COVID-19 has placed enormous strain on healthcare systems around the world, causing untold disruption and tragic outcomes that will take time to measure in full. At the same time, the way healthcare leaders have risen to the challenge has been admirable, and the array of innovative new ideas and practices developed during the crisis bodes well for the future.
The pandemic has revealed many leadership lessons too. As Professor Bernard Crump, himself a qualified clinician, and a former CEO of Shropshire and Staffordshire Strategic Health Authority and CEO of the NHS Institute for Innovation and Improvement points out, “The pandemic has really brought home to people the fact healthcare has this intrinsic set of characteristics—meaning that to lead in the context of healthcare is somewhat different than leadership in other contexts.”
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Crump, who will be leading a new online course, Leading Strategic Innovation in Healthcare at Warwick Business School in September, points to the profound implications for leadership caused by these intrinsic characteristics. “The tradition in some countries has been to create a cadre of leadership professionals, clinicians usually, who have risen to become the C-suite of the organization. Those organizations have chief execs who are originally from a medical background. That's not our tradition in the UK.”
Unlike in the corporate sector, where the C-suite leads the way, in healthcare the leadership team relies on experts to determine direction. We will have observed the same dynamic with politicians in governments around the world in many cases ‘following the science’. “Many of the decisions that happen on a daily basis that commit the resources of the organization happen in the hands of people who are experts, clinical experts, very close to the front line of the organization.”
Professor Crump describes his mission as wanting to introduce more people to the principles of leadership and to narrow the gap between the way managers and clinicians think about their roles. “Helping managers to understand how clinicians think and helping clinicians to understand some of the basic tenets and principles of what it means to lead.”
“Some of the best leadership I've ever seen has been leadership demonstrated from within public organizations,” says Crump. “On the other hand, I've seen huge benefits from being able to introduce NHS organizations to some of the practices and principles applied in commercial organizations.” While 20 years ago it would be impossible to imagine clinicians seeing any value in examining Toyota’s production system, today most clinicians are at least aware of the principles of ‘lean’ and many could tell of instances where some of those tools and techniques are being used in practice.
Some of the best leadership I've ever seen has been leadership demonstrated from within public organizations
Following criticism a decade ago that senior leaders in the NHS could be preoccupied with cost-cutting, targets and processes, at the expense of their fundamental responsibility to patients, there were calls to adopt more shared or distributed leadership—modelling practices in progressive corporates. Asked how this has gone Crump replies, “It’s a journey. To me, leadership is the demonstration of a series of behaviours that influence other people. To lead successfully in healthcare, because so much of the important decision making and influence within the organization sits close to the periphery, one must align the leadership behaviours of lots of different people. It's not that it would be a good idea for leadership to be more distributed within hospitals or healthcare systems. It's the fact that—by definition—many people in these organizations will be every day demonstrating behaviour, which is influencing other people—they'll be leading. The trick is to try to engage them in a way that means there's more alignment between their leadership behaviours and what you're trying to do as an organization overall.”
“You have to engage them on the values of the organization, and on their own values too. You have to engage them by ensuring they're involved in all the important decisions that pertain to the way they practice, so they feel less imposed upon with external requirements or targets they don't have ownership of.”
There is far less conflict now than in the past between professional NHS managers and those who come from a medical background. “Clinicians who see one of their colleagues moving into a more formal management role as having ‘gone to the dark side’―this is much less the case now,” observes Crump. “But it's still the case that there are quite deep seated differences in terms of perspective on the extent to which general managers are as interested in improving things for the patients the organization serves, as they are required to feed-in a series of regulatory requirements. The trajectory has moved very positively towards the professional clinical side and the management side working together in the kind of engaging relationships that lead to success.”
Professor Crump was involved, a decade ago, in the establishment of the Faculty of Medical Leadership and Management; a membership body for those clinicians whose work encompasses a formal leadership role to sit alongside their clinical professional home. “We deliberately did this not for a small subset of doctors who would go on to become medical directors, but for every doctor, to be supported and to develop a range of competencies and understandings, and be able to demonstrate those in their practice—competencies around really important issues, such as: managing oneself, being able to work in teams and make a positive contribution, use expertise around data and evidence in order to set strategic direction.”
The UK is the first country in the world to have developed a framework for developing healthcare leaders that carries an expectation that all doctors—in training in their post graduate period, and subsequently across their professional lifetime—will engage in developing their leadership potential.
Innovation in healthcare
Professor Crump defines innovation in healthcare as, “Doing things differently or doing different things that lead to a step change in performance.” Those different things or things done differently may not be entirely novel to the system, but they are different in the ways they are applied in a particular context.
Continuous improvement and innovation are closely linked. Both draw on similar expertise, notes Crump, “Continuous improvement is more of a gradual rising of the boats, over time. Whereas innovation involves more of a step change, more of a discontinuous change. In the UK, we've been phenomenally contributory to innovation across the world from the point-of-view of the ideation and the invention of new medications, and ways of doing things.”
What the UK has been far less successful at is spreading innovation—putting new ideas, technologies, and ways of doing things into every day clinical or managerial practice in a reasonably equitable way across the system and sustaining those changes for the long term. This reality would likely come as a surprise to outside observers, given the benefits the UK has in having one unified NHS.
What the UK has been far less successful at is spreading innovation
The main barrier to spreading innovation is to do with organizational culture, believes Crump. “We've not been good at creating a culture which is conducive to innovation across our organizations. Too many of the attempts to try to resolve this problem have focused on top-down initiatives around centrally picking winners or identifying best practices. And then expecting that the benefits will be so self-evident they will drop into place.”
During the pandemic there has been an accelerated adoption across the system of new ways of working, many of which will be retained. For example, Crump is certain that “we have crossed the Rubicon with the role of remote virtual consultation, for appropriate patients and appropriate conditions. A substantial proportion of our patient appointments and primary care consultations will continue to be done virtually after the need for it to happen for cross infection reasons reduces.” But current circumstances are unusual—due to the urgency of the situation and because many of the legal and regulatory hurdles normally in place have been removed or suspended, and because of a recognition that this is not a time to block or delay such adoptions.
In normal times, finance—if not the main barrier to innovation—has certainly been a factor. Often the people responsible for investing in an innovation were not those who would see the financial returns, and those returns were often forecast some way into the future. To resolve this Crump recommends that, “The commissioners of services, providers of services, and the industry that's creating a new innovation need to find a way that works for all of them from a business model point-of-view.”
The culture within healthcare organizations tends to be relatively risk averse. Not all innovations turn out to be a good thing and an attitude can prevail that it is better to be a follower than a first adopter. “Most healthcare organizations I've had much to do with, haven't been very good at setting their risk appetite in a way that varies appropriately in relationship to the relative risks,” says Crump. “NHS chief executive leaders haven't in general in the past been identified, promoted, or their careers developed because they've been conspicuously good at creating innovation. Delivering performance has been the watchword.”
“One of the key reasons the NHS has done remarkably well in responding to the challenge of the pandemic is because it had a few very simple expectations of it. A few—not easy to do, but very well-defined—priorities,” observes Crump. “A lot of other things that were less important were put on one side. It would be interesting to see some of that simplicity, some of our ability to allow local leaders to deliver the things that really matter, but with less watching over their shoulders about how they do.”
Warwick’s Leading Strategic Innovation in Healthcare online program
Scheduled to launch September 2021, this innovative new program takes account of one of the key challenges for leadership development in healthcare: “To give people the opportunity of gaining some understanding and then to take that understanding into their everyday work, at a time in their careers when they have many other things that they're required to learn, many other expectations in terms of keeping up to date with their clinical practice.”
For this reason, it is essential that participants have flexibility in how they learn and apply their learning. “So what we're devising is a relatively low intensity six-week or so program,” explains Crump, “in which, in each week, they might need to devote six hours or so to engaging with the materials we're developing. They'll be able to do that very flexibly because it will all be online learning.” All the learning will be delivered asynchronously—but with opportunities for feedback and discussion—to allow this flexibility.
This will not be an accredited program. “Our experience is that the extent to which healthcare professionals want to engage in learning that leads to a formal qualification varies a lot,” points out Crump. Many qualified clinicians, as well as getting their initial degree, and meeting specialty requirements and on-going training requirements, may also be engaged in research, doing master's programs or a doctorate. “It's more being able to access relevant and valuable learning in a flexible way, that allows them to show the competencies that are expected of them that are not necessarily associated with the qualification.”
The program is designed for healthcare professional from around the world, from both public and private sector systems. There are essentially three types of person who will benefit from the program. The classical type is somebody who is trained clinically and who recognizes the need to play, or is being approached to play, a role in the formal leadership of their organization. Another type is somebody working in an NGO or in a policy role, from a developed or developing country, who wants to understand more about the values that sit behind healthcare leadership. Another type might be somebody contemplating a move into a general management role in healthcare or somebody moving from general management in a different sector.
As far as the structure of the program, there are five main strands:
- Leadership. Leadership itself and what is special about leading in the context of healthcare.
- Improving services. Different approaches to improving the quality and safety of services.
- Strategy. Understanding strategy and how to play a part in developing strategy.
- Operational management. The tenets of operation management.
- Managing people. At the heart of healthcare is the workforce. 75% of the resources in any healthcare system typically are spent through the workforce.
Commenting on this all important fifth strand Crump states: “There's a huge global challenge, which many countries are facing already, and all will in time—to be able to have available the workforce and the skills and the competencies necessary to meet healthcare for the future. It’s vitally important people understand about that, but also about how to work in teams—healthcare as a team sport.”
Bernard Crump is a Professorial Teaching Fellow in Medical Leadership at Warwick Medical School, and Professor of Practice at WBS. Bernard, who was the first CEO of the NHS Institute for Innovation and Improvement, writes and lectures on a wide range of topics in healthcare, including aspects of population health, the role of clinicians in management, health and healthcare improvement, the use of metrics in encouraging improvement and the use of health economics in decision-making. Full bio.