The NHS is the largest public sector employer in the UK, with over 1.224 million staff on its payroll (NHS Digital, 2022a); of these, management and senior management account for around 2% of employees (Kirkpatrick and Malby, 2022). With these figures in mind, it is clear that for the NHS to be able to provide the safest, highest-quality healthcare, leadership must come from every staff member across every service and not just rely on those in formal leadership positions.
Leadership in the NHS has been a key talking point for many years (Martin et al, 2015). As the numbers and acuity of patients have increased, there has been a corresponding rise in the number of complaints about every aspect of the health service, when compared to 10 years ago (NHS Digital, 2022b).
The need for strong leadership at every level of the health service has been commented on by many, including clinicians themselves, service users and politicians. Conservative politician Baroness Cumberlege remarked in the House of Lords that multi-faceted, complicated organisations such as our NHS ‘need outstanding, in-depth leadership from all quarters’ (Parliament UK, 2013).
To understand the issues more fully, this article will seek to clarify the difference, if any, between leadership and management by examining some definitions of each. Different leadership styles will be considered, alongside their effect on the motivation of staff within an NHS organisation.
Management and leadership
The terms ‘management’ and ‘leadership’ continue to stir up debate in the academic fields of all professions. There is a copious amount of literature available to read, the majority of which is based on theory and experience rather than a concrete evidence base (Ellis and Abbot, 2013).
Some argue that management refers to the areas of business where an aspect of control is required—for example, the management of rostering—whereas leadership is about increasing the effectiveness of the workforce in whichever process they are employed (Marquis and Huston, 2017); however, there is no one agreed definition of each term.
Semantically speaking, there is only a superficial difference between the two. The Oxford English Dictionary (2022) defines each as the following:
- Management: the ‘organisation, supervision, or direction; the application of skill or care in the manipulation, use, treatment or control (of a thing or person), or in the conduct of something’
- Leadership: ‘the action or influence necessary for the direction or organisation of effort in a group undertaking’ (Oxford English Dictionary Online, 2022).
Both definitions imply an action, or actions, used to influence the behaviour of others.
It can be said that management is a defined set of tasks that a person employed as a manager is required to perform to ensure the smooth running of a business; this definition is supported by others in the literature (Gillam and Siriwardena, 2013). It can also be argued that leadership is more of an art form, where a leader influences the performance of a team through their own behaviour, rather than with the threat of discipline that a person in a management role can legitimately use against persons under their supervision (Sullivan and Decker, 2005). To be a good manager, the interpersonal skills that are required to be an effective leader, such as listening to your team or the ability to maintain a level of self-awareness, are also needed (NHS Leadership Academy, 2013). However, leadership is not the sole remit of managers within the organisation. To improve the quality of care in the NHS, leadership is required at all levels of the employee hierarchy (Jones and Bennett, 2012). The statement that not all managers are good leaders and not all leaders are in management positions (Stewart, 1995), is readily apparent throughout the health service.
There is an abundance of literature describing different types of management and leadership theories (van Diggele et al, 2020; James et al, 2021). The literature would support the idea that the best type of leader is one who has an awareness of these theories and uses parts of each to guide their behaviour, rather than attempting to use one theory in its entirety in every situation (Gill, 2006). A key concept that spans these theories is the capacity of an individual to reflect on their leadership style and the influence they have on people. It is this reflection and evaluation that may help clinicians to recognise when an alternative leadership style may be more appropriate in a given situation (Oliver, 2006).
Entire textbooks have been written on the theory of management and leadership in large organisations; however, for the purpose of this article, it is pertinent to discuss theories that are more relevant to the healthcare field, which are being used in many NHS hospitals today.
Scientific management theory
Scientific management theory (Taylor, 1911) became popular in the early 20th century and was first described by Frederick W Taylor. Taylor theorised that there was one best way to complete a task and therefore once this ‘ideal’ method was known, productivity would be at its highest (Marquis and Huston, 2017). There are four key principles of scientific management that can be seen in operation in the health service today (Gopee and Galloway, 2009; Marquis and Huston, 2017):
- Work should be organised scientifically; for example, time and motion studies carried out to define the most efficient way of performing tasks. Many nurses and allied health professionals will remember a quality improvement programme entitled ‘The Productive Ward’, which used time and motion studies to highlight areas for improvement in ward systems and processes, releasing time that could then be used in direct patient care (NHS Institute for Innovation and Improvement, 2009)
- Bringing science into recruitment: systematic hiring, training and promotion of employees based on each employee's strengths and weaknesses. Job roles in the NHS are now all clearly defined, with job descriptions and person specifications tailored to the role. There can be very little flexibility around the recruitment of people who do not already fit into a prescribed list of essential criteria, despite potential strengths in other areas. Scientific management theory remains apparent in NHS terms and conditions of service (NHS Staff Council, 2023)
- Employees should be able to see where they sit in an organisation and how they contribute to its productivity. This will provide common goals and a sharing of the organisation's vision. Most, if not all, NHS trusts these days widely publicise their mission, values and goals so that all employees can work towards them and know what part their work plays in the bigger picture. Taylor (1911) also advocated financial incentives for high levels of productivity, but this is not something commonly seen in the NHS today
- Management and staff should work co-operatively; workloads should be equivalent. This is not to say that the work is the same, but there is a clear division of work and responsibility between management and staff.
Visible leadership has been encouraged across all professions in the NHS over recent years, (Francis, 2013) with the goal of breaking down barriers between management and employees and improving safety. It can be argued that in periods of difficulty, the division of types of work between mid-level managers and staff is blurred, as managers are increasingly expected to put their management responsibilities aside to support junior staff in the clinical areas. Scientific management theory still applies today, as many of its principles remain appropriate in today's NHS.
Human relations management theory
Human relations management theory, or the ‘behavioural’ or ‘informal’ approach, emerged in the years following the introduction of scientific management theory. One proponent of the approach was Mary P Follet, who believed that there should be shared decision-making between employees and managers, so that both sides were satisfied (Marquis and Huston, 2017). Contrary to the goals of scientific management, human relations management puts psychological and social needs of employees at the fore of management thinking (Gopee and Galloway, 2009). It is common practice in the NHS today for teams to have meetings in which future plans can be discussed between managers and employees, rather than decisions being made unilaterally without employee participation.
The Hawthorne experiments (Mayo, 1933), were key studies related to human relations management; they noted that when management paid more attention to employees, productivity increased (Marquis and Huston, 2017). Apart from the increased visibility of leaders, as recommended by Francis (2013), part of the management role in the NHS is the appraisal of staff directly reporting to them. These appraisals are supposed to give the manager and employee a personal update on performance; often, they result in staff feeling more motivated and performing at a higher level, as they believe their manager cares about them. The author's personal experience of appraisals with several different managers has highlighted the importance of a manager's good communication skills, as well as the devastating effect that inappropriate leadership styles can have on management functions, such as appraisals.
Transactional leadership theory
Transactional leadership theory suggests that there are leaders who are focused on achieving the goals of the organisation on a day-to-day basis, without ever going above and beyond what is required of them. In a team led by a transactional leader, there is also a lack of shared vision and goals between the leader and the team (Marquis and Huston, 2017). Remembering the differences between groups and teams (Goodwin, 2006), discussed in more depth below, it could be viewed that transactional leadership is more suited to leading groups, rather than the high-functioning multi-disciplinary teams we aim to have in today's NHS. However, there are situations in healthcare where task- or goal-focused teamwork is required, such as in a cardiac arrest situation (Giltinane, 2013). Having said that, for the most part, task-orientated working has no place in nursing, as it can lead to a lack of holistic care (Bach and Ellis, 2011), which is a real defining factor of the nursing profession when compared to some other health professions.
Transformational leadership theory
Transformational leadership is widely billed as being the superior leadership style for use in healthcare (Gopee and Galloway, 2009; Ferreira et al, 2022). Transformational leadership theory introduced the concept of inspiring a shared vision among the team; a factor that is widely cited as criteria for defining a well performing team in the literature (Mahon et al, 2014; Martin et al, 2014).
Morgan (2005) describes transformational leadership as ‘the ability of leaders to influence others by transforming their behaviour without necessarily being in positions of authority’. This kind of leadership can be seen in action in the NHS daily. Often, truly inspirational leaders can be passed up for promotion into formal management positions; it is often these transformational leaders, working hard at the bedside providing excellent care and motivating those around them, who are overlooked.
It should be noted that critics of the theory highlight that transformational leadership skills alone are insufficient to lead teams long-term; strong and consistent organisational skills of the transactional leader are also necessary to ensure that the leader can perform their role efficiently (Marquis and Huston 2017).
Aspiring leaders in healthcare need to excel in the strong building blocks of transactional leadership. From here, they can transcend this limited concept of leading the day-to-day achievement of goals and motivating their teams, and can then begin to look to the future and excel as a transformational leader. Further research is needed into defining the common competencies of a transformational leader, and investigation is warranted into whether ‘transformational leadership’ is something that can be taught (Fischer, 2016). The results of such studies could contribute to ensuring leadership development programmes in the NHS are creating the kind of leaders that are essential to the service.
As an organisation, the NHS consists of hundreds of different teams, all working alongside each other to provide a comprehensive service, which is free at the point of delivery; the service prides itself for demonstrating the highest standards of excellence and professionalism (Department of Health and Social Care (DHSC), 2015). Some teams can be seen to be performing at a higher level of efficiency than others. High-performing teams are likely to achieve their goals quickly and effectively, and are more resilient in challenging times (Goodwin, 2006).
The differentiating factor that separates a team from a group, is the team's feeling of being accountable for achieving a shared goal, both as individuals and as a whole (Gopee and Galloway, 2009). Many NHS staff will have worked in groups where productivity has declined because group members were seeking individual interests over high-quality group outcomes. Strong leadership can, and should, convert any group into a high-performing team by articulating the shared goal and inspiring team members to collectively work towards it (Goodwin, 2006).
Unfortunately, the effects of poor leadership are seen on a regular basis in the national press. There is now a greater need than ever for ethical leadership, where leaders with good morals motivate others to do what is right for the good of others. Theories surrounding ethical leadership are, again, based mostly on experience, with few studies examining the actual nature of the leadership style (Northouse, 2013). On occasion, ongoing research has been driven by scandals across a multitude of organisations (Xu et al, 2011). The theory of ethical leadership has been born out of a need to ensure that leaders are influencing people around them in a morally sound way (Brown et al, 2005).
Ethical leadership is extremely relevant to health and social care settings, particularly in the current climate of scarce resources, as many decisions made by leaders will involve some kind of ethical component (Marquis and Huston, 2017). Furthermore, ethical leadership applies at every level of practice, from a bedside nurse administering medications, to a director of nursing discussing budgetary requirements for the forthcoming year (Ho and Pinney, 2016).
Any absence of ethical leadership is a stark reminder of the importance of using an ethics-based framework. Healthcare practitioners will be well-versed in the findings of the Francis Report and the appalling conditions described at the Mid Staffordshire NHS Foundation Trust (Francis, 2013). At that time, a prevailing unethical culture prevented people from behaving morally; the NHS as a whole has learnt a powerful lesson from this.
Moving forward from Francis, Berwick (2013) highlights the importance of leadership in maintaining patient safety. It is likely that most staff in the NHS joined the health service because they had the desire to help people. Keeping ethics at the forefront of your mind when practising at any level in the organisation, whether clinical or not, will help to ensure that disasters such as Mid Staffordshire are not repeated. Ethical leadership is inextricably linked to the drive to provide compassionate care, and leaders in the NHS—at all levels—need to support their colleagues to deliver care that reflects the 6Cs; care, compassion, competence, communication, courage and commitment (NHS Commissioning Board, 2012).
Healthcare in the NHS is becoming increasingly complicated. The complex nature of patients' clinical and social situations are difficult enough for staff to manage, but there are ever more acutely unwell patients in increasing numbers for teams to cope with. For those in more senior positions, with responsibility for leading teams and ensuring high standards of care, quality and safety, it can, at times, feel like they are fighting an uphill battle. Maintaining the motivation of staff is imperative to ensure these high standards of care can be achieved; transformational leadership techniques are an essential tool in the pursuit of such standards, as they motivate and empower staff participation (Curtis and O'Connell, 2011).
Despite the best efforts of healthcare professionals, negative attitudes and behaviours can creep into daily work as a consequence of the many issues that affect staff personally—clinical staff are not robots. However, when these behaviours begin to influence the leadership of key organisations, problems can, and do, arise. History teaches us the significant impact that poor leadership can have on an organisation.
Effective leadership not only has a great influence on the quality of care patients receive, but is also more cost-effective. If a leader can influence a disengaged employee to become re-engaged in the organisation, then the individual's performance can increase by up to 57% (Roebuck, 2011). Leadership is the key to shaping organisational culture (West et al, 2015), and so, if the NHS wishes to provide the best healthcare services in the world, then the organisation needs the highest quality of leaders. For strong leaders to flourish, they need to be nurtured and supported by the organisation in which they are working (McKimm and Swanwick, 2011).
- The NHS employs a huge number of people, but only a minority of these are in formal management positions
- Leadership and management are not the same things. Staff at any level of experience, or professional background, can be leaders
- Over the years, many different leadership and management theories have been proposed; knowing these theories can help clinicians develop their leadership skills
- A safe NHS that provides high-quality patient care needs strong leaders throughout the organisation.
CPD / Reflective Questions
- Think of someone from your career who was in a formal management position—what qualities did they have, or lack, that contributed to their skills as a leader?
- Think of someone from your career who was a strong leader, but did not hold a formal management position—what qualities did they have and how did their leadership skills influence their area of work?
- What type of leader do you want to be? What continuing professional development needs do you have to grow your leadership skills, whatever stage of your career you are in?