The need
With increasing
sustainability challenges of rising care needs for chronic conditions in an
aging population the need has never been greater for the NHS to harness
technology to support new models of care delivery, avoid unwarranted variation
by providing better access to information at points of care, and to embed
evidence based digital decision support tools to enable population health
management (NHS, 2017), (NHS,
2019). Though these
ambitions are firmly supported by the findings, principles, and recommendations
highlighted by Professor Robert Wachter (Department of Health and Social Care, 2016),
addressing the challenges relating to financial investment and the need for
thoughtful stakeholder engagement are key to ensuring successful digital
transformation (Honeyman,
2016). Furthermore;
there are workforce challenges which arise from the impact digital solutions
bring to the roles and functions of clinicians (Topol, 2019).
These challenges and opportunities that have been discussed at national forums
hold true to this project, are pivotal in shaping the expectations of leaders,
and are critical to understanding how leaders respond to 'radical new care delivery options' for safer
and more efficient delivery of care (NHS,
2014).
Management and leadership
In bureaucratic
settings of strong (often stifling) management structures the ‘leader’ of the
project was seen to be the person responsible for ‘managing’ group activity
–the project manager. This perception of leadership is antiquated (Van
Vugt, 2008)
.There was neither differentiation of the terms ‘leadership’ and ‘management’
in professional communication, nor an applied appreciation of their translation
to practice in the project’s context. Grint with references to sensory
perceptions (déjà vu and vu jàdé) describes ‘leadership’ and ‘management’ as
opposing terms that may have overlap in their execution (Grint, 2005).
Another perspective is that the two terms are ‘distinctive and complementary
systems of action’ (Kotter, 2001),
which are mistakenly used interchangeably, thereby illustrating that the terms
are not well understood (Kotter, 2013).
This misinterpretation may result in misalignment of resources, culture, power
and motivation and could be catastrophic for the project; highlighting the need
to define leadership within the project team.
The Team
As the project team comprised professionals from multi-disciplinary HI
functions with diverse technical, analytical and interpersonal skills, it may
be inferred (somewhat naively) that the team constitution lent itself to a
‘high performing team’ (Horwitz, 2007). Though
Horwitz’s meta-analysis provides immense evidence on the correlation of
performance and task-relevant heterogeneity, it is limited in its analysis of
the emerging Gen Z HI workforce, and more importantly does not consider
diversity of values and drivers of motivation in relation to team performance.
Recognition of these limitations is supported and can be built on by understanding
the need for teams to become ‘powerful units of collective performance’ by not
only possessing complimentary skills, but by having mutual accountability,
common commitment and shared purpose (Katzenbach, 1993). Therefore,
in this setting of a diverse interdisciplinary team that required clear
purpose, explicitness in leadership was essential for the project (West, 2013).
Collaborative leadership
Leadership is not
merely a set of attributes possessed by an individual to distinguish them from
their followers; it is also a resource for the team (Van Vugt, 2008),
with leaders being recognised as organisers of collaborative activities (Vangen, 2003).
These collaboration theories have similarities to ‘servant’ leadership which is
proven to increase productivity by investing in people to facilitate autonomy
and inculcate a sense of purpose (Tait,
2020). These
theories contrast from traditional pyramid-esque leadership that relies on
hierarchical leader-follower relationships (Van Vugt, 2008).
The ‘post-heroic’, shared and
distributed leadership (Turnbull, 2011)with a focus
on inclusive and compassionate leadership practices (NHS Improvement, 2016) are
recognised as the next stage of leadership evolution (Turnbull,
2011).
This is especially true in the setting of innovation (described as ‘any
introduction or development of new ideas with the aim of improving healthcare’)
where collective leadership plays a vital role in problem-solving processes (West, 2017). As the
project relied on loosely coupled departments, with associated challenges of
task coordination, a decentralised but collaborative leadership model to
facilitate cooperation and collaboration was required.
Power
Having appreciated the need for collaboration it is important to
acknowledge the distribution and effect of ‘power’ and its influence in
relation to the project team. Affirmation of power tends to be reinforced by
one’s followers, and appointment of power tends to be facilitated via
attainment of position from one’s superior (Zaleznik, 1970), or through
acquisition of formal position (French, 1960). It is
interesting to note Turnbull’s views of flattening hierarchies – ‘shared and
distributed leadership’ (Turnbull, 2011), which
contrast Zaleznik’s reference to ‘pyramids of power’. Having said that,
Zaleznik acknowledges a preference for a ‘problem solving’ approach to
‘structures’, and stresses that structures must align with and facilitate
collaboration and coalition (Zaleznik,
1970).
It may be debated whether ‘leader-follower’ dynamics that contribute to the
ratification of power still hold true in the current ‘post heroic’ age, and
whether instead of a focus on relationships based on structure, there is now a
need to increase autonomy and improve team performance by nurturing
relationships based on the sources from where influence (power) may be derived.
This view is supported by Keith Grint in his description of ‘Relationships not
Structures’ (Grint, 2008).
Lukes’ ‘dimensional views’ on power (Lukes, 1974) mirror
Zaleznik’s three sources of power – Formal authority, Expertise and reputation,
and Attractiveness of personality (Zaleznik, 1970). Despite
conceptual similarities this differs from the more explicit six bases of power
which can be easily understood and grouped as Positional, Personal and
Informational power as described by French and Raven (Mindtools, n.d.). The
interpretation of power was necessary to identify varying degrees of both
perceived and actual stakeholder influence (NHS England and NHS
Improvement, 2021)
in relation to the project. As the project was a collaborative initiative, team
members had strong bases of ‘expert’ and’ referent’ power derived from their
expertise and professional reputation and possessed a degree of ‘ideological’
and ‘non decision making’ power to influence project tasks and contribute to
the project agenda. However, as team members were reliant on the contributions
and commitment of others for task delivery, they had little (if any) formal
authority in relation to major project decisions. Consequently ‘authority’ was
deferred to the Project Board for ‘participative’ decision making (Vroom, 1974). This was a
useful approach to support the spirit of collaboration, but at times was not
appropriate where immediate decisions were required. This approach also failed
to take into account interpersonal dynamics of team members leading to conflict
when ‘critical’ problems arose.
The nature of the problem
Before discussing leadership models used in the project, it is
imperative to understand the nature of the problem that required addressing.
This is important as leadership approaches and the corresponding execution of
power need to vary depending on the degree and nature of the problem. The
categorisation of problems as Tame, Wicked or Critical can be subjective as it
depends not only on preconceived attitudes towards the issue but also depends
on the knowledge, skills and resources available to fix it (Grint, 2008). This has
been echoed by Pearce and Conger in 2003 who appreciated that sufficient and
relevant information may be lacking at decision making points in dynamically
changing environments (Turnbull, 2011). As the
project revolved around redevelopment of an existing system and because system
development of similar scope and magnitude had previously been successfully
achieved (in the first version) (déjà
vu), the task at hand though appearing
complicated at face value may have been described as a ‘Tame’ problem which
could be tackled through a management approach of linear and organised process (Grint, 2008). However, the
new version was being developed using a new technology stack (software toolset)
which required the DevOp team to learn together in the pandemic affected
climate of remote/offsite working. System development was not only reliant on
clinically determined specification but was also influenced by the eight steps
in the data lifecycle (Stobierski, 2021) with need to
fathom how structured data entries support clinical decision tools. There was
also the need to understand the interoperability of this system with other
clinical and administrative systems. Thus this initially perceived complicated
yet ‘Tame’ problem was actually a complex one with a high degree of uncertainty
caused by numerous evolving and interdependent components, reliant on a design
thinking approach to solve a ‘Wicked’ problem through collaborative leadership
sustained by execution of ‘soft’ power (Grint, 2008).
Leadership styles
In relation to the project, the need for a collaborative approach has
already been established and discussed. Vangen and Huxham describe four
‘activities’ - Embracing, Empowering, Involving and Mobilising -to facilitate
‘the spirit of collaboration’ (Vangen, 2003). Relating
these activities to stages of team development described by Tuckman (Wageningen
University and Research, 2012), it is worth
considering the interplay of each ‘activity’ as a corresponding facilitator in
the stages of team development. However, due to the varying intricacies in
relational and power dynamics, and the need to contextualise the nature of
problem, the authors prescribe the need for a pragmatic approach to leadership (Vangen, 2003). This
flexible approach to leadership especially in dealing with wicked problems is
further supported by Heifetz (Heifetz, 2009). Though
Goleman’s ‘six styles of leaders’ (Goleman, 2000) also supports
this approach, in the practicalities of its application there are overlap in
styles – ‘Affiliative’ leaders share characteristics with ‘Democratic’ and
‘Coaching’ leaders making clear distinction between the styles ambiguous. Baker
also highlights some of the limitations of Goleman’s adaptive leadership (golf
club analogy) by considering a leader’s uncertainty of and preference for
particular styles (or golf clubs) (Baker, 2016). The need to
understand the 'maturity' of leaders and followers from Hershey-Blanchard’s
Situational leadership model (Hersey, n.d.) and Fiedler's
Contingency model (Verkerk, 1990) supports
Baker’s argument because choosing a style depends on the competence/maturity
and commitment of parties involved. These two models are also similar in their
descriptors of 'Tasks' and 'Behaviours'. Importantly, where Hersey- Blanchard’s
model describes how overall performance relies on the leader's ability to mould
their 'style' to the 'maturity' of the followers; it may be argued that
Tannenbaum & Schmidt's Continuum model (Mind Tools, n.d.) is better
suited for group/follower development, and like Fiedler's model draws attention
to the more personal(ity) related aspects of situational leadership. This
argument links well to the theme that leadership development and organisational
change need to be in harmony with each other (Zaleznik, 1970).
'Adaptive
leadership' makes a lot of theoretical sense in an 'ideal' world, and there are
case studies that provide anecdotal evidence of its practical application (Healthcare Financial Management Association,
2019).
However, based on personal experiences the governance (management) structures
within which the NHS functions are too rigid to create a climate conducive to
facilitate and nurture adaptive leadership in practice. This challenge is
confounded by the need for NHS organisations to renew their ‘leadership
concept’ in order to mitigate fantasies that appointing leaders to positions of
power will suffice transformative change (Probert, 2011).
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