Values-based leadership in a time of austerity

 

When I was advising The Health Foundation on their leadership programme* back in 2004, no-one was very interested in discussing the values central to healthcare leadership. That was why I embarked on the research programme that ended up underpinning my book Moral Leadership in Medicine (Cambridge, 2012). Right now, it is a vital time to be thinking about moral leadership in the NHS. When organisations are struggling to survive it is easy to lose sight of values. But this is precisely when moral leadership becomes important. Moral leadership keeps health organisations focused on their purpose. And their purpose is not survival at all costs. It is providing a service.

The King’s Fund reports that at this year’s NHS Confederation annual conference Jeremy Hunt was exhorting leaders to look to their values, telling them that ‘values-driven leadership matters in every walk of life, but it matters more in health care than anywhere else’. It was a timely reminder. The Health Services Journal recently published a report on its inquiry into the ‘crisis’ of NHS leadership. It is only two years ago that the Berwick review into patient safety called for better leadership, arguing that a focus on safety should be NHS leaders’ first concern.  It is striking therefore that the words ‘safe’ and ‘safety’ are entirely absent from the HSJ Report. How quickly the ‘lessons’ of Mid-Staffordshire are being forgotten.

WHAT ARE NHS LEADERS LEADING – AND DOES THAT MATTER?

I agree with the Secretary of State that values-based leadership is of signal importance in healthcare. But we need to look at bit more closely at how challenging values-based leadership in healthcare is. Having values does not automatically give you good answers to hard leadership questions. And leadership in healthcare presents very hard questions indeed.

One of the strengths of the HSJ Report is that at least it takes a look at the nature of the NHS beast that we are asking leaders to lead. Its weakness is that its characterisation of the beast is so partial. The word ‘values’ appears at the beginning of the report, in the definition of leadership, but does not make a second appearance. ‘Structure’, though, is mentioned 24 times and there are 4 references to ‘system’. Whatever the reason for the emphasis in the HSJ report, it disturbs me. It hints that in a time of austerity, leaders are worrying more about the viability of their organisations than the quality of their services.

When I interviewed NHS medical leaders 5 years ago about the moral challenges they faced, medical directors chose to focus on their concerns with fighting for the interests of individual patients and groups of patients, keeping patients safe, dealing with the aftermath of medical harm, and supporting their colleagues through difficult times. They described having to weigh competing moral claims, feeling torn between difficult choices and wondering whether their values were ‘good enough’.

These medical leaders were not having difficulty deciding between good and bad. They were having to choose between good and good. Values are important, but simply ‘having values’ does not provide the answer to common leadership dilemmas.

THE FIVE HORNED LEADERSHIP DILEMMA

Being a medical leader means having to juggle at least five morally essential, but often contradictory, goals. In my book I identify these goals, and the leadership behaviours that serve them. For want of a better name I call these leadership behaviours “propriety”.

‘Fiduciary propriety’ needs least introduction. Fiduciary propriety exhibits in action the principle that a doctor’s (and any other clinician’s) first priority is to attend to their patients’ needs. Learning the skills of fiduciary propriety begins at the start of professional education, and developing them is a life’s work. In the normal run of things, fiduciary propriety is evident in how it mandates an unwavering focus on patients, needs and grants a licence to speak very assertively on their behalf. At its best fiduciary propriety is courageous action on behalf of people shunned by others – those stigmatised, infectious, unappealing, vulnerable, rejected and abandoned. At its worst it becomes bullying.

‘Bureaucratic propriety’ is concerned with the moral constitution of the organisation. The idea of bureaucracy has come in for quite a bit of stick, but I think it’s important to recognise its virtues. Virtuous bureaucracy is about public institutions serving the public fairly. Public organisations are the repository of the collective interests of those they serve (current patients and families, and future patients and families) and their stakeholders (for example suppliers – which may themselves be enterprises with a social mission – and staff). Of course serving the interests of patients must come before everything else, but to do this effectively means building stable, responsive, honest, accountable organisations. Good bureaucrats distribute community goods – such as healthcare –  fairly, efficiently,  predictably and transparently. Public organisations that embrace the virtues of bureaucracy serve us very much better than organisations run on nepotism, bribery, corruption or dictatorship. Good clinical leaders are (admittedly rather well-disguised) virtuous bureaucrats.

‘Collegial propriety’ is behaviour essential to an enterprise in which things get done through co-operation, collaboration and ‘discretionary effort’ (going the extra mile). Collegial propriety is a bond that sustains the medical professional community, and in doing so it also serves patients. In the positive form of collegial propriety, we see practices such as peer pressure to drive up clinical standards, reciprocal aid in caring for patients, mentoring of juniors, unpaid work for professional bodies, and recognition of exceptional service. At its best, collegial propriety is the bond that underpins patient care. At its worst, it puts loyalty to colleagues before patient safety.

‘Inquisitorial propriety’ is a set of moral practices that clinical leaders exercise when allegations of harmful treatment, poor performance, or misconduct arise. Misconduct, misbehaviour and medical mistakes present many medical leaders with their most intractable moral troubles. For the person leading an investigation into something that has gone wrong, ‘inquisitorial propriety’ suggests demeanours such as candour, objectivity, neutrality and openness to ‘hearing the other side’.

‘Restorative propriety’ is the fifth propriety. It is conduct that seeks to restore moral relations after harm and it turns on acknowledgement: acknowledging that a harm has occurred, acknowledging that certain persons or bodies are responsible, acknowledging that a complaint is legitimate, acknowledging that the person who was harmed has a ‘moral right’ to define the situation in their terms, acknowledging that steps must be taken to respond.

DANCING ON THE FIVE-HORNED LEADERSHIP DILEMMA

The problem for clinical leaders in health organisations is that the five proprieties come into conflict. Each serves the interests of patients and service users – but each propriety gives priority to a particular aspect of ‘what is good for patients and service users’.

As a result, leaders find themselves being pulled in different directions by equally desirable and equally strongly argued moral claims. Here are some examples.

Rationing decisions often present clinical leaders with a choice between what is in the interests of individual patients (fiduciary propriety) and what is in the interests of patients-in-general (bureaucratic propriety). When there are poor clinical outcomes, clinical leaders may find themselves having to choose between being supportive towards a colleague (collegial propriety) and remaining strictly impartial (inquisitorial propriety). Equally, when a patient complains of injury clinical leaders can be torn between the need to ‘hear both sides’ (inquisitorial propriety) and the need to acknowledge and respect the patient’s perception of harm (restorative propriety). In my experience, it is precisely when clinical leaders have to make a choice between such goods that they are most vulnerable to being accused by those who disagree with them of ‘unethical’ or non-moral behaviour.

CHOOSING BETWEEN GOOD AND GOOD

Exhortations to values-based leadership are becoming increasingly common, but we hear remarkably little about the dilemmas that go with it.  Where there are leaderly decisions to be made, there will inevitably be choices about which good to prioritise. If there wasn’t a tricky choice to be made, we wouldn’t need leaders. I think we do a real disservice to clinical leaders if we hide the awkward fact that values-based leadership presents them with difficult choices.

If you’re interested in following a passionate advocate for values-based leadership have a look at the twitter feed for 

(*I’m proud that at The Health Foundation we were among the first advocates for healthcare leadership development programmes focusing on distributed and network leadership)