Leadership for safety in a time of austerity


The Health Services Journal recently published a report on its inquiry into the ‘crisis’ of NHS leadership. Some two years ago 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?

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 once in the report, in the definition of leadership, but does not return. ‘Structure’, though, is mentioned 24 times and there are 4 references to ‘system’.

Whatever the reason for the emphasis in the HSJ report, it is worrying. 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 talked to me about concerns with serving the interests of patients, keeping them safe, and supporting their colleagues through difficult times. They described how they found themselves faced with difficult choices in these areas. In my view, these sorts of choices are what makes leadership in medicine uniquely challenging. Because they concern the purpose of the enterprise, such choices also, for me, define what leadership in healthcare is really about.

So here is my analysis of medical leadership challenges that have not gone away, and are not about juggling systems and structures.

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 Moral Leadership in Medicine I identify these goals, and the leadership behaviours that serve them. For want of a better name I call the behaviour “propriety”.

In the course of medical management these five proprieties inevitably come into conflict. So what are they?

‘Fiduciary propriety’ needs least introduction. Fiduciary propriety exhibits in action the principle that a doctors’ first priority is to attend to their patients’ needs. Learning the skills of fiduciary propriety begins in medical school, and developing them is a life’s work. In the normal run of things, fiduciary propriety is  evident in how it grants a licence to speak very assertively on behalf of patients. At its best fiduciary propriety is courageous action on behalf of people shunned by others – those stigmatised, infectious, unappealing, vulnerable, rejected and abandoned.

‘Bureaucratic propriety’ has as its first concern the needs of the organisation. The idea that leaders might have organisational needs at the forefront of their attention has come in for quite a bit of stick in the Francis and Berwick reports. So it is important to understand that 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.

‘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.

‘Inquisitorial propriety’ is a set of moral practices called forth 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 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 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’. Where there are leaderly decisions to be made, there will inevitably be choice about which good to prioritise. (If there wasn’t a tricky choice to be made, we wouldn’t need leaders.) And the chances are, that each desirable aim will have its own defenders pressing its claim to be the most morally worthy priority.

As a result, leaders find themselves being pulled in different directions by equally desirable and equally strongly argued moral claims. Clinical leaders may find they have to choose between enacting the good of partiality towards individual patients in fiduciary propriety, or enacting the good of impartiality towards patients-in-general in bureaucratic propriety; between enacting the good of fellowship in collegial propriety and enacting the good of neutrality in inquisitorial propriety; or between enacting the good of ‘hearing the other side’ in inquisitorial propriety and enacting the good of acknowledging a patient’s perception of harm in ‘restorative propriety’.

Treading on dangerous ground?

It may be that leadership choices such as these do not affect the structural viability of NHS organisations, nor their ‘bottom line’. But they are decisions about the core purpose of the business, choices that have a fundamental impact on patient and service user safety and experience. We are treading on dangerous ground indeed if organisational structures assume greater importance than organisational purpose in our analysis of leadership.