Clinical commissioning groups (CCGs) are now well advanced in their journey to become commissioning organisations. The authorisation process may start as early as the summer and there is much to do; leadership development being a crucial foundation of these new organisations. All too often leadership is seen as a bolt on, a stand-alone entity, as though ‘magical leadership dust’ sprinkled on the anointed few will deliver us from all evil.

The perceived wisdom on leadership has evolved markedly from the early works of commentators such as Thomas Carlyle and Francis Galton. Carlyle, in Heroes and Hero Worship (1841), identified the capabilities and attributes of men who rose to power. Galton, in Hereditary Genius (1869), examined leadership qualities in the families of powerful men and concluded that leadership was inherited. These early observations still hold sway today, with some continuing to believe in born leaders and the ‘heroic’ notion of leadership as the salvation of ‘hard times’.

In considering the leadership challenge for CCGs, we need to stand back and reflect upon what type of organisations they will be. They will certainly be very different from previous statutory health organisations, as member-only organisations operating through a devolved structure with a very bottom-up accountability. Let’s also consider the modus operandi of these new organisations; groups of similar-minded GPs, coming together, united in their desire to make a difference. Indeed, this is the most common feedback I hear: “We just want to get on with the job of commissioning”. Success will depend upon translating this desire into action not only in the boardroom but also in the sanctity of the consultation and the heat of the ward.

Research has shown there are distinct leadership styles: directive, coaching, visionary, affilative, participative and pacesetting (as per the Hay Group Model). Applying different styles in different circumstances is the hallmark of a successful leader. Unfortunately individuals often have only one or maybe two styles and in the past the predominant style among NHS leaders, including myself, was pacesetting – the hallmark of this style being a strong focus on accomplishing the task in hand. This was certainly appropriate for some of the challenges we faced, but it won’t work in the new world. The single-domain leadership trait is best exemplified in the ‘heroic’ style of leadership, where many will rally to the drumbeat of the leader’s call to action, but sustainability is lacking (although many seek comfort in the false safety of the hero’s deluded reassurances).

Leadership is often perceived as a dark art for the chosen few, yet CCGs will only succeed if they are able to develop a distributed type of leadership: a style that has been labelled by some as ‘followership’.

Followership is not merely passivity; it requires a high degree of skill and patience, as actions by followers can significantly increase the leader’s ability to implement the organisation’s agenda. Equally, at times, it will be necessary for followers to act as the checks and balances, limiting the leader’s power.

We need to look upon these two categories, leadership and followership, as two emergent properties that will ebb and flow. Today’s leader may be tomorrow’s follower and indeed it will be highly context-specific. This builds upon the notion that CCGs are complex adaptive systems, in essence non-linear in the way they react – hence they cannot be run by command and control and the traditional pulling of levers. We control little but influence everything, and the skill that leaders need to learn is to determine where the points of influence are.

Leadership will be distributed and vested in many, often with changes in roles from followers to leaders depending upon the different situations and challenges. This may be an uncomfortable place for the traditionalist but it is entirely explicable by the notion of the complex system these groups will be operating in.

We are in uncertain and challenging times at the mercy of the global economy. To prosper, CCGs must have an ability to work across boundaries, both organisational and sector, be it the public, independent or voluntary. All too frequently the boundaries we put in place are barriers to patient care and, at present, there is a sense of ‘organisational xenophobia’ from many commentators, which risks suffocating innovation. So one of the most important attributes of skillful CCG leaders will be the ability to work across the boundaries, developing skillful and constructive relationships, as relationships are the fundamental currency of delivery.

Having acknowledged the complexity of the environment CCGs will need to operate in, it’s also important to recognise that we don’t need superhuman heroes to lead these organisations. Leaders can take a few simple but important steps to prepare themselves for the challenges ahead.

Feedback
The first skill, almost a foundation, is the ability to seek feedback and to reflect. A good place to start is with one of the many leadership assessment programmes that will help you to understand your different styles. However, this is just the start. The recognition that there is no right set of skills and of the importance to reflect on your actions and seek feedback – both internally and, crucially, externally – will enable the leaders to develop their ability to respond to the wide range of challenges they face.

Team
Next, let’s aggregate up to the team. How do the differing styles of individual team members fuse and aggregate? There is a compelling need to develop a team that challenges each other. Beware the nodding dogs of agreement; they all too often collude in the comfort of mediocrity.

Innovation
Innovation will be central to the future success of CCGs. This will require our leaders to have the ability to lead transformational change and not get weighed down in the day-to-day transactional details. It’s all so tempting to jump down into the detail, yet the big wins reside in the transformation across the boundaries of care.

Execution
The final skill is probably recognised as one of those terrible pacesetting skills mentioned above. It’s perhaps the single most important skill and one that is often overlooked: execution. We plan, we dive into the detail, we review our plans, but all too often we don’t give half enough time to execution. A plan is nothing but a collection of words. Execution is king.

So, how do we best obtain these skills? We all have different learning styles and there are many different approaches, but the one that trumps them all is ‘on-the-job learning’. There’s nothing more powerful than learning through experience, particularly learning with those from different organisations on real-life issues. It may be urgent care, it may be frail elderly, but take a local challenge and it will provide a rich learning environment for you, the organisation and your partners.

Alternatively, some use simulations of situations, again working with partners, but this does provide a rich seam to give you a deeper understanding of both your individual needs and the local economy’s needs. There is also immense benefit in working with coaches, mentors or in learning sets.

Finally, let’s not forget communications. Communications are essential in all organisations and are frequently highlighted as the single most important area for improvement in any organisation.

This will be so much more important in a membership organisation, as members will not only want to be kept abreast of developments but will also, more importantly, expect to have their voices heard. Indeed, failure to do this will lead rapidly to a terminal dissociation of the members from the essential corporate ownership. Look, listen and understand before seeking to be understood.

For further advice and questions on leadership development, please contact Paul at The King’s Fund.
Email: [email protected]