Superior management not superior leadership is what will save the NHS

Stories of the difference made by great leaders are very attractive in the world of organisations and armies. But they grossly exaggerate the role of individuals and understate the role of effective organisational systems. This is another vital lesson the NHS has yet to learn.

There is widely thought to be a crisis around leadership in the NHS with too many vacant senior management posts in hospitals and a general struggle to find good Chief Executives. Richard Vise, for example, say this in his recent Guardian piece on Addenbrooke's:

It is difficult to see why anyone would risk their reputation [as an NHS leader] when the chances of failure are so high.

Recent commentary (e.g. by Polly Toynbee or Roy Lilley) about the situation at Cambridge University Hospitals has tended to blame the regulatory environment, government policy and the general pressures on the NHS for driving out people who seem like good leaders. I've already argued that are learning the wrong lessons from the problems at Addenbrooke's but there is a more general problem with the focus on leadership: leadership isn't what really matters.

You can write great stories about how a visionary leader transforms organisations or wins battles. Stories about management and organisation are harder to write, duller and far less popular. But we should not confuse what makes a gripping narrative with what actually matters. Most narrative on the NHS falls into this trap.

The argument I want to make is that organisational systems matter far more than great leaders. It is vitally, existentially important that this is understood for the future of the NHS. If we focus our attention on leaders and not systems, continued failure will be assured (and hospitals will continue to fail, not just leaders).

It isn't that leaders don't matter, it's just that leadership alone has all the hope of success as a castrated Yorkshire terrier dry humping your leg in an effort to father puppies. And a constant focus on leadership as the silver bullet distracts from the prosaic, but far more important, work of designing and managing effective operations.

The best analysis of the mistake that we might call the leadership fallacy (it afflicts the world of business nearly as much as it afflicts commentary on the NHS) is found in two books by Stephen Bungay. The first, Alamein, is a history and analysis of what happened in North Africa in the second world war. The second, The Art of Action, is a distillation of the lessons for management Bungay learned when reanalysing military history (I've used stories from his analysis of the Battle of Britain to derive lessons about the importance of effective management for the NHS in another blog).

The military battles in North Africa are relevant because the way the story is normally told focusses on the leaders involved and tries to explain what happened by focussing on their characteristics. In telling the stories this way the reader is (implicitly) urged to believe that the selection of the right leader is what makes the difference between success and failure. Their characteristics, their visions, their skills matter and all those other boring details don't.
Bungay makes the point like this:

It is common to identify the actions of armies with their generals, to imagine that the Panzerarmee was quick and clever because Rommel was, and the Eighth Army was slow and cautious because Montgomery was. In fact, those characteristics were rooted in the institutions themselves, in the behaviour of hundreds of middle ranking officers on both sides. The Eighth Army behaved the way it did long before Montgomery arrived, and German troops in every theatre of war behaved much like the Afrika Korps whoever commanded them. Both armies did what they had been told to do in the way they had been trained to do it in the 1930s.

We have been conditioned to believe that the battles in Africa were decided by the characteristics of the generals involved. He argues they were, in reality, determined by the ways the competing armies were organised. These longstanding organisational characteristics, in the British case, made victory far, far harder despite large advantages in the resources available over their better organised German adversaries (the British had enormous advantages in manpower and equipment in North Africa).
The key point is that organisation systems matter far more than leaders (I highly recommend reading Bungay's books not just for the evidence and detail but because they are both very readable and surprisingly insightful).

Bungay's book on management makes this point (my emphasis):

We need not worry about how to make the structure perfect. However, unless the structure of the organization broadly reflects the structure of the tasks implied by executing the strategy, the strategy will not be executed. Every organizational structure makes doing some things easy and doing other things difficult. If the structure makes doing some things so difficult that there is a conflict between structure and strategy, the structure will win.

The lesson generalises. I've argued before (using Bungay's work) that the RAF won the Battle of Britain not because it had better pilots, better technology or better aircraft but because it had a better system to organise the technology, aircraft and pilots.

This is where the NHS needs to pay attention. If the focus is on appointing great leaders with great visions then the focus is wrong. The best leader and the best vision will be undermined if the organisational processes in their hospital are broken. Vision is a fine thing to have, but only attention to operational detail will translate it into effective action. When we tell stories about great NHS leaders and their transformational ideas we distract attention from the simple fact that those leaders matter little compared to the organisational systems in their hospitals. If those boring operational management details are not addressed then leadership is irrelevant.

This is where the specific failures at Addenbrooke's tell us something important for the whole NHS. Keith McNeil was by most accounts a great leader and had an important vision for how the hospital would run (a large part of which involved a new eHospital system that would put all administration and record keeping into a single online system). There is nothing wrong with that vision. If it worked, it would transform the quality and efficiency of day to day activities at the hospital. But McNeil, by his own admission, had no grip on operational detail or finances. In other words, he had no grip on the organisational processes required to translate his vision into effective action. And the hospital failed to appoint anyone else to the board who could fill in that gap. So, instead of leading to to a better and more effective hospital, the vision has led to chaos on the ground where basic processes no longer work reliably.

The leadership at Addenbrooke's (not just McNeil) focussed on the vision and neglected the boring management detail around the basic operational processes that have to work to translate the vision into action. In doing so they epitomise a pervasive neglect in the NHS. You can tinker with top level organisational policy and structure as much as you want but you won't see effective improvement unless you get the operational processes and management right from bottom up. Operational management matters and, if you don't get it right, you will cripple the best vision, the most carefully crafted top down strategy or the most highly respected leader.

I don't want to go so far as to say that leadership doesn't matter at all. But the greatest vision and most attractive and popular personality matter little if they have no grip on the operational detail. Until the NHS and the leaders it appoints get to grips with the prosaic detail of effective operational management, there is little hope for improvement and leaders will continue to fall.