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Creating better leaders in the NHS in England and Wales

1. Summary of the impact

A programme of research by the Health Services Management Centre (HSMC) has improved the delivery of NHS healthcare in England and Wales by driving new approaches to leadership development via the design and delivery of two innovative NHS leadership programmes, which train senior and middle-tier leaders across England and Wales. The programmes have changed how NHS leaders go about their work in terms of their ability to: challenge and stop poor practices, value staff and provide integrated care by working collaboratively with other organisations and professions which have resulted in demonstrable benefits for the NHS, other healthcare organisations, patients and staff.

2. Underpinning research

Leadership is key to the effective and safe running of a large, complex organisation such as the NHS. Weaknesses in NHS leadership have long been recognised, and these resurfaced in national debates following the Francis inquiry (initiated in 2010) into the Mid-Staffordshire care scandal. Historically, NHS leadership development programmes have been short-term, piecemeal and uncoordinated. In 2012, the NHS Leadership Academy (NHSLA) commissioned ambitious national programmes — the Nye Bevan (Bevan) and Elizabeth Garrett Anderson (EGA) programmes — to provide leadership training for senior and emerging leaders. HSMC, in partnership with Alliance Manchester Business School, KPMG and Harvard University, were commissioned to deliver these novel programmes, which provide the national structure for leadership development in the NHS.

The programmes were informed by HSMC research that examined the reasons for poor performance in parts of the NHS. In particular, this body of work identified the unintended effects of NHS structures, the excessive focus on targets and performance management, and the complex personal and social forces that shape organisational behaviour [R1]. HSMC research demonstrated that, although there was a plethora of guidance on effective leadership available to NHS organisations, the empirical evidence base was “meagre” [R2]. In recognition of this, HSMC research shed light on key problems and challenges in the NHS, and identified the central role of leaders in bringing about necessary change. In particular, HSMC research highlighted three important areas where improved practice was required.

Tackling poor practice: HSMC research identified that, in the NHS, dysfunctional professional behaviours and malpractice were not always effectively challenged [R1, R2]. The research provided insights into the reasons why NHS staff often feel unable to ‘speak up’ and the role played by leaders in either preventing or enabling more ‘open’ cultures, and encouraging and responding to whistle-blowers [R2]. This research highlighted the challenges involved in tackling poor practices but also indicated that leaders can tackle them if they are provided with the tools to do so via effective training and development [R1].

Valuing staff: HSMC research demonstrated that organisations deliver more effectively on aspects of performance that are most valued, affirmed and celebrated within the organisation [R1]. Linked to this, the research demonstrated the detrimental impact that negative cultures have on NHS staff, and documented how pressure (for example, to meet external targets) can increase anxiety and result in poor performance [R1]. HSMC studies showed that better staff experiences were associated with improved patient outcomes. Conversely, negative employee experiences such as ‘aggression, discrimination or unequal opportunities’ were correlated with lower employee and patient satisfaction (R3, p. xix). HSMC research provides deep and qualitative insight into this relationship, through exploring the ‘emotional labour’ involved in caring roles, and the role leaders play in supporting staff and reducing isolation, thereby improving patient care [R4]. In short, staff who feel valued by their leaders provide better care which is more focused on patients not targets.

Partnership working: The NHS was not designed to provide integrated care, and HSMC research showed how fragmentation and isolation within and between organisations contributed to its poor performance and patient outcomes [R5, R6]. Patients are poorly served by an insular NHS which only thinks about its own services, because patient needs are not just medical. Integrated care is critical to getting the best outcomes for patients requiring partnership working and NHS leaders to work across organisational and professional boundaries with local government and the third sector [R5, R6].

Underpinning each of these findings, the research uncovered many different entrenched localised cultures, which made nationally led change difficult. This identified that any attempt to shift the culture of the NHS needed a very large and sustained intervention, but one which was also tailored to local contexts, reflecting variation within organisations and across professional groups [R1]. This body of HSMC research identified training in key areas as a necessary vehicle for cultural change and improved performance within the NHS. These insights were incorporated into the design and delivery of the major new suite of NHS leadership programmes, in a way that enabled sensitivity to local context.

3. References to the research

R1. Mannion, R., Davies, H., Harrison, S., et al. (2010). Changing Management Cultures and Organisational Performance in the NHS. Available on request.

R2. Mannion, R., Freeman, T., Millar, R., and Davies, H. (2016). Effective board governance of safe care. DOI: 10.3310/hsdr04040

R3. Powell, M., Dawson, J., Topakas, A., et al. (2014) Staff satisfaction and organisational performance. DOI: 10.3310/hsdr02500

R4. Sawbridge, Y., and Hewison, A. (2013) Thinking about the emotional labour of nursing - supporting nurses to care, Journal of Health Organization and Management. DOI: 10.1108/14777261311311834

R5. Dickinson, H., Glasby, J., Nicholds, A., et al. (2013) Joint commissioning in health and social care. Available on request.

R6. Glasby, J., Dickinson, H., and Smith, J. (2010) ‘Creating NHS local’: the relationship between English local government and the NHS, Social Policy and Administration. DOI: 10.1111/j.1467-9515.2010.00711.x

The research was supported by the following competitively awarded grants: Effective board governance of safe care, 2012–2016, NIHR, £450,000 (Mannion); Staff satisfaction and organisational performance: evidence from the NHS staff survey, 2012–2013, NIHR, £180,000 (Powell); Joint commissioning in health and social care: an exploration of definitions, processes, services and outcomes, 2009–2012, NIHR, £300,000) (Glasby).

4. Details of the impact

HSMC research has changed the understanding of leadership in the NHS and subsequently influenced ways that NHS leaders are trained and developed. It has improved the practice of NHS leaders in terms of their ability to challenge poor practices, support the delivery of compassionate care and work collaboratively across organisational boundaries. This, in turn has led to improved standards of care in the NHS.

  1. Changes to NHS leadership development

Key aspects of HSMC’s research influenced the content and delivery of the Bevan and EGA programmes. The programmes included specific objectives relating to HSMC research: ‘challenging negative practice and creating open cultures’; ‘creating the conditions to enable integrated, personalised and cost-effective care, with compassion to both yourself and others’; and ‘development of an appropriate level of collaboration, alliances, partnerships and relationships’ [R1-R6]. The HSMC research provided programme content which formed the basis of lectures, work-based and experiential learning, key readings and case study materials, as well as content for the “virtual campus” resources and interactive learning materials [R1–R6]. It also shaped the approach to learning; for example, by including the negotiation of individual learning goals alongside overall programme outcomes, and blending academic and developmental elements [R2].

The programmes have become the gold standard for all future NHS leaders, with the NHS CEO in England describing them as ‘the key means through which many NHS leaders are trained and developed’ [C1a]. The value of the programmes to the NHS, and the specific contribution of HSMC, is evidenced by the decision to continue the programmes for five years after the initial contract, and to award the new contract for EGA to a refreshed consortium led by HSMC in partnership with the University of Manchester. The contribution of Bevan and EGA was recognised by the European Foundation for Management Development (an international membership organisation of Business Schools/corporations with nearly 900 members across 88 countries) Gold ‘Excellence in Practice’ award for ‘Changing the Culture of the English NHS’ in 2016.

Nearly all NHS Trusts have benefited from the programmes, with 97% sponsoring staff to participate. By 2020, 4,302 senior and mid-career leaders had undertaken Bevan/EGA (1,430 and 2,572 participants, respectively) representing a significant proportion of NHS leaders — equivalent to between one-third (4,302 participants/11,691 senior managers) and one-quarter (1,430 Bevan participants/5,410 board level managers) of the NHS’s senior and mid-level management [C2a, C2b]. This has created a network of effective leaders with the skills, confidence and insight to identify areas in need of change and to implement interventions of sufficient resource, scale and reach to bring about cultural change within the NHS [R2].

  1. Changes to NHS leadership practice

NHS leaders have changed their practices in line with HSMC research evidence on effective leadership. A 2017 evaluation by Ipsos MORI reported an overall improvement in leadership practice attributable to the EGA programme, stating that there had been a ‘notable improvement in their [participants] effectiveness as leaders, and these improvements were typically seen to be a result of participation in the Programme’ [C3, p.16].

Bevan/EGA programmes have built participants’ personal resilience, confidence and influence, enhancing their capabilities to challenge poor organisational practices and negative cultures and to create more positive and inclusive team environments [R2]. Ipsos MORI found that ‘participants were able to articulate clear examples of how they had been able to deploy skills and/or tools gained through their participation […] to deliver a positive outcome on the team’s morale, sense of shared vision, conflict resolution and engagement’ [C3, p. iv]. A subsequent survey of former Bevan participants indicates improved understanding of positive organisational practices/cultures and confidence/skills in challenging poor practices (90% of 203 respondents agreed that their skills were improved, with 80% identifying that they/their organisation had made practical changes to the way staff work to promote a more open culture). One graduate of the EGA programme noted that ‘EGA gave me the grounds and the confidence to develop wider trust learning and encouraging more open and honest team meetings and discussions. From setting up learning forums we have been able to improve patient care and spotlight on negative and positive practice’ [C4]. In a survey of former EGA participants, 86% of 318 respondents believed that the programme had increased their skills to challenge poor practices [C4]. Respondents refer to being given the ‘courage to speak truth to power’ and the ‘confidence to challenge people and issues where I felt uncomfortable’.

That the changes in leadership practice are effective is evidenced by an evaluation of Bevan by the Institute for Employment Studies (2016), which found the programme provided ‘different ways to make practice more patient-centred and empowered participants to strengthen the links between their own roles and patient outcomes and experiences’ [C5, p. 6]. This is further evidenced by surveys of former participants on the programmes showing between 80–90% of respondents report an increased understanding of how to deliver more person-centred care as a result of the programmes [C4]. For example, one graduate of Bevan reported having ‘strengthened my awareness of staff wellbeing’ and ‘worked with my HR business partner to ensure staff are being supported appropriately’ [C4]. Another reported that ‘Bevan has really focused me to support and influence others to start with the patient and work outwards. It has also refocused me on the importance of the staff I work alongside and lead, and helped me to be able to proactively address difficult conversations where the patient or staff get lost.’ [C4]. The 2016 evaluation of Bevan also found that participants ‘gained an understanding of the importance of influencing across boundaries and beyond the limits of positional authority’ [C5, p. 8]. Similarly, the 2017 evaluation of EGA concluded that ‘participants have been able to join-up services within their organisations, thus bringing about improved communication channels and closer working relationships between otherwise less connected areas’ [C3, p. iv].

A new appreciation for, and methods of, partnership working learnt as a result of the Bevan/EGA programmes has been utilised to good effect in response to COVID19. Whilst the first wave of the pandemic resulted in suspension of many routine health services, in one NHS hospital Trust, led by a graduate of EGA, treatment for cancer patients was continued by rapidly moving the provision of intravenous chemotherapy to a new independent sector site. This new model of safe, temporary service relocation has since been adopted as a template elsewhere in the Trust and wider NHS, including for elective surgery [C6]. The lead for this work noted ‘the core of the idea was to put the patient at the centre of everything, which was based on the Anderson [EGA] programme. It taught us how to co-ordinate with external organisations which is something — as a hospital manager — I hadn’t done before. The Anderson programme explains how you can influence others and behave with compassion towards staff and patients, which really helped me to achieve this.’

93% of Bevan participants surveyed reported that the programme had increased their appetite and skills for partnership working, which had resulted in better integrated care for patients [C4]. Participants described becoming ‘more confident in terms of collaboratively [ sic] leadership’ and being able to ‘drive the delivery of integrated care’ and ‘confidently and competently lead and develop collaborative leaders across our systems’ [C4]. 77% agreed that collaborative working with other organisations had increased, and that this had resulted in positive changes. These included, for example: successful joint tenders with partner organisations; new partnerships with third sector organisations to tackle specific health needs and taking on leadership roles in major new policy developments such as ‘integrated care systems’. 82% of EGA participants reported having new skills to work across service or organisational boundaries. For example, one survey respondent noted: ‘I make a more system-orientated contribution, transcending organisational boundaries to consider what we can do collectively to improve quality of care and outcomes, whilst also bringing the specific information from my own organisation into the discussion.’ [C4]

The promotion of a high proportion of programme participants to more senior leadership positions within the NHS means that they are able to bring about sustained change because they are in more influential positions. 40% of Bevan participants and almost half of EGA participants were promoted within 6–12 months of completing the programme. Nearly all of these (90%) directly attributed their promotion to the programmes [C7a, C7b].

  1. Improved standards of care

There have also been measurable outcomes for the NHS as a result of the programmes in terms of care, as consistently reported by graduates of the programmes [C4]. For example, a Clinical Director for End of Life Care described how participation in Bevan inspired him to lead a change programme that saw the service’s rating with the Care Quality Commission (CQC – the national regulator) upgraded from ‘inadequate’ to ‘good’ within a 9-12-month period [C8a]. As a result of the change programme, this Trust was recognised nationally through being shortlisted for two Nursing Times awards (2020) for ‘Enhancing Patient Dignity’ and ‘Nurse Leader of the Year’ [C9]. In recognition of such impacts, the Director General of Defence Medical Services has described the ‘research-based curriculum design and delivery’ of EGA and Bevan as having directly led to ‘better patients, service users and indeed staff experience and outcomes’ [C8b].

Crucially, the scale and reach of the programme has enabled multiple participants to develop their leadership skills and to form communities of improvement practice within their local health systems. The current Chief Executive of the NHS in England states that the programmes have ‘created a national network of aspiring leaders’ whose practice is ‘rooted in research-informed development’, and that the programmes have ‘equipped them with new ways of working, and hence improve[d] the experiences of patients and staff’ [C1a]. For example, the Chief Executive of a large NHS Foundation Trust reported that a group of 12 leaders who had been on the programmes subsequently ‘led culture change work that has received various accolades and was picked up by the CQC when they visited, and it has influenced our ratings, of that I have no doubt.’ He further noted that ‘patients have benefitted as a result of the staff being liberated, and the staff have been liberated as a consequence of involvement in the programmes.’ [C1b]

The programmes have been recognised at the most senior levels of the NHS for their impact. For example, a Senior Director in the NHS People Directorate has hailed the programme’s ‘hugely positive and beneficial impact on participants and the services they provide in health and care’, adding that ‘robust research has underpinned the design of both programmes from their inception, not just in terms of what the health and care system required at that point, but equally what was required for a new integrated and fast-paced system […] and yet always keeping true to those golden threads of compassionate and inclusive leadership, patient centred decision making and continuous improvement.’ [C10]

5. Sources to corroborate the impact

C1. Testimonials:

  1. From Chief Executive of NHS England (4th February 2021) [Available as PDF]

  2. From Chief Executive of Midlands Partnership (29th January 2021) [Available as PDF]

C2. Evidence to calculate the proportion of staff taking part in the programmes:

  1. Binley’s Database of NHS Management 2020 [Available as PDF]

  2. NHS Workforce statistics (accessed March 2020) [Available as PDF]

C3. Ipsos MORI (2017) Evaluation of the NHS Leadership Academy [Available as PDF]

C4. NHSLA (2020) The Nye Bevan and Elizabeth Garrett Anderson NHS Leadership Programmes: evaluating impact on leadership behaviour and organisational practices [Available as PDF]

C5. Institute for Employment Studies (2016) The Nye Bevan Programme: Evaluation Report [Available as PDF]

C6. Testimonial from Service Manager, Cancer Services, Surrey and Sussex NHS Trust (24th January 2021) [Available as PDF]

C7. NHSLA website:

  1. Elizabeth Garrett Anderson programme [Available as PDF]

  2. Nye Bevan programme [Available as PDF]

C8. Evidence of improved standards of care:

  1. Testimonial from Clinical Director for End of Life Care, Isle of Wight NHS Trust (16th December 2020) [Available as PDF]

  2. Testimonial from Director General of Defence Medical Services (28th January 2021) [Available as PDF]

C9. Nursing Times shortlist [Available as PDF]

C10. Testimonial from Senior Director of NHS People Directorate [Available as PDF]

Additional contextual information

Grant funding

Grant number Value of grant
10/1007/02 £418,019
10/1011/11 £158,364
08/1806/260 £299,476