Elsevier

Social Science & Medicine

Volume 74, Issue 3, February 2012, Pages 281-288
Social Science & Medicine

A critical account of the rise and spread of ‘leadership’: The case of UK healthcare

https://doi.org/10.1016/j.socscimed.2010.12.002Get rights and content

Abstract

This paper considers the rise of ‘leadership’ in discourses relating to the British health service, and the application of the term to increasingly heterogeneous actors. Analysing interviews with NHS chief executives from the late 1990s, and key policy documents published since, we highlight how leadership has become a term of choice among policymakers, with positive cultural valences which previously predominant terms such as ‘management’ now lack. We note in particular how leadership is increasingly conferred not only on those in positions of formal power but on frontline clinicians, patients and even the public, and how not just the implementation but the design of policy is now constructed as being led by these groups. Such constructions of the distribution of power in the health service, however, contradict the picture drawn by academic work. We suggest, therefore, that part of the purpose of leadership discourse is to align the subjectivities of health-service stakeholders with policy intentions, making their implementation not just everyone’s responsibility, but part of everyone’s sense of self. Given the realities of organizational life for many of the subjects of leadership discourse, however, the extent to which leadership retains its current positive associations and ubiquity remains to be seen.

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Highlights

▸ The term ‘leadership’ is used more and more in policy relating to health-service management and other activities. ▸ Not just managers, but frontline clinicians and even patients are now portrayed as ‘leaders’. ▸ This notion of dispersed leadership contradicts academic accounts of increasing centralisation of power by policy makers. ▸ The rise of leadership might be seen as an attempt to align the subjectivities of clinicians and others with policy aims.

Introduction

‘Leadership’ has been the focus of increasing attention for both policymakers and academics. Seen as a key component of organizational success, the popular, policy and academic literatures on leadership have grown greatly over the last three decades. In the private and public sectors, leadership has become more than merely a function within management: it is constructed as something to be enacted by employees across an organization, not just those at the apex (Bryman, 1999). In the public sector in particular, where power is more diffuse and organizational objectives more plural, there has been an increasing emphasis in recent years on the importance of spreading leadership qualities across organizations (Hartley & Allison, 2000). Recent British governments have been particularly strong exponents of this ‘call to leadership’ (e.g. Cabinet Office, 1999), and the National Health Service (NHS) has been seen much policy rhetoric, and financial investment, around developing ‘leadership capacity’ (e.g. NHS Institute, 2005).

Much contemporary leadership research is concerned with themes such as how leadership can be understood and conceptualized, and how its benefits can best be harnessed by individuals and organizations. Thus leadership researchers often draw on debates in the wider social sciences to ask whether leadership is best enacted through, for example, ‘transformational’ (Bass, 1985), ‘distributed’ (Gronn, 2000, Spillane, 2005), or ‘collective’ (Denis, Lamothe, & Langley, 2001) approaches. But while there are significant disagreements about its precise nature, it is largely accepted that leadership should be treated as a real, empirically distinctive entity. Furthermore, it seems more-or-less axiomatic within these debates that leadership (at least when properly practised) is beneficial for individuals and organizations.

The idea that leadership is universally beneficial seems holds for most studies of leadership in health. Reviewing this field, Gilmartin and D’Aunno (2007) draw attention to several distinctive aspects of healthcare delivery (e.g. the existence of “powerful professionals, especially physicians, who dominate many aspects of day-to-day work in healthcare,” p.390)–distinctive features of healthcare which, they contend, add complexities to attempts to transfer leadership theories from elsewhere. Nevertheless, they offer conclusions that resonate with the assumptions of mainstream leadership research outlined above. In healthcare, Gilmartin and D’Aunno (2007, p. 408) suggest, “leadership is positively and significantly associated with individual and group satisfaction, retention and performance”. Such ideas are echoed in the ways in which healthcare professionals are asked or aspire to ‘do’ leadership. In the US, for example, the influential National Center for Healthcare Leadership (NCHL) declares that it

works to assure that high quality, relevant and accountable leadership is available to meet the challenges of delivering quality patient healthcare in the 21st century. NCHL’s goal is to improve health system performance and the health status of the entire country through effective healthcare management leadership.1

In contrast to these dominant ideas, however, a small but increasingly influential body of work is emerging within organization studies, which we label ‘critical leadership studies’ (see, e.g., Alvesson and Sveningsson, 2003, Barker, 2001, Ford, 2006, Ford et al., 2008, Grint, 2010). Such work, though adopting diverse theoretical orientations, is united by scepticism towards leadership’s supposed benefits. Indeed, leadership, as the “process whereby one or more individuals succeeds in attempting to frame and define the reality of others” (Smircich & Morgan, 1982, p.257), is generally seen as a nefarious political project, one concerned with facilitating subtle forms of control: leaders seducing their followers into accepting what may not be in their interests. One response of some critical leadership scholars in resisting its seductive appeal is to focus less on what leadership is and more on what it does.

Here, in this vein, we critically consider the rise of ‘leadership’ in NHS discourse, over the last 10–15 years in particular, drawing on ideas from the critical leadership literature. We ask: what are the consequences–for individual healthcare staff, and for healthcare policy and practice as a whole–of labelling things ‘leadership’? In doing so, we draw on empirical fieldwork conducted with NHS managers in the 1990s, and then key policy documents produced from the late 1990s to the present. We highlight a shift in the terminology used to refer to ‘administration’, then ‘management’, then ‘leadership’ in the NHS. We note an expansion in the ways in which the term ‘leadership’ is applied in the policy literature, as an attribute not just of formal leaders/managers, but to an increasingly plural set of stakeholders, including clinicians and even patients and the public. We illustrate how this policy focus on leadership might be understood as seeking to affect the work and even the subjectivities of health-service professionals and other actors (such as patients and the public). By ‘subjectivities’, we mean individuals’ senses of themselves, their biographies and their personal trajectories. These we understand, following Knights and Willmott (1989, p.537), as neither essential and innate to the individual, nor externally imposed by social structure, but rather produced through “involvement in relations of power through which conceptions of identity are generated.” As such, subjectivity is not “that creative autonomy or personal space not yet captured by political economy” (p.549), but is rather “intimately bound to power/knowledge relations which traverse both the subjects and (what are conventionally seen as) social structures” (Newton, 1998, p.418). Our concern here, then, is with what leadership does–or might do–to the subjectivities of NHS staff.

In particular, we highlight how health-service staff are increasingly represented not just as the objects of policy interventions, but as subjects implicated in policy design. We suggest that claims made by health policy about the engagement of professionals as leaders in the design and delivery of reform are best understood as efforts to reconstitute these actors’ subjectivities: a co-optive means of ‘governing at a distance’ that complements more coercive modes of rule such as performance management and associated surveillance regimes.

Section snippets

Methods

Our paper draws, in sequence, on two sources. First, we offer an analysis of empirical material: interviews with 16 NHS hospital chief executives, conducted by ML in 1998–1999. Each interview lasted 45–60 min and was audio-taped and transcribed. Participants had agreed to be interviewed in the context of research investigating how NHS chief executives make sense of their professional world. Interviews were framed by an opening question–“What do you see as the heart of your job?”–and proceeded

Administration, leadership, management

There have been striking changes in the way that organizational roles in the NHS have been represented over the last 30 years or so. From the origins of the NHS until the mid-1980s, ‘administration’ was the term overwhelmingly preferred for formal organizational functions, within official documents and mundane discourse (Gorsky, 2008). Administration was finally displaced from its dominance by ‘management’ in the mid-1980s, following the publication of the NHS Management Inquiry, the Griffiths

The pluralization of leadership

In the previous section, we focused on the discourses of administration, management and leadership in the self-descriptions of NHS chief executives in the late 1990s. We highlighted both the potentials of this discourse–in promoting particular constructions of the place of management in the NHS–and its limitations–as a discourse that also prompts resistance. However, we are not (merely) arguing for an understanding of leadership as a form of semantic inflation, aggrandizing and legitimizing the

Discussion: the discursive appeal of leadership

The previous sections attempt to illustrate two related shifts in discourse around policy and management in the NHS. Firstly, there has been a notable shift in the terminology used to describe one area of activity in the running of the health service, from ‘administration’, through ‘management’, to ‘leadership’. Secondly, this label of ‘leadership’ has been applied to the activities (actual or aspirational) of increasingly heterogeneous actors, including not just those in senior management

Conclusion: limits to leadership discourse?

We have argued that within the UK NHS in the last 10–15 years, leadership has become the taken-for-granted discourse through which many organizational roles are represented, at least at policy level, and potentially by role-holders themselves. Today, it is not just administrators/managers who are to think of themselves as leaders, ‘leader’ is be enacted by all healthcare professionals. Even patients and the public, recent policy claims, can be(come) leaders.

In drawing attention to these

Acknowledgements

The authors would like to thank four anonymous reviewers for their constructive comments.

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