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It’s more than 40 years since Abraham Zalenzick, in a now classic Harvard Business Review article, asked the question, Managers and Leaders. Are They Different? 1 His conclusion was that ‘yes’, they were, and quite fundamentally so. Decades of debate have followed as leadership and management as distinct, if complementary, practices have been compared, contrasted and scrutinised through innumerable theories, frameworks and lenses. Zaleznik’s fundamental point was that leadership was a creative process requiring imagination and an appetite for risk and uncertainty. Management by contrast tended to seek stability, order and control. And it is this polarity that has been at the heart of the management/leadership debate ever since.
Management’s primary concern is with the here and now and the immediate operational environment. It can be seen to revolve around six core tasks: planning, allocating resources, co-ordinating the work of others, motivating staff, monitoring output and taking responsibility for the process.
Management, then, is about getting things done and doing things right. Managers focus on the process, not the substance, of issues and in doing so may be seen as inflexible, detached and occasionally manipulative.1 Management is inherently a transactional process in which those that are ‘managed’ do so in their own self-interest, in return for some reward or punishment, be it financial, or related to job prospects or prestige. Effective management is essential for the smooth running of organisations, without which they would degenerate into an anarchic melee of competing self-interest groups. And in healthcare, a mounting body of evidence points to the fact that poorly managed organisations fail patients, frustrate staff, deliver poor quality care and are ill-equipped to adapt to the changing demands of the environment in which they operate.2
But management, as defined here, isn’t enough on its own. The tasks described in the list above assume a degree of organisational stability and that the strategic direction is clear and unambiguous. But healthcare is a complex, ever shifting territory in which neither of these two assumptions hold true. Making sense of the world, setting direction and taking others with you in an environment of constant change requires something more, and it is to this missing ingredient, leadership, that we will turn to next.
Leadership is a complex social construct with almost as many definitions as people who have attempted to define it. In recent years, leadership has attracted huge international interest and is often seen as a panacea for the organisational ills of the 21st century. Worldwide investment in leadership development has followed, despite which there remains no consensus as to exactly what leadership is, in whom it resides, and how best to develop leaders or leadership within an organisation. “Leadership”, wrote Bennis and Nanus, “is like the Abominable Snowman, whose footprints are everywhere but who is nowhere to be seen”.3 Perhaps as a consequence, there is relatively little objective evidence available as to whether leadership makes a difference on performance or productivity. Despite these misgivings, leadership is generally considered to be a good, and necessary, thing and, although elusive, continues to attract considerable attention in organisations throughout both the private and public sectors.
A recent review of the leadership literature4 identified four themes common to the various ways leadership has been conceived, namely that leadership is a process that occurs in a group context involving the influence of others towards the attainment of a common goal. The literature from which these themes derive stretches back across the 20th century, and in order to understand leadership better, it helps to examine the different theoretical lenses through which the concept has been viewed. Broadly, these can be divided into three overlapping categories; theories that:
Focus on individual personal attributes (eg, ‘great man’ theories, emotional intelligence).
Relate to the interaction of the leader with others (eg, situational leadership, leadership styles).
Seek to explain leadership behaviours in relation to their interaction with the surrounding environment or system (eg, shared, distributed, collaborative leadership).5
More detailed resumes can be found elsewhere,6 and many of these ideas will be explored in future editions of BMJ Leader’s Learning Zone.
So, as Bennis and Nanus laconically summarise, “leaders do the right thing and managers do things right”.3 But this distinction, summarised in table 1, has not always held true and it is only recently that the discourse has shifted from one to the other. At the beginning of the millennium, it would have been much more common to refer to the need for better management than leadership, and almost unheard of, in the decades preceding that, to talk about leadership other than in relation to that at the apex of organisations. But times have changed; the discourse of management has become one of leadership, and the emphasis on positional leaders has led on to one that values leadership at all levels, collaborative working and the sharing of power across relatively unbounded complex systems.
So, management or leadership? What’s needed is of course, both. As Kotter wrote in 1990:
‘Leadership is different from management, but not for the reason people think. Leadership isn’t mystical and mysterious. It has nothing to do with having charisma or other exotic personality traits. It’s not the province of the chosen few. Nor is leadership necessarily better than management or a replacement for it: rather leadership and management are two distinctive and complementary activities. Both are necessary for success in an increasing complex and volatile business environment’. 7
A few years later, Bolman and Deal highlighted why it is so crucially important for organisations to be both well led and well managed:
‘Leading and managing are distinct, but both are important. Organisations which are over-managed but under-led eventually lose any sense of spirit or purpose. Poorly managed organisations with strong charismatic leaders may soar temporarily only to crash shortly thereafter. The challenge of modern organisations requires the objective perspective of the manager as well as the brilliant flashes of vision and commitment wise leadership provides’. 8
Indeed, more contemporary views co-locate the two practices, with Gosling and Mintzberg warning of the consequences of their separation.
‘The separation of management from leadership is dangerous. Just as management without leadership encourages an uninspired style, which deadens activities, leadership without management encourages a disconnected style, which promotes hubris. And we all know the destructive power of hubris in organizations…’. 9
In practice, the tasks of leadership and management often fall to the same individual—it is usual to be appointed to managerial positions from which we are expected to lead—and the most effective practitioners are those that can draw on the complementary skill sets of both; creating coherence and shared purpose in an uncertain environment, while delivering results through high-performing organisations and systems.
The terms management and leadership have been used synonymously, as distinct concepts and as two sides of the same coin. Managers are generally considered to work within an existing paradigm promoting order and consistency, whereas leaders seek to produce change and movement in the face of uncertainty. The discourse has changed over time, largely due to shifting ideas of leadership and the increasing complexity of the organisations and systems in which leaders and managers operate. Contemporary views suggest that the two practices are interrelated and that their separation is harmful to organisations.
Hospitals are complex entities, involving large numbers of people, both service users and those providing care. Many interlocking processes involving human, physical and informational resources must come together to support individual interactions between healthcare professionals and patients. Interactions, which are themselves just points in time in care pathways that may track across multiple organisations and systems. Due to a range of drivers, economic, technological and demographic, these are also systems in constant flux. Someone, somewhere must try to tie the threads together in a way that delivers the intended results, that is, better health and care, with the most efficient use of resources. This is the job of management and such responsibility will often come within the remit of posts such as the Chief Operating Officer and Director of Finance. Defining the purpose and priorities of the organisation or system, setting the culture (the way things are done) and influencing the external operating environment will often fall to the leadership of the organisation: the Chief Executive and her senior leadership team. But in high-functioning hospitals, effective leadership and management are distributed throughout the organisation and may be found ‘from the board to the ward’.
Contributors TS planned, wrote and submitted the article and responded to feedback.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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