The leadership challenge for the next five years

Sciana Senior Ambassador David Behan delivers Sciana Lecture

The text below is a transcript of the Sciana Lecture delivered by David Behan on November 24, 2021. The text has been edited for length and clarity.

It is a pleasure, even if it is a little daunting, to share my thinking on the health and care leadership challenge of the next five years and beyond. In this lecture, I want to set the context for the leadership challenge ahead and then propose some possible leadership responses.

Have you heard of the acronym “VUCA”? A few years ago, a front-line manager asked me this same question. They had been on a leadership development course and discovered this concept, and they generously shared it with me. It stands for volatility, uncertainty, complexity and ambiguity.

It was first used as long ago as 1987 by Warren Bennis and Burt Nanus in their book "Leaders: The Strategies for Taking Charge". In 2014 the Harvard Business Review described it as a catchall for “Hey, it is crazy out there,” whilst setting out these four challenges require different leadership responses. More recently, it has been accepted as a reflection of current realities. As Bob Johansen puts it: “It won’t be getting easier. Leaders must accept this reality”.  

When I first came across the concept in 2014, it described my felt and lived reality. I did not feel out of control, but I did feel challenged as I tried to reshape the national regulator to restore political, professional and public trust in the way it operated. Today, in 2021, VUCA continues to feel relevant. The past 20 months have brought volatility, uncertainty, complexity and ambiguity on a vast scale. The concept provides the context for the leadership challenges of the coming years.

As we look to the next five years, what are the opportunities and challenges facing health care services? My experience is of health and care services in England, so I hope colleagues from Germany, Switzerland, Austria, Scotland and Wales will allow me to draw on my experience. You will, however, have an intimate and direct relationship with your own health care system. I hope I can do that in such a way that the issues I raise are transferrable and relevant to you.

The first challenge I wish to consider is this: how focused are our services on the needs of the people who are using health and care services? The demographic challenge to the health and care system in Western Europe is how to respond to an ageing population, where healthy life expectancy has not kept pace with life expectancy and where resources are constrained.

Over my career, in my roles at the national and local level, I have always asked myself, "How will this policy, this decision or this action improve the quality of a person’s life?" I carry four people in my head against which I measure the answer to this question.

• The older person, 80 years plus, living alone with dementia and no nearby family.
• The family of a profoundly disabled five-year-old, fighting for services from health, education and social services.
• The 35-year-old black British man detained in a medium secure mental health unit after a struggle with mental ill-health and the criminal justice system.  
• The adult with learning disabilities, living with support in the community.

If we get it right and work together, services can transform their lives rather than let them fall, unseen, through the cracks.

In contrast to other sectors, the health and care system in England appears to be much more provider or producer dominated. If this perception is accurate, this raises a further question: “How can we develop a much more user-focused approach?”

The English health care system has a reputation for being one of the fairest and best health care systems in the world. It is a tax-funded, universal system available to all and free at the point of delivery. It was ranked as the most affordable healthcare system by the Commonwealth Fund in 2021. Strengths include its prevention services - as demonstrated by vaccine programmes - a strong history of primary care, and well-developed secondary care services.  

Public support for, and satisfaction with, the NHS is high. Trust in doctors and nurses is also very high. In the annual veracity index, they have regularly scored over 90 per cent, with politicians under 25 per cent. Yet, it is clear there is concern that the system is being overstretched and public expectations of the service are increasing. More recently, there is evidence of public frustration and, at times, anger, stoked by the media, that they can’t access their general practitioner and other health care services.

The system does have several significant challenges. Avoidable mortality, whilst falling, is still high when compared to other countries. Treatment effectiveness, as measured, for example, by five-year survival rates for cancer, lags other countries. The number of doctors and nurses per 1,000 of the population is below the OECD average. The number of beds per head of population is also lower than many comparator countries. Capital investment also compares poorly, and this has an impact on diagnostic services and bed capacity.

The system was under pressure pre-pandemic, and this has been exacerbated by the pandemic. Primary care is responding to increased demand over and above demographic pressures. There is similar pressure on urgent and emergency pathways with accident and emergency attendances at record levels. Elective waiting times are also increasing due to increased demand, constrained diagnostic capacity and lower activity levels.

Expenditure levels for the NHS have been set for the next three years, but health care spending is the second-lowest of the G7 countries as a share of GDP. Productivity is historically about one per cent per annum but might not be achievable while COVID-19 is still in circulation, as infection control places extra burdens on services.

Staff pride in the NHS is very high, but the current message from staff is they are exhausted after 20 months of responding to the demands of the pandemic. For many, the psychological impact of dealing with the intensity of death and illness has been profound. Morale in some places is low, with many staff planning to retire early or simply leave. This is not just a UK phenomenon. The recent article in the Atlantic, by Ed Yong, “Why healthcare workers are quitting in droves,” vividly sets out the US experience.

The WHO set out the global workforce challenge when they predicted a shortage of healthcare workers of 18 million by 2030. In England, there are record numbers of people applying to become clinicians – doctor and nurse undergraduate numbers are at an all-time high – but there is a danger we are pouring water into a leaky bucket, and numbers are not increasing in overall terms. Staff retention of the current workforce, alongside securing the future workforce, is the highest priority for leaders. I am personally of the view that workforce demand and supply has replaced money as the key rate-limiting factor in health care.

What are the opportunities that can be utilised as we look forward five years? There is a ten-year vision for the NHS in England. The Long-Term Plan sets out a vision for the future and has broad-based support. Whilst it needs to be revisited to ensure the lessons from COVID can be incorporated, it provides a clear direction of travel for more joined-up care and better outcomes for major illnesses.

We have potential enablers: policies to improve data and digital services and a thriving scientific sector delivering new developments in AI and genomics. The potential for people to take more control of their own health is improving. Similarly, the move by the UK government to introduce legislation to support the greater integration of services to meet the needs of people who use the services is significant.

But coming out of the pandemic - if indeed we are coming out -the challenges look huge. The political and service priority in England is elective recovery. Nearly six million people are now waiting for hospital treatment, which was delayed, either directly or indirectly, by the pandemic. The vaccine programme, which got off to such a good start, must continue, as must work to improve primary care and the emergency pathway.

I would also argue there is a need to work on two additional priorities: working to promote healthy lives and prevent ill health developing- particularly important with so many preventable diseases. The second linked priority is to address growing health inequalities. Perhaps one of the upsides of the pandemic is a much greater awareness of the consequence of inequality. Leaders will have to work on the short-term priorities set out above and the longer-term ambitions to promote healthy lives and reduce health inequality. These are not binary choices – a sustainable health care system of the future will depend on the promotion of good population health. Public health leadership has never been more prominent.

As leaders, we do have agency. We can make things happen, and we have an opportunity to address health care inequalities and contribute to a more socially just society.

So, if that is the wider context for the development of health and care services in England - and I hope English colleagues will recognise the description - what does that mean for the leadership of health and care services over the next five years? How do we turn the weaknesses and threats I outlined into opportunities?  

As I set out in the introduction, these are volatile, uncertain, complex and, ambiguous times. Leading in them will be exciting and challenging, to say the least!

For several years now, I have used a definition of leadership that describes leaders as people who inspire and motivate others to have the confidence to do things they might not have otherwise done.

Leadership is different to management. Management sets goals and objectives and assesses performance against those goals. Management skills are a way that a leader’s vision becomes operationalised. Good management practices and skills are fundamental to any organisation. Leadership and management are not mutually exclusive, nor is leadership more important than management.

To respond to the challenges of the next five years and beyond, systems and organisations will require highly skilled leaders and managers. Over the years, I have been asked by many younger colleagues to help with their career development. In many of these sessions, people want to discuss how to be a leader. Few ask how to become a better manager. We need both if we are to succeed.

So how do we inspire and motivate people given the context I have set out here? How do we as leaders grow the leaders and managers of the future? I want to set out some of the qualities I think will be essential for successful leaders over the next few years.

The most important quality is for a leader to set out a compelling vision for the future that unites people and helps people see their place in that future. I have been concerned that the dominant narrative in England has been about how challenging the current situation is. Commentator after commentator has echoed this narrative. What has been less noticeable is a narrative that sets out a vision for the future: a vision that describes a brighter future and provides hope for the future.

But how do we do this in these challenging times? I was recently reacquainted with the book I read many years ago, “Good to Great” by Jim Collins, who tells the story of the Stockdale Paradox. Initially, I found it very provocative and then helpful. I share it with you in the hope you, too, will reflect on its relevance.  

Admiral Jim Stockdale was a prisoner of war for over seven years during the Vietnam War, in conditions that were unimaginably difficult. Collins said when Stockdale was asked about the characteristics of those who didn’t survive, he observed the optimists died first. They were the ones who thought they’d be out by Christmas, and Christmas would come, and Christmas would go. Then they’d say, "We’ll be out by Easter", and Easter would come, and Easter would go. And then Thanksgiving. And then it was Christmas again. And they died of a broken heart…

‘….and this is a very important lesson,’ Admiral Stockdale said. ‘You must never confuse faith that you will prevail in the end – which you can never afford to lose – with the discipline to confront the most brutal facts of your current reality whatever they might be.’

This formulation became known as the Stockdale Paradox – where you have faith yet still confront reality. Whilst it first received attention in "Good to Great", during the pandemic, it has reappeared in leadership literature. I think it offers a useful framing for us today to accept our current reality and hold hope the future can and will be different and never lose faith we will ultimately prevail.

For me, this is one of the key leadership characteristics that will be required. It's to inspire and motivate people to a brighter, more hopeful future whilst at the same time recognising the reality of the present.

The vision for the future needs to be compelling and hopeful. It also needs to connect with the personal purpose and values of the workforce; it needs to engage the workforce psychologically and emotionally. I believe people chose their careers in health and care because they wanted to make a difference.

So, another leadership skill is to connect the personal purpose of members of a workforce with the wider purpose of an organisation or system. My own personal sweet spot has been when the purpose of the organisation I work for or lead and my own personal purpose are aligned. Then, I feel a sense of balance, a sense of belonging, a sense of shared purpose.

It is purposeful, value-driven leadership which communicates, connects and provides that feeling of belonging. This is not just about what leaders say but is critically about what leaders do and how they do it. If there is a gap between what people say and what people do – the “say-do gap” - then leaders will not be seen as authentic. This is critical, given that people look for authenticity in their leaders. Followership comes from authenticity.

Michael West has set out a compelling argument on the importance of developing cultures of compassion in workplaces. In his recent book, Compassionate Leadership, he emphasises the importance of leaders creating compassionate cultures:

“Organisational culture is shaped by all of us but particularly by its leadership. It is the behaviour of leaders top to bottom and end to end, individually and collectively in health care organisations that powerfully determine whether care quality is the priority….”

Bob Klaber’s recent Sciana Masterclass on kindness is a coherent addition to the approach that Michael West promotes.

In 2010 I was very influenced by the work of Scott Keller and Colin Price, “Performance and Health”. They identified successful organisations were the ones where leaders actively engage their workforce. Engagement is not just about consultation, but it is an active process that attends to the psychological wellbeing of staff. This approach listens with fascination and asks staff what is preventing them from being the best they can be and then acting on what they are told.

I am sure there is a potential thesis as to the differences and similarities between compassion, kindness and engagement, but what matters is how, as leaders, we behave. It is how we demonstrate compassion, kindness and engagement in both what we do and how we do it.  

There is no doubt in my mind there is a moral argument for this type of leadership. Fairness is a defining value of British society. Individuals and teams that feel valued, respected, appreciated, and psychologically safe will be able to be the best they can be. Compassionate leaders enable all their staff to bring their best selves to work. They create inclusive cultures which promote fairness and work to ensure equity for all staff. Leaders seek to create good work and celebrate the dignity of work.

What does this mean in a practical sense? Do we employ people who need to undertake two or three jobs to pay the rent? Are our senior leadership roles reflective of the populations we serve? Are all the healthcare workforce able to see themselves in senior positions in their organisations and systems?

In England’s health care system, about 80 per cent of the workforce are women, but most senior leaders are men. People from Black, Asian and Minority Ethnic (BAME) backgrounds and people with a disability are underrepresented in senior leadership positions in the English NHS, which does not reflect the diversity of the communities we serve. We know not all decisions are inclusive. As leaders, we need to do more to promote diverse and inclusive organisations.

As well as the moral argument, there is a business argument, where we understand that diverse teams and organisations are more effective. Happy, engaged staff, who feel they belong, can be effective - they deliver high quality, safe care. To paraphrase the Florence Nightingale School of Nursing research – happy fulfilled nurses equal happy fulfilled patients. One of my often-repeated phrases is: look after the staff, and they will deliver quality care for people who use services, and that will deliver the bottom-line results.

Earlier I talked about complexity. Complex problems require diverse, multi-skilled teams to solve them, whether at a societal level or individual level. Delivering high-quality health and care to people with complex co-morbid conditions will require a range of professions and backgrounds. Tackling health inequalities and promoting healthy lifestyles requires a range of organisations to work together at a local level. The determinants of ill health often sit outside the direct control of health care services.

In England, the responsibility for education, housing, economic development, transport, public health, and social care sit with local authorities. The connection with science and technology will require collaboration with industry, life sciences, pharma, universities and research, which will inevitably mean public and private partnerships.

No one organisation holds all the levers to make change happen. To address these challenges of complexity, organisations must collaborate for success. Leaders must adopt a collaborative approach.

In England, the NHS is reorganising away from the principle of competition and towards the principle of collaboration. The creation of Integrated Care Systems from April 2022 will demand a different type of leadership that has been required over the past 30 years. Playing for the system to win will demand different leadership behaviour than playing for the organisation to win. This move will demand a shift in the mindset of leaders where collaboration becomes the default.

As the boundaries between organisations become blurred, leaders will be watched to see if they demonstrate collaborative behaviours. If they model collaborative behaviours, their teams will behave collaboratively. The collaboration will lead to greater integration of services, which will lead to better outcomes for people who use services. In many respects, the shift to playing for the system to win will be the most fundamental shift leaders will need to make.

One part of the system that leaders will need to collaborate and engage with is the political system, whether at a national or local level. In a tax-funded system, as we have in the UK, this will be a core part of national leadership capability. At a local level, building alliances across the system to meet the needs of local communities will similarly be crucial.

Engaging politicians, whether local or national, will be key if services are to be transformed. Politicians can help accelerate change, or they can stop it. This has never been more apparent than over the past 20 months. What health care leaders can take comfort in, especially clinical leaders, is they are at the top of the table of public trust. Clever politicians will understand this and work with them. The challenge for leaders is to win the trust of politicians.

I want to end by focusing on some of the personal attributes of the leadership required in the future.

There has always rightly been a priority given to the IQ of leaders, but I want to emphasise the importance of emotional intelligence (EQ). In a complex world, the ability to see an issue through the eyes of others is a key attribute of successful leaders. This is true from the perspective of those who use services, those who deliver services, or key partners.

EQ is an essential component of compassion and kindness. Successful leaders know they do not possess all the answers. They use this humility to build diverse teams of people with different talents. They trust the leaders in their systems and organisations and distribute power to them so they can be effective. Giving power away takes courage, alongside humility.

Curiosity has been one of my favourite leadership words. Endless curiosity and self-reflection are essential leadership traits. Being curious as to how to grow, learn and improve oneself, as well as the organisation or system, has never been more important.

Being self-compassionate is also key to effective leadership. Taking time out to rest and do other things - and being seen to do this - sends a powerful signal. People notice when there is a gap between what leaders say and what they do - back to the point about authentic leadership.   

Leaders need a range of styles. I often use the metaphor of an artist with their palette: selecting and mixing colours. Similarly, a leader requires a palette of styles from which they make a deliberate choice to fit the challenge they face.

Again, we have seen through the pandemic very directive leadership in respect of hygiene control measures and very democratic approaches, for example, in how to connect with BAME communities to increase vaccine take-up. The uncertainty of the future will continue to demand a deliberate selection of leadership styles to fit the challenge.

It will also demand that leaders are agile. They can adapt to changing environments and the threats and opportunities that they bring. Agility and foresight are linked. Leaders who look outwards and scan the environment can adapt and move quickly. They are focused on managing today and the future.

Over the next few years, leaders will need to set out a clear, shared purpose and vision for the future. I feel strongly that this vision should acknowledge the current reality of the health and care system and hold hope for a brighter, better future for people who use services and the staff that deliver services. The role of leaders is to inspire and motivate individuals, teams, organisations and systems to deliver the vision.

I want to end with one of my favourite quotes, which inspires me from the poet Maya Angelou: “I have learned that people will forget what you said, they will forget what you did, but people will never forget how you made them feel.”