A pressing challenge facing all NHS organisations is to nurture cultures that ensure the delivery of continuously improving, high-quality, safe and compassionate healthcare.

Leadership is the most influential factor in shaping organisational culture, and so ensuring the necessary leadership behaviours, strategies and qualities are developed is fundamental.

Current NHS conditions make good leadership even more important. Demand in primary and secondary care is huge; 6.3 million patients are waiting for more than 7.5 million treatments, and 75,000 people have been waiting more than 65 weeks.1

While the fact that people are expected to live 13 years longer now than when the NHS was established in 1948 is a triumph of medicine and public health, an ageing population brings more chronic disease, polymorbidity and polypharmacy. Alongside improved diagnoses of cancer, ADHD and mental health, the NHS needs more capacity to treat these extra patients. Extra patient throughput and capacity increase costs, but this year’s fiscal climate is already grim. For example, in the first 4 months of this financial year, the 42 integrated care systems in England recorded a collective deficit of £2 billion, compared with a planned £2.2 billion deficit by the end of the 2024/25 financial year, HSJ reported.

"Just as we teach evidence-based medicine, approaches to developing leaders should be based on robust theory and evidence of what works in healthcare."

The NHS estate is also ageing; it’s hard to improve clinical outcomes in old buildings with outdated equipment and, despite recent pay settlements, the NHS continues to face significant staffing shortages and poor morale.

So there is a lot for leaders and managers within the health service to do, with limited resources, and an increasingly challenging operating environment.

Just as we teach evidence-based medicine, approaches to developing leaders should be based on robust theory with strong empirical support and evidence of what works in healthcare. While no-one can foresee the future, leaders can assess, analyse and prudently plan.

To assist this, the simple ‘4C’ leadership model summarises central components of the leadership evidence base and is offered as a handrail to help current and future leaders to lead. Leaders should be:

Compassionate

Leaders should enable those they lead to feel valued, respected and cared for, so they can reach their potential and do their best work.

Compassionate leadership results in more engaged and motivated staff with high levels of wellbeing, which in turn results in high-quality care.2

Leaders should empathise with their colleagues, seeking to understand the challenges they face. They should support others to cope with and respond successfully to work challenges. Compassionate leaders don’t simply tell people what to do, instead they engage with their people to find shared solutions to problems.

Compassionate leadership is underpinned by four key behaviours:3

• attending: being present, focusing on others, and listening carefully4
• understanding: taking time to understand people’s challenges and exploring different proposals about how to overcome them, rather than imposing didactic solutions5
• empathising: mirroring and feeling colleagues’ distress, frustration, joy etc, without being overwhelmed by emotion and becoming unable to help6
• helping: taking thoughtful, intelligent action to remove obstacles that impede people doing their work (eg chronic excessive workloads, conflicts between departments) and providing the resources people and services need (eg staff, equipment, training)7

Credible

Credibility is the foundation of leadership. Before people will follow, they need to have belief, trust and confidence in their leaders.8

Within healthcare, characteristics of credibility include approachability; clinical competence; being supportive; acting as mentors or role models; being visible in practice; directing and helping people; being inspirational; having effective communication skills and behaving with integrity.9 In short, leaders must practise what they preach!

The most effective leaders also recognise leadership is a journey, not a destination. We are all “incomplete leaders” and who we are determines how we lead.10 Leaders must be humble, recognise their own limitations and, when appropriate, balance ‘me’ with ‘we’ by seeking support from others more knowledgeable, skilled or experienced.11

Collaborative

Leadership is about creating the conditions for other individuals, teams, organisations and systems to succeed.12 To enable this, leaders must make connections within, across and beyond their own areas of responsibility.

Stakeholder consultation is the leader’s work, not a sidebar to their work.13 The most effective patient care pathways are multidisciplinary; they put the right team around a patient at the right time enabling more accurate diagnoses, comprehensive treatment plans and better management of complex conditions.

Leaders should facilitate communication between healthcare providers and enable a coordinated, efficient approach to care. Well-led collaborations also promote lifelong learning, allowing the sharing of best practice and experiences.14 This creates a supportive environment that not only enhances patient outcomes, but also boosts job satisfaction, recruitment and retention.15

Curious

Curiosity drives clinical advancements that improve patient care and enhance efficiency.

From the development of new technologies to groundbreaking procedures and novel therapies, leaders’ support for professional curiosity and innovation is at the heart of early diagnosis and personalised care.

Telemedicine has revolutionised access to care and enabled remote consultations and biophysiological monitoring.16 Artificial intelligence facilitates class-leading diagnostic precision, such as mammography and melanoma assessment.17 Laparoscopic and robotic surgery have reduced post-operative complications, hospital stays and patients’ recovery times.18

In addition to technology, innovation in clinical systems and practices, such as value-based care models, improve patient satisfaction and reduce costs.19 As part of a culture of research and lifelong learning, leaders’ support for curiosity, empowerment of colleagues to try and acceptance without blame that sometimes innovations fail can ensure clinical care remains evidence-based, cutting-edge and able to meet the evolving needs of the UK population.

The leadership task is to ensure direction, alignment and commitment within teams and organisations. The 4C leadership model can help healthcare leaders and their teams, organisations and systems face the future with confidence and deliver high-quality care to the populations they serve.

References

1. British Medical Association. NHS backlog data analysis. Accessed 21 October 2024
2. West M A. Compassionate Leadership: Sustaining wisdom, humanity and presence in Health and Social Care. Swirling Leaf Press, 2021
3. Atkins P W and Parker S K. Understanding Individual compassion in organizations: the role of appraisals and psychological flexibility. Academy of Management Review 2012; 37:524-546 [full text] (subscription required)
4. Kline N. Time to Think: Listening to ignite the human mind. Octopus Publishing Group, 2002
5. Gallo A. Guide to dealing with conflict. Harvard Business Review, 2017
6. West M A and Chowla R. Compassionate leadership for compassionate healthcare. In: Gilbert P. Compassion: Concepts, Research and Applications. Routledge, 2017
7. McCauley C and Fick-Cooper L. Direction, Alignment, Commitment: Achieving Better Results Through Leadership (Second Edition). Center for Creative Leadership, 2020
8. Kouzes J M and Posner B Z. Credibility: How Leaders Gain and Lose It, Why People Demand It (Second Edition). Jossey-Bass, 2011
9. Stanley D. Clinical leadership characteristics confirmed. J Res Nursing 2014; 19: 118-128 [full text] (subscription required)
10. Yukl G A. Leadership in Organizations. Pearson/Prentice Hall, 2006
11. Lepez C O. Invisible challenges in healthcare leadership. Health Leadership and Quality of Life 2023;2:35 [full text]
12. Pendleton D, Furnham A and Cowell C. Leadership: No more heroes. Palgrave Macmillan, 2020
13. Schaufeli W B, Arnold B and Bakker A B. Defining and measuring work engagement: Bringing clarity to the concept. In: A B Bakker and M P Leiter. Work engagement: A handbook of essential theory and research. Psychology Press, 2010
14. Domik G and Fischer G. Transdisciplinary Collaboration and Lifelong Learning: Fostering and Supporting New Learning Opportunities, 2011. In: Calude C S, Rozenberg G and Salomaa A. Rainbow of Computer Science. Lecture Notes in Computer Science. Vol 6570. Springer, Berlin, Heidelberg.
15. Chang Y W, Ma J C et al. Job satisfaction and perceptions of quality of patient care, collaboration and teamwork in acute care hospitals. Journal of Advanced Nursing 2009;65:1946-55 [full text] (subscription required)
16. Barbosa W, Zhou K et al. Improving access to care: telemedicine across medical domains. Annual Review of Public Health 2021;42:463-481 [full text]
17. Patel R H, Foltz E A et al. Analysis of artificial intelligence-based approaches applied to non-invasive imaging for early detection of melanoma: a systematic review. Cancers 2023;15:4694 [full text]
18. Buia A, Stockhausen F and Hanisch E. Laparoscopic surgery: a qualified systematic review. World J Methodol 2015 26;5:238-254 [full text]
19. Reiss-Brennan B, Brunisholz K D et al. Association of integrated team-based care with health care quality, utilization, and cost. JAMA 2016;316:826-834 [full text]