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The NHS needs to align boards with middle management

Malcolm Lowe-Lauri Malcolm Lowe-Lauri

NHS improvement programmes – such as those run by the NHS leadership academy – work in part to connect board members with day-to-day managers. But are these enough, asks Malcolm Lowe-Lauri?

The separation of leadership and management in the NHS is not helpful. Nowhere is this more true than right in the middle, where clinical aspirations and a thirst for quality meet operational and financial requirements. In my work with nursing and therapy managers and clinical directors, I regularly see a disconnect between the operations and policy drive of executives and the pragmatism and work-around savvy of those charged with operational delivery. So high-level leadership and day-to-day management are put in different places. At times this can create mutual groaning – clinical directors and operational managers grumble about lack of interest from the top unless it’s about something which squares with key performance targets; execs worry that their middle tier doesn’t get it.

Is off-the-job training enough to improve issues with the NHS organisational structure?

I’m not the first to see this problem. There are some wonderful improvement programmes where connecting the board with middle tier staff members has moved trusts a long way forward, such as the case with east London and west Sussex. And there are some imaginative programmes - at the NHS leadership academy for instance - which focus on different levels of NHS organisations and create plans for the individual to pull leadership and management back together. The weakness here, however, is that this is off-the-job training. This learning is brought back into the Trust or CCG and immediately does battle with the local status quo. In these times of relentless operational priorities, this can be a one-sided contest.

NHS service delivery is a team game and staff at all levels need to share priorities and their thoughts and feelings about resolving these. Leadership and management should operate as one function, so the people steering the ship also know what it feels like in the engine room. These “leader-managers” need support from advisers and trainers who have a profound understanding of the NHS in its local context; theory is not enough. Henry Mintzberg says that you learn to swim by doing it, not reading about it. The same is largely true of leadership. It’s not a theoretical activity, and neither is management. Training in leadership and management should be an interaction between those who do the work and those who know the work but also have wider experience to share.

Generating new ideas for NHS leadership

Seeing development as a conversation between leader-managers and trainers with one foot in the NHS and another in management theory will generate new ideas for teamwork and operational delivery. It will help teams work out the degree of freedom they actually have (more than they think) and encourage entrepreneurial capability – in effect turning learning into a better bottom line. We work on, inter alia, teams, making your own information, doing deals and localising strategy. At the end of this the sense of control, and thus the capacity to innovate, should be more front and centre. And although I have been critical there are stellar examples of where the connections to the “middle” are well made and the trust enjoys a commensurate level of quality and performance.

There’s plenty of work on board governance and board development, but much less about helping leaders in the middle where strategy and policy meet day-to-day situations, where the key resource decisions are taken, and where the reconciliation of quality, operations and money has to be made. It is the place to bridge leadership and management. And it has the additional benefit of connecting the board to service delivery.

To start a conversation about this, get in touch with Malcolm Lowe-Lauri.