Governing the New NHS: Issues and Tensions in Health Service Management

All these changes have made governance a crucial and contested issue in health care. Governing the New NHS makes sense of the new systems and will enable anyone interested in healthcare governance to navigate their way confidently through the maze. It describes, assesses and critiques the new governance arrangements. It examines how they are working in practice and how practitioners are responding. Each chapter is supplemented with expert witness statement written by leading practitioners in the health system. This practical book will be invaluable to all those interested in health governance, policy and management - whether academic, student or practitioner.

The Architecture of Governance: Conclusions and the Way Ahead. He is Chairman of the IPA. He has held board level positions in NHS, not-for-profit and private sector organisations. He was formerly Head of Governance at Humana Europe. We provide complimentary e-inspection copies of primary textbooks to instructors considering our books for course adoption. It is also at this point that clinicians, defined as any frontline health care professionals, have opportunities to fulfill leadership roles. For consumers of health care to achieve optimal health outcomes and experience optimal hospital care, many believe effective clinical leadership is essential.

In this paper, we discuss clinical leadership in contemporary health care, definitional issues in clinical leadership, roles of hospitals in contemporary health care, preparation for clinical leadership roles, and the facilitators and barriers to effective clinical leadership in the hospital sector. The importance of effective clinical leadership in ensuring a high quality health care system that consistently provides safe and efficient care has been reiterated in the scholarly literature and various government reports.

In the more recent Francis report 7 from the UK, a recommendation was made for similarly positioned ward nurse managers to be more involved in clinical leadership in their ward areas. In the United States, clinical leadership has also been identified as a key driver of health service performance, with the Committee on Quality of Healthcare suggesting considerable improvements in quality can only be achieved by actively engaging clinicians and patients in the reform process. However, leadership in health care is often very complex, and some authors claim it faces unique contextual challenges.

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For example, Schyve 5 claims aspects of governance are sui generis in health care, noting. In healthcare, because of the unique professional and legal role of licensed independent practitioners within the organization, the organized licensed independent practitioners — in hospitals, the medical staff — are also directly accountable to the governing body for the care provided. So the governing body has the overall responsibility for the quality and safety of care, and has an oversight role in integrating the responsibilities and work of its medical staff, chief executive, and other senior managers into a system that that achieves the goals of safe, high-quality care, financial sustainability, community service, and ethical behaviour.

This is also the reason that all three leadership groups — the governing body, chief executive and senior managers, and leaders of medical staff — must collaborate if these goals are to be achieved Schyve While nursing is not specifically named in the above quote, we believe nursing to be implicit and integral to leadership in hospitals.

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There is recognition of the challenges associated with health care governance, evidenced by significant investment internationally in building systems for leadership development in health care. This points to the realization that the cost and consequences of poor clinical leadership greatly outweigh the costs and potential benefits of provision of formal programs to enhance clinical leadership capacity ideally in a multidisciplinary health care team context. Indeed, across the health care sector, evidence exists of the need for clinical leadership to optimize care delivery.

In addition to challenges associated with resources and demand, episodes of poor patient outcomes, cultures of poor care, and a range of workplace difficulties have been associated with poor clinical leadership, 8 , 9 , 14 and these concerns have provided the impetus to examine clinical leadership more closely. Within the health care system, it has been acknowledged that clinical leadership is not the exclusive domain of any particular professional group. While effective clinical leadership has been offered up as a way of ensuring optimal care and overcoming the problems of the clinical workplace, a standard definition of what defines effective clinical leadership remains elusive.

A secondary analysis of studies exploring organizational wrongdoing in hospitals highlighted the nature of ineffectual leadership in the clinical environment. The focus of the analysis was on clinical nurse leader responses to nurses raising concerns.

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Three forms of avoidant leadership were identified:. These forms of leadership failure were all associated with negative organizational outcomes.

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Similarly, McKee et al employed interviews, surveys, and ethnographic case studies to assess the state of quality practice in the National Health Service NHS ; they report that one of the most important insurances against failures such as those seen in the Mid-Staffordshire NHS Trust Foundation is active and engaged leaders at all levels in the system.

Despite the definitional uncertainty, a number of writers have sought to describe the characteristics, qualities, or attributes required to be an effective clinical leader. Synthesis of the literature suggests clinical leadership may be framed variously — as situational, as skill driven, as value driven, as vision driven, as collective, co-produced, involving exchange relationships, and as boundary spanning see Table 1. Effective clinical leaders have been characterized as having advocacy skills and the ability to affect change. Table 1 The characteristics of clinical leadership and the attributes of clinical leaders Notes: Despite acknowledging the lack of a standard definition of clinical leadership, the authors in one literature review identified common themes:.

Many articles assert that clinical leadership is leadership provided by clinicians often recognized as clinical leaders.

While transformational leadership positions the leader as a charismatic shaper of followers, 33 clinical leadership is more patient centered and emphasizes collective and collaborative behaviors. Edmonstone notes following the implementation of numerous clinical leadership programs in the UK the little research undertaken has largely focused on program evaluation, rather than the nature or outcomes of clinical leadership.

Globally, hospitals are under increased strain and scrutiny.

Increased demands and fiscal pressures have increased the pressures on all health professionals as well as clinical and non-clinical staff. A number of nationally and internationally influential reports 6 — 8 have resulted in changes in visibility, scrutiny, and accountability in relation to hospital care. This scrutiny has increased the emphasis on the role of health professionals, including nurses, in monitoring standards, developing and evaluating better ways of working as well as advocating for patients and their families; and led to a substantial momentum in the quality and safety agenda, including the promotion of various strategies such as promoting evidence-based practice.

In the hospital sector, the demands placed upon leaders have become more complex, and the need for different forms of leadership is increasingly evident. To derive cost efficiency and improve productivity, there has been intense reorganization. Coupled with these reforms has been increasing attention upon improving safety and quality, with programs instituted to move attention beyond singular patient—clinician interpretations of safety toward addressing organizational systems and issues of culture.

In part, this shift has been in response to growing recognition that while designated leaders in positions of formal authority within hospitals play a key role in administration and espousing values and mission, such leaders are limited in their capacity to reshape fundamental features of clinical practice or ensure change at the frontline. There is considerable evidence to suggest nurses may experience dissatisfaction with the working environment in hospitals, 38 with poor work environments impacting negatively on the delivery of clinical care and patient outcomes.

The thrust of much recent attention upon attaining reform in hospitals through clinical leadership has positioned clinical leadership as a vehicle for improving clinician engagement in not only their own work, but also the care delivery microsystems in which they operate. This type of work engagement requires forms of citizenship behaviors that are focused upon improving clinical systems and practices. Hospitals are complex socio-political entities, and the ability for engagement and leadership among clinicians can be hampered by power dynamics, disciplinary boundaries, and competing discourses within the organization.

The tension inherent between clinical and administrative discourses is evidenced in the findings from the evaluation of clinical directorate structures in Australian hospitals, with close to two thirds of medical and nursing staff surveyed reporting the primary outcome of such structures was increased organizational politics. Edmonstone 11 cautions that without structural and cultural change within institutions, the move toward clinical leadership can result in devolution of responsibility to clinicians who are unprepared and under resourced for these roles.

Evidence emerging from the NHS suggests particular value in leadership coalitions between managers and clinicians. There is also a concern that many health professionals may not be well prepared to understand the nature of leadership, or take on leadership roles because of the lack of content on leadership in undergraduate course curricula. As Gagliano et al comment, there is some evidence that health service provider groups are attempting to address issues pertaining to leadership issues through design and implementation of leadership development programs.

Other countries have developed education and professional development programs in clinical leadership for doctors, nurses, and allied health professionals working in their respective health systems. Some of these programs have similar features to UK NHS leadership frameworks and associated strategies. For example, in New Zealand medical schools are working to provide leadership training in their undergraduate medical curriculum.

Governing the New NHS: Issues and Tensions in Health Service Management

Globally, the International Council of Nurses identifies leadership as one of the major considerations underpinning their activities and has established a Global Nursing Leadership Institute as a vehicle for these activities. Clinical leadership, if it is to be evident and successful, requires broader clinician engagement and forms of citizenship behaviors within the clinical context that mediate the realization of this form of leadership.

Much has been written in the organizational and health care literature about employee work engagement and the benefits derived through promoting work engagement. Considerable evidence confirms positive associations between constructs such as job satisfaction, work performance, improved productivity, and engaged employees. Edmonstone 35 cautions that the emphasis upon competency-based leader development has done little to foster effective clinical leadership in the UK, despite its potential usefulness, and informative and summative evaluation of leader development.

Although considerable discussion has occurred on the need for clinical leadership, and large scale pubic inquiries evidence the considerable patient harm that has occurred in the absence of such leadership, 7 , 8 there continues to be a major disconnect between clinicians and managers, and clinical and bureaucratic imperatives.

Recensie(s)

The debate over who is best positioned to lead service delivery and the place of clinicians in governance continues. Effective clinical leadership is associated with optimal hospital performance. It is allied to a wide range of hospital functions and is an integral component of the health care system. Developing clinical leadership skills among hospital nurses and other health professionals is of critical importance.

However, despite the widespread recognition of the importance of effective clinical leadership to patient outcomes, there are some quite considerable barriers to participation in clinical leadership. As the focus on hospital performance intensifies, leadership to increase efficiencies and improve quality will be of increasing importance.

National Health and Hospitals Reform Commission; Accessed March 22, Mountford J, Webb C. Global health care leadership development: It describes, assesses and critiques the new governance arrangements. It examines how they are working in practice and how practitioners are responding. Each chapter is supplemented with expert witness statement written by leading practitioners in the health system. This practical book will be invaluable to all those interested in health governance, policy and management - whether academic, student or practitioner.

With all the changes and developments in the Health Services it is essential to be able to steer a straight course and intelligent governance gives us the necessary vehicle. The Architecture of Governance: Issues and Tensions 2. The Role of Regulators in the Governance Process 3. The Governance of Networks 4. Governing the Commissioning Organisations 5.