The Labour Party's ascendancy into government in 1997 marked a turning point in the amount of focus that was given to the public sector including the NHS (Currie et al. 2005, Gaughan 2001). The newly elected government quickly set about creating initiatives designed to modernise the NHS; the manner in which the NHS was managed was being revamped in order to improve the quality of healthcare being offered to the public. One such initiative was developing primary care with the creation of Primary Care Groups (PCGs) at the transitional stage before eventually becoming fully-functional Primary Care Trusts (PCTs) at the local level (Gaughan 2001). The leadership structure within the NHS came under scrutiny in line with some other facets of management. The empowerment of the majority of employees was seen as crucial in the transformation of the NHS. This reflected the values advocated by the Labour Government and was in contrast to previous notions of leadership that were authoritarian and had no reservations for any degree of autonomy (Jasper and Jumaa 2005).
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A study by Gaughan (2001) was carried out in the early stages of the development of PCTs, one of the objectives being to test the appropriateness of models of leadership in use in the USA's public sector on this new development. This essay evaluates the form of leadership that exists within PCTs; the sole focus is on PCTs as PCGs were generally perceived to be transitional. Critical analysis of the case study's methodology and results will be undertaken and existing literature regarding leadership within the public sector will also be drawn upon as these steps will be vital to prescribing further recommendations on how leadership within PCTs can be improved further in order to fully realise the objectives that are set out in their nationwide charter.
MANAGEMENT AND THEMES OF MANAGEMENT IN HEALTHCARE
Management exists in all organisations within both private and public sectors. It is the primary bearer of the maintenance of order at all levels. It is often confused with one of its main themes, leadership, leaving them both open to erroneous definitions. According to Robbins (2005), management works in a systematic manner to bring about the designing of rigid organisational structures, development of formal plans and monitoring those plans through to fruition as completed tasks. Some of the themes that are vital to the success of management are: leadership, knowledge management (KM), human resource management (HRM) and organisational behaviour. While the other three themes will be explained briefly in this section, leadership will be explained in more detail in the next two successive sections as it is the core theme that is being analysed in this essay.
According to Hennessey (1998), organisational culture can be defined by a set of values that are shared and understood by members of an organisation. It is encompassing although it can always evolve or change radically as a direct result of the leadership at the organisation. Wilson (1989) aptly defines organisational culture by stating that it is "to an organisation what personality is to an individual".
Knowledge Management consists of a range of strategies used in an organisation to ensure that information gets to the appropriate receiver on time in order to maximise performance (O'Dell and Grayson 1999).
Armstrong and Baron (2002) defined HRM as the "strategic and coherent approach to the management of an organisation's most valued assets- the people working there who individually and collectively contribute to the achievements of its objectives". HRM also ensures the effectiveness of an organisation's corporate strategy through the delivery of practices that are necessary for its achievement.
WHAT IS LEADERSHIP?
Leadership in healthcare is a relatively new concept; it only came into popular use within the sector post-1997 (Jasper and Jumaa 2005). As outlined earlier, leadership is often mistaken for management, of which leadership is one of its core themes. Bass (1990) defines leadership as "an interaction between two or more members of a group that often involves a structuring or restructuring of the situation, perceptions and expectations of the members. Leaders are agents of change- persons whose acts affect other people more than other people's acts affect them".
Two paradigms exist in the study of leadership: transactional leadership and transformational leadership. Transactional leadership is the more authoritarian of the two and it seeks to ensure that the leader's vision for the organisation is met. It may offer incentives such as a bonus in order to motivate the workgroup to meet set objectives. It also has little to no room for lateral sharing of views. Transformational leadership on the other hand seeks to empower the workgroup by offering encouragement and considering the views of individuals. Inspiration can come from anywhere across the workgroup and individuals are encouraged to share their views for the benefit of the workgroup as a whole (Hartley and Allison 2005).
Theories of Leadership
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The study of leadership can be traced as far back as the 1920s. Different theories of leadership have emerged since then. The first leadership theory, trait theory, was based on shared characteristics that effective leaders were presumed to possess (Jasper and Jumaa 2005; Walshe and Smith 2006). These characteristics included intelligence and self-confidence. Style theory, eventually replaced trait theory as the dominant leadership theory in the 1940s. This strand of theory was based on the leader's behaviour rather than the leader's personal qualities as drawn on by trait theory as the main point of emphasis. Thus, different leaders would fall under
different style spectrums with some being task-oriented and others being people-oriented.
Contingency leadership, as the name implies, is contingent upon situational factors. It is 'focused on identifying styles and behaviours which were dependent on a range of situational factors" (Gaughan 2001). Thus, it takes into context both the traits and the styles of the previous two theories but it highlights their weaknesses by drawing on their dependence on varying situations. Many organisations adopted this leadership form as it enabled leaders to strengthen their organisations by considering the situational factors unique to each organisation.
Transformational leadership has been in use in the Private Sector for the last two decades; it made a late foray into the Public Sector only at the turn of the millennium. This strand of leadership "is made up of four components: charisma, inspiration, individualised consideration and intellectual stimulation. The leader develops a vision and in doing so engenders pride, respect and trust" (Currie and Lockett 2007). This form of leadership flattens hierarchies and empowers other staff besides the leader to contribute to shared objectives for the whole work group.
Leadership within the Public Sector
The election of the Labour Government in 1997 marked a shift from the market-oriented ethos of the public sector towards an emphasis on quality improvement and community governance (Hamilton and Redman 2003). Effective, management and provision of public services required cooperation between the central government, the various local governments, and the organisations within the public sector. According to the Cabinet Office (1999), some sections of the public sector lacked efficiency and dynamism hence they needed to be modernised.
The need for leadership across all levels was also advocated as it was seen to be crucial to the success of public sector organisations. Transformational leadership was the type of leadership envisioned by the Labour Government for the public sector.
The attributes of transformational leadership have encouraged leaders in the public sector to exhibit characteristics such as impetus, vigour and enthusiasm, akin to a CEO in the private sector (Currie et al. 2005).
Criticisms of transformational leadership exist. One of such criticisms comes from Terry (1998) who ascertains that leaders that are cast in transformational mould in the public sector are a threat to democratic governance because they are liable to exhibit an "anti-traditionalist orientation and obsession with self-promotion, rule breaking, power politics, risk taking and radical change" (Terry 1998). However, this view is disputed by Borins (2000) who believes that these sort of reckless leaders that initiate risky, drastic changes are rare. Borins (2000) goes on to state that transformational leaders are innovative and usually demonstrate their skills by solving problems before they become crises, and also by being diplomatic in their approach to situations.
Overview of PCTs in England
PCTs came into being following the Labour Government's decision to overhaul the structure of the NHS; they now account for circa 80% of the NHS' annual budget. "Primary care trusts (PCTs) are the local statutory organisations in the English NHS responsible for improving public health, providing primary health care, and commissioning secondary and tertiary care services" (Smith 2005). They were setup to provide primary care to the public whilst bridging the gap between health services and social services thus providing increased accessibility to these services. A PCT is often the first point of contact for healthcare for members of the public; it comprises of GPs, dentists, opticians, pharmacists, NHS Direct, NHS walk in centre and local partner agencies including local authorities and representatives from the local community (Gaughan 2001; NHS Choices 2008).
In addition to primary care, PCTs also make decisions about both the range and quality of services that hospitals provide. They also control funding for hospitals. The autonomy that PCTs are given stand them in good stead to provide health and social services as warranted by their respective locales.
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Each PCT is overseen by a board comprising both executive and non-executive directors. The majority of the board members are usually non-executive members and they are headed the occupier of the lay chair; these members are appointed by the Secretary of State following open advertisement. The team of executive directors is headed by a Chief Executive. The trust's Professional Executive Committee is elected from local GPs, opticians, pharmacists and community nurses; they are the other board members (Gaughan 2001).
Effective leadership behaviour- a case study
Gaughan (2001) conducted a study on PCGs and PCTs with the principal aim of discerning the type of leadership behaviour that will be required to lead the groups and trusts most efficiently.
Gaughan (2001) posits that transformational leadership gained ground in the 1980s as the contingency approach gradually fell out of favour. Two independent studies that were carried out in the US helped to promote this paradigm shift; the theory that was presented by Bass (1985), later refined by Bass and Avolio (1994) using the Multifactor Leadership Questionnaire (MLQ) and also the study carried out by Kouzes and Posner (1987). Similar leadership factors were identified in both studies, with the data from the research by Kouzes and Posner (1987) validating Bass' earlier findings; it gave a more detailed breakdown of transformational qualities in terms of behavioural dimensions. The central tenet in both of these studies is the inter-relationship that the leader has with the subordinates, according to Gaughan (2001).
Hunt et al. (1988), cited in Gaughan (2001) observed that every healthy organisation goes through a life cycle. These are the Birth, Growth, Maturity and Revitalisation. They believed that different leadership skills are required to effect change at various stages of the life cycle.
The key leadership behaviours that Hunt et al., (1988) believed were necessary at the Birth stage were described as 'External transformational' and 'Representational'. The former skill could be likened to the transformational qualities listed by Bass (1985)
and Kouzes and Posner (1987) as it signified the relationship between a leader and subordinates. The latter, however, is the skill employed by the leader to represent the organisation to other partners and stakeholders, none of whom come under the direct influence of the leader. This marks a limitation as the two US models provide no allowance for this skill.
Research that was carried out across the local governments in conjunction with the NHS using a draft Leadership Questionnaire - Local Government Version (TLQ-LGV), found a wider range of transformational dimensions than in the US models. This model was more explicit and again, it illustrated the limitations of the US models.
A qualitative research study conducted by Gaughan (2001) to ascertain the themes which leaders deemed relevant in the performance of their roles was conducted by two PGC management boards consisting of twelve members. The findings revealed some commonalities between the PCG-RGI data and TLQ-LGV data; some other leadership themes were exclusive to the PCG-RGI model. These include valuing and supporting staff, being approachable and sociable, having a clear vision and direction, communicating and sharing a vision and also clarifying roles and responsibilities. Other findings were having integrity and honesty, developing partnerships and networks and possessing intellectual capacity and experience.
Other leadership themes that emerged included: building a team, clinical background, drive and ambition, influences and negotiates and time management. These themes are also important and need to be reflected in the development of leadership programmes.
Firstly, the methodology that was adopted by Gaughan (2001) could have been improved. The sample, which comprised two management boards, could have been extended to include non-management staff too. The members of the management
board are in positions of leadership and thus, there is the possibility of them talking about leadership in a manner that defines their own personal qualities; this could leave the recommendations made Gaughan (2001) flawed. This is why it would have diminished selection bias and ensured that a more objective understanding of leadership across the two PCTs besides just the management board (Smith et al. 2005).
According to Gaughan (2001), the recruitment and development of leadership initiatives should not rely on US models, evident by the study undertaken. The findings, from the US study, while present in the case study, reflect only part of the complexity of the leadership required within PCTs. The study goes on to highlight the point that some leadership themes may be ignored if the US models are followed; thus, a more complex set of leadership behaviours is required.
What the study fails to acknowledge, however, are the organisational stages of the US organisations when the US studies were carried out. Indeed, if PCTs were still at the stage of infancy during this study, the US organisations were definitely past the birth stage (Bass and Avolio 1994; Kouzes and Posner 1987). Thus, just as Hunt et al. (1988) believed that different leadership qualities are required at different stages of an organisational life-cycle, one can surmise that skills that can be perceived to be key within the PCG-RGI model may not be perceived to be as essential if a similar study is to be carried out once PCTs move to another stage of the life-cycle.
The study, did, however, consider external constraints that can be placed on leadership such as the central government's policy. According to Currie et al. (2005), the government's agenda for modernisation exhibits a tension between centralisation and decentralisation. Although the agenda sets out to promote devolution and increased flexibility, central government still demands accountability by setting performance targets for short-term targets and efficiency savings. This in itself is a problem because the short-term objectives of some PCTs may differ from the targets that have been set from them. This issue was considered in the leadership theme 'political sensitivity and skills' but the theme is still loosely amorphous and will need to be more defined.
The study also validated the point stated by Hunt et al. (1988) about representational leadership. This leadership behaviour is vital when dealing with other partners and stakeholders. It was noted in the leadership themes 'political sensitivity and skills' and 'developing partnership and networks'.
No off-the-shelf recommendation can be given with regards to the leadership structure of PCTs. However, it is very vital that leadership skills should be reviewed regularly because, as the PCTs grow, so will their objectives, which may increase or reduce. Another point worthy of note is that it would be more advisable to have a local leadership programme that is ideally suited to the needs of each PCT as opposed to the concept of the national leadership programme currently in place. Each PCT is different from the other with no uniform growth so different competencies in leadership will be required at different PCTs, dependent on factors such as the nature of challenges faced at the PCT and the demographic of its service users.
Leadership programmes should be made more accessible to the professional staff within a PCT. In their study of leadership in complex organisations, Denis and Pineault (2000) contend that new leaders recruited from outside the organisation are more likely to initiate major change compared to a new leader that was promoted within the organisation. The content regarding newly recruited leaders lends weight to Terry's (1998) argument. Furthermore, the opportunity to progress through the ranks to the top is an initiative that will be certain to motivate the individuals within a workgroup.
There should be periodic performance appraisals for leaders identifying skills that must be acquired, areas in which one must improve, and educational courses that must be completed. Performance appraisals will also enable leaders to keep abreast with, and align their goals to the aims and objectives of the organisation.
Performance targets should only be set for PCTs in the long-term by the government as opposed to the short-term targets currently in place. Leaders within the public sector are wary of empowering others with leadership skills because they (the leaders) are solely held accountable for the performance of the organisation (Currie et al. 2005; Currie and Lockett 2007). This marks a return to the principles of transactional leadership with a hierarchy developing between the leader and the central government. Thus, this leaves the leader with little time to enact leadership when there is a need to maintain management systems to prescribed levels (Currie et al. 2005).
Finally, contingency leadership is not completely obsolete and may yet be a more viable form of leadership for PCTs. As stated earlier, PCTs differ from the next so it is more important to have a form of leadership According to Currie and Lockett (2007), contingency leadership "is constantly changing as different issues arise requiring interaction with a wide range of stakeholders".
The shift from internal markets to one based on community governance in the public sector has been in place since the Labour Government took over in 1997. A transformation of leadership itself was seen as one way via which this shift could be made to work successfully as it sought to break down hierarchal boundaries between the leader and the subordinates in a way that empowered the subordinates and propelled them into working for the collective benefit of the whole work group. The modernisation agenda that was mapped out for the NHS has seen the introduction of PCTs as the providers of primary care. They also commission funding for secondary care.
Gaughan's (2001) study of effective leadership behaviour for PCTs underlined why it would be unfeasible to adopt US models of transformational leadership in PCTs as it demonstrated that the dimensions of transformational leadership in PCTs was cast in a wider context.
In conclusion, no foolproof template exists for the type of leadership that is required to drive PCTs towards the realisation of the objectives that have been set out for them. Although transformational leadership eschews values that run inherently to the vision set out by the government, it is still limited in its realisation by the short-term targets that have been set by the government. A contingency approach to leadership will seem to be the best approach to take as it is more likely to take the unique conditions faced by different PCTs; this is until a more suitable approach can be diagnosed.