In the first of a two-part commentary on leadership within the ambulance service, a distinction is made between leadership and management, with the traditional position of leadership within the ambulance service reviewed. The limitations of leadership competency frameworks are discussed and the importance of recognising the uniqueness of paramedic practice is highlighted. The challenges faced by leaders within the NHS are emphasised, specifically in relation to change, and the position of clinical leadership is examined as a possible medium to reconcile tensions between clinical and managerial roles.
Background
Effective leadership is central to the success of providing a modern and responsive NHS (Institute for Innovation and Improvement, 2006) but one of the difficulties of looking at leadership for healthcare professionals is that most leadership theories have not been developed within a healthcare context. Typically, leadership theory has been developed within a business arena and then applied to healthcare (Vance and Larson, 2002). For a paramedic profession which is in the process of forming a new identity (Woollard, 2006) and continues to define its unique body of knowledge and practice (Gregory, 2011), this represents a significant challenge.
Leadership within the health professions has been borne out of the ‘professionalisation’ process, with the emergence of regulatory bodies such as the Health Professions Council (HPC) (Saks, 2009), yet the role of leaders within the health professions is just as crucial as the various regulatory bodies. Initial research into leadership, however, pre-dates the HPC by several decades. As early as the 1920s, trait theory emerged in an attempt to identify common characteristics of an effective leader and early theorists could be categorised as either descriptive theorists (Wald and Doty, 1954; Ghiselli, 1963) or prescriptive theorists (Barnard, 1938). Into the 1940s, and style theory emerged (McGregor, 1960; Likert, 1961; Blake and Mouton, 1964) as an alternative to the management principles espoused by Frederick Winslow Taylor (Taylor, 1911). Although a greater emphasis was placed on ‘human’ factors, it was not a theory which effectively evaluated leadership in itself.
‘Although a greater emphasis was placed on ‘human’ factors, it was not a theory which effectively evaluated leadership in itself?’
Leadership definitions
Defining leadership is more complex (Bass, 1990; Grossman and Valiga, 2009) with leadership being seen as a characteristic trait, a position, a quality, a process and a power relationship (Barr and Dowding, 2009). A useful framework is offered by Bennis and Nanus (1985) who have considered leadership from the following perspectives:
Leadership, as opposed to management, has been seen as involving ‘softer’ factors such as influencing and supporting (Bass, 1985; Graen and Scandura, 1987; Gardner, 1990; Senge, 1990; Owen, 2005; Barr and Dowding, 2009) and even mediation (Barge, 1996; Witteman, 1991). It has also been referred to as an art (Draft, 2005). Yet
some of the most influential leaders in recent history do not subscribe to such rhetoric. Sir John Harvey Jones does not believe in the romantic ideal of a leader who can engender in his people a vision arguing ‘the reality is more traumatic and more demanding’ (Harvey-Jones, 1994) and former Prime Minister Margaret Thatcher refected in her memoirs ‘you cannot lead from the crowd’ (Thatcher, 1993). Other theorists take up a similar position, with Northouse (2004) identifying goal attainment as a key leadership trait, Osseo-Asare et al (2005) emphasising the importance of knowledge and technical expertise in a leader and Hosking (1988) viewing leadership as a structured role in a hierarchy.
Competency frameworks
Attempts to define what qualities, competencies and standards a leader should demonstrate have not resulted in an improvement in the quality of leaders and leadership in general (Bolden et al, 2003).
A reason for this is that defined competencies identified through leadership matrixes may be too narrow (Barnett, 1994) and are reductionist (McAllear and Hamill, 1997) and fail to capture the underlying cognitive and affective skills required for a leader (Bloom, 1956; Savery and Duffy, 1995; Le Var, 1996; Lillyman, 1998). There are also contextual factors to consider and paramedic practice is becoming more complex and unpredictable (Caroline, 2007; Moulton and Yates, 2007; Gregory and Mursell, 2010; Willis, 2010; Russell et al, 2011).
Despite the plethora of leadership theory promoting desirable leadership traits, people don't ‘fit’ neatly into a box—a classic approach adopted by the NHS via the Knowledge and Skills framework (Department of Health (DH), 2004). A leader's competence is greater than the sum of each discrete element of their job role and the content and component parts of each competence is comparatively easy to construct than to predict performance in line with each of these competencies (Tuxworth, 1989). Personal attributes are undoubtedly important but need to be considered in line with other factors when considering the exercise of leadership (Bolden et al, 2003).
Leadership vs management
A clear distinction which can be made with leadership is how it compares to the concept of ‘management’. Stanley (2006) makes a clear distinction between a ‘manager’ and a ‘leader’, arguing that a failure to recognise the distinction potentially compromises the quality of patient care (Stanley 2006). This is supported by Zaleznik (1981) and Bennis and Nanus (1985) who draw on the earlier work of Fayol (1949) which identified specifc management activities as incorporating planning, organising, commanding and controlling (Fayol, 1949). Within a clinical setting, Christian and Norman (1998) conducted a study in 28 Nursing Development units in the UK and examined the roles of clinical leaders and managers.
‘The adage that you don't have to be a manager to be a leader but you do need to be a good leader to be an effective manager, will no doubt resonate with many working in the ambulance service’
Those with day-to-day operational responsibilities were pre-occupied with administrative duties and had difficulty thinking strategically, while those who were not bound by daily, routine responsibilities were able to develop a strategic vision but had little authority among those who would be responsible for realising that vision (Christian and Norman, 1998).
Perhaps some middle ground can be found in what has been categorised ‘transactional leadership’ (a focus on rules, policies and procedures and routine aspects of daily work) (Brazier, 2005) and ‘transformational leadership’ (enabling others, developing a shared vision, inspiring and communicating, developing trust and valuing others) (Manley, 2001). Early leadership theory favoured the transactional model (Burns, 1978) and more contemporary theorists continue to support this approach where leaders work within a status quo and power-based relationships (Murphy, 2005). Parallels with a modern day NHS can easily be drawn here although Welford (2002) argues that transformational leadership is best suited to a clinical setting. The NHS Executive (1999) is also promoting a transformational leadership approach for driving change in the NHS.
The adage that you don't have to be a manager to be a leader but you do need to be a good leader to be an effective manager, will no doubt resonate with many working in the ambulance service. The danger of having too many managers and not enough leaders is the prevalence of processes and procedures which are doubtless efficient, but their effectiveness can be questioned (Bennis and Nanus, 1985). But as health systems become more complex and require greater integration, those who perform managerial and clinical work must co-operate and co-ordinate their efforts to produce results—especially where patient care is concerned (Sullivan and Decker, 2005).
Clinical leadership
More than focussing on the concept of caring and being guided by ‘qualities of the heart, by passion, compassion’ (George, 2003), the uniqueness of clinical leadership has been historically unrecognised and undervalued (Lett, 2002).
The traditional trend of promoting clinical leaders on the basis that they have attained high levels of clinical practice, while of value to patient care, does not necessarily ensure that appropriate leadership qualities are employed (Harris, 2004). Clinical leaders must strive to improve the services for the benefit of patients (Øvretveit, 2005) and not simply be an expert clinician (Cook, 2001). The ability to connect with political imperatives, the academic dimension, the managerial perspective and the actual clinical care is inherent in a clinical leader (Antrobus and Kitson, 1999) but it can lead to conflict with managerial roles (Firth, 2002; Macklin, 2009; Stanley, 2009).
In 1995 the Royal College of Nursing established a clinical leadership development programme to identify how clinical nurses in leadership positions could improve the quality of patient care. Four senior nurses, twenty-four ward sisters in four hospital trusts in England were involved in the study over an eighteen month period, which concluded that more clinical leadership development programmes were needed for nurses.
Clinical leadership training which had already been introduced was shown to have a positive impact on patient care (Cunningham and Kitson, 2000). Later this year, the College of Paramedics is due to publish the third edition of its curriculum guidance and the importance of clinical leadership within the paramedic profession is likely to be emphasised. The benefits of clinical leadership can be seen for patients (improved responsiveness to patient needs), for individual paramedics (improved knowledge and skills through CPD) and also at an organisational level, through providing a more flexible response to an ever-changing environment (Timpson, 1998).
Leadership in context
Reform within the NHS has been identified in itself as having a significant impact on leadership, with the five year electoral cycle of governments causing a perpetual flux due to policy changes (Walby et al, 1994; Parkin, 1997; Hayes, 2005; Cork, 2008). The context in which leadership is considered has a profound influence on its design (Hartley and Hinkson, 2003; Grubb Institute, 2004; Parkin, 2009).
Between the public and private sectors, a key contextual difference is that in the public sector, profit is not the primary organisational objective (Gopee and Galloway, 2009) and the focus is on providing a service to the general public (Smith and Perry, 1985; Pollitt, 1990). The authors believe that this distinction has become blurred with the emergence of Foundation Trusts but as early as 1983, Sir Roy Griffiths played down the differences between the public and private sectors (Department of Health and Social Security (DHSS), 1983). Conversely, in a study conducted by Pettigrew, Ferlie and McKee (1992) into the change process within the NHS between 1986 and 1990, it was the Griffiths Report which has been cited with challenging the cultural continuity within the NHS with the introduction of general management (Pettigrew et al, 1992) and internal markets (Davies and Harrison, 2003).
‘The tensions between a strategic level (doing the right things) and an operational imperative (doing things right) appear as polarised as ever’
In a further study into UK organisations in 2001, public sector leadership did not compare favourably with that in the private sector (Horne and Jones, 2001) and in 2003, the Government's public sector reform agenda was seen as being potentially compromised due to a lack of good quality leadership (Chartered Management Institute, 2003).
Ambulance services, and the NHS in general, are in a perpetual cycle of change (Davies and Harrison, 2003; Walshe, 2003; Goodlee, 2006) and clinicians who understand change management are more likely to influence change in a positive manner (Cork, 2008). The problem for leaders within the paramedic profession is that the traditional concept of leadership in healthcare is refected in a very hierarchical model of authority (Cook, 1999).
The ambulance service in particular is structured and designed to operate on a military-style model of organisation, with an emphasis on command and control through autocratic leadership styles (Morgan, 1997; Archibald, 2003; Taylor, 2008). Such a hierarchical structure has an adverse impact on autonomy and leaders, who should be more concerned with ‘infuencing’ rather than ‘autonomy’ (Sullivan, 2004) can get marginalised.
Leadership evolving?
Grundy (1993) makes a distinction between implementing and leading strategic change, believing that 15% of change management is focused on development and planning while 80% of time is spent on implementing a project (Grundy, 1993).
Paramedics who lack influence when it comes to strategic change are not alone, as those allied health professionals who have the majority of patient contact have little influence in terms of policy making (Bishop, 2009). The tensions between a strategic level (doing the right things) and an operational imperative (doings things right) (Roberts, 2002) appear as polarised as ever.
Former NHS Chief Executive, Nigel Crisp, recognised the importance of leadership, arguing ‘We need leadership in setting out the vision and working with and through people to achieve it’ (DH, 2002).
Despite these remarks being made a decade ago, Jasper and Jumaa (2005) and Bolden et al (2003) argue that there is still little solid work to link leadership models to the challenges of leading a modernised NHS where little remains the same. But perhaps this position is changing.