What makes a good leader? There are hundreds of books on the subject clogging up the business section of bookshops but most of them offer top tips on getting where you want to be, and getting those underneath you to do as you command. Few address what leadership actually is. When I was a lecturer in medical communication at Birmingham University, my leader—John Skelton—saved me the trouble of buying any management books by observing that the secret of effective management was to hire people who you knew could do the job, and then let them do it.
This makes a lot of sense. The quality of the workforce is the most important resource in any organisation, but only if they have the resources, freedom, and control to innovate. Control, or rather the lack of it, is at the heart of many successful comedies. Blackadder is stuck between Queenie and Baldrick; Basil Fawlty between Cybil and Manuel; and David Brent is just stuck in middle management in the dreary office of a Slough paper manufacturer. The reason these sitcoms are so popular is because they ring so many bells with their audience.
We can be freed if our leaders have the foresight to let us get on with our jobs. But there has to be a clear sense of purpose and value to stop us going horribly off piste. I was reflecting on this (yes, I’ve just had my appraisal) as the Mid Staffordshire scandal was unfolding in the press. How could a flagship trust have achieved foundation status—the Government’s highest accolade—despite (according to the Healthcare Commission) ‘appalling standards’ of emergency care?1
An investigation is underway that will doubtless pin the blame (or rather share it out) on everyone other than the politicians. The Chief Executive has been suspended and the Chair has resigned, and it’s likely that ‘managerial failure’ will be top of the blame list. The regulatory bodies are also likely to get a good kicking. Monitor, which oversees foundation trusts, seems to be able to hand out this title without a handle on the quality of care. It will probably pass the buck onto the Healthcare Commission for waiting until 2009 to warn us how awful things had become when signs of discontent were evident as far back as 2003.
But the overarching problem is the nature of our political leadership and its effect on the health service. The ‘marketisation’ of healthcare has lead to a culture obsessed with targets and performance indicators that may bear no relationship to patient care. And the pressure to succeed is so great that the temptation is to deny and bury bad news (such as high mortality rates) rather than accept and address them.
Leadership, particularly in public service, means we all have a duty to serve. A key lesson from the Bristol heart scandal was that we must never lose sight of the patient, and yet hundreds of patients and their relatives complained about standards of care at Mid Staffordshire, but it took years for them to be heard. In a 2006 Healthcare Commission survey, only 27% of the staff at this hospital said that as a patient they would be happy with the standard of care provided.1 Surely, this was a powerful indication that standards were unacceptable.
In May 2007, Wrightington, Wigan and Leigh NHS Trust was told that its mortality rates were one of the highest in the NHS. But instead of challenging and denying the data, the Chief Executive, Andrew Foster, accepted it, got the board and clinical staff behind him, and focused relentlessly on the quality and safety of patient care. As a result, mortality rates have now dropped by 15%, saving 200 lives a year (pers. comm.). So something can be done, even when care goes badly wrong, but it takes brave leaders who serve their patients, rather than their political masters.