nhs-nurse-giving-flu-shotNurse jokes with patient, by NHS Employers, under a CC-BY-2.0 licence

NHS targets are a contentious, highly politicised, topic in the UK. Some claim they drive quality and achieve cost savings, whereas others vilify them for distorting clinical priorities and reducing the importance of compassionate care. The subject of much debate, cases where poor management of their achievement has led to the detriment of high quality patient care are well known and widely publicised. While political figureheads have publically recognised the detrimental effect the push to achieve targets can have on staff and patient wellbeing, it is widely accepted that top-down determined targets are here to stay and new ways of approaching their achievement must be sought.

The approach considered to address the root of these issues (the most notable root being heroism in management) focuses on the distribution of power and is commonly known as collaborative leadership. Also known as distributed or collective leadership, it is achieved by ‘everyone taking responsibility for the success of the organisation as a whole – not just for their own jobs or work area’. This is accomplished through the empowerment of staff and removal of organisational silos to promote a sense of ownership and community.

While very appealing, many deeply engrained NHS realities, top-down driven targets being one of them, directly oppose this model of leadership and threaten to subvert any collaborative leadership effort. Targets in particular are task or process driven, reducing success to a single outcome measure, or aspect of care. Additionally, they often simplify the complex nature of healthcare, often making success appear achievable by one person or small group, non-collaboratively.

Empowering staff to take responsibility but failing to address these realities and develop the right environments to support collective accountability will simply allow cultures to revert back to those of isolation and fear. It is therefore important that leaders and boards ensure their attempts to drive collaborative leadership encompass all aspects of healthcare delivery, not just those that are appealing.

Develop narratives for the organisation

To ensure collaborative leadership is effective, all employees must understand the direction in which the organisation is headed. Without a clear picture of organisational success, employees are unable to take responsibility for its realisation. Collaborative leadership therefore places senior leaders more importantly than ever as visionaries – it is their responsibility to truly understand how each component of the system fits together to achieve an end goal – even top down determined targets. Targets should be incorporated into organisational narratives; they must be recognised as important determinants of organisational success and psychological as well as physical contracts woven to place collaboration as the way to achieve them. Once these topics are matters of public conversation, those who were previously isolated in their responsibility are now at the heart of a community and are able to more powerfully speak out about the real issues faced.

Develop narratives for employees

While NHS staff are expected to have a clear understanding of how their role impacts patient care and experience, the expectation to understand how their role impacts corporate goals is not so apparent. For staff to take responsibility of their organisation’s success, they must understand how their efforts impact the achievement of goals outside of their immediate area. Raising employees’ internal locus of control by detailing the significance of their actions, big or small, will empower them not only to make the incremental improvements important to them, but make the clear links between their work and others.

By making those connections, senior leaders facilitate the development of relationships and a sense of community, opening up channels of communication and breaking down barriers. Fail to do this however and staff will naturally revert back to determining their actions by what they can physically see is impacted, subverting collaboration by allowing silo working and departmentalism. Their narratives will be determined by their immediate managers and organisational narratives will be more easily lost in favour of those that support individual success. Collaborative leadership requires engagement 2.0; senior leaders are required now, more than ever, to understand their workforce on a detailed level and be capable of connecting every task and behaviour to organisational priorities.

Develop focused networks

Investing time in the development of psychological contracts for collaboration is only wise if the supporting infrastructure is in place. Without this the rituals, routines and control systems that ensure sustainable culture change are unable to exist in any notable form; a broken psychological contract is more damaging than one that doesn’t exist and leaders must facilitate real action.

Collaborative leadership requires “high levels of genuine team work and co-operation across boundaries”; it is realised most compellingly in networked organisations and those that utilise models that reject the standard hierarchical and departmental structures. While the removal of these structures within the NHS is neither likely nor advised, understanding where they actively counter collaboration will support leaders to foster the environments in which community traits can realistically exist. It is therefore important that the use of networks to achieve top-down targets is promoted and corporately supported.

Leaders should develop interdisciplinary, cross departmental networks dedicated to the understanding and achievement of top-down targets, and reward employees for participating. These networks will not only lighten the burden of responsibility from one person, but strengthen the narrative developed by leaders.

Raise their own capability

To be successful, leaders must most importantly raise their own capability to view their organisations in new ways. Systems thinking is essential now more than ever and leaders are required to appreciate the many micro components of their organisations, understanding wholly and in the most informed way how every piece fits together.



  • The post gives the views of its authors, not the position of LSE Business Review, the London School of Economics or the University of Minnesota.
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polly-pascoePolly Pascoe is a senior manager in the NHS, focusing on quality assurance and knowledge productivity. She is also currently a PhD candidate at the University of Bradford, studying support mechanisms for evidence-based management.