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Leadership and change in health and health services

By Stephen Leeder - posted Thursday, 27 October 2011


Leadership is an ambiguous quality. Leaders can be strong and good, strong and bad, weak and good, weak and bad. Leadership is morally neutral but like electricity, it is the power in the wires that lead to the motor of change and development. Was Hitler an effective leader? Indeed. So, too, Martin Luther King. "I have a dream." It may be of heaven, but the path we walk behind our leader may instead lead to hell or most commonly, nowhere at all!

In the immensely complex social system that we refer to as 'health care,' leadership is the sap in the tree of reform. Its branches include organisational restructuring, changes to governance, new ways of funding health care through mixtures of private and public insurance, information system development and the fraught reallocation of resources away from the most expensive, often useless therapies to prevention. In all these activities, where change is needed, leadership is essential to achieve results.

Leadership in health research is often a lonely vigil. Faith in one's ideas drives experimentation in the face of the possibility of failure - in the laboratory, the operating theatre, on the ward or in developing a new administrative or managerial service model.

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To lead a health research team requires resilience, a strong belief in the power of science, capacity for political trading with funders, empathy for anxious research subjects and sincere respect for the hope of those desperate for cure. Fail in one or more of those elements of leadership (and many do) and leadership can lose its grip and the research frequently fails to fulfil its promise.

The political efforts of research workers are at times Herculean – read the history of Nobel laureates to see how leadership skills in the political domain are critical alongside scientific prowess in advancing new ideas, research programs and institutes, and in succeeding.

The Harvard Business Review recently published a slim volume entitled HBR's 10 Must Reads on Change. Each essay is written by one or more experienced managers and manager/research academics. The cover blurb says that the book will inspire the reader to "lead change through eight critical stages:

  • Establish a sense of urgency;   
  • Overcome addiction to the status quo;   
  • Mobilise commitment;   
  • Silence naysayers;   
  • Minimise the pain of change;   
  • Concentrate resources; and   
  • Motivate change when business is good."

Although not always explicit, each of the essays about change and how to manage it also concerns leadership. None assumes that change will occur without leadership. I suppose that assumption might be contested, but when it comes to deliberate innovative change, the assumption is probably sound. No leader, no go.

In 1991, I attended a seminar for international medical educators offered by the Harvard Medical School. The weeklong program provided insights into Harvard's new medical curriculum, which was built, as many innovative medical education programs are now, on small groups of students engaging in problem-based, multidisciplinary learning. This was a serious break with the traditional lectures and laboratory education of conservative universities. Harvard had imported educational methods from several 'radical' new medical schools including McMaster University in Canada. The international attendees in the seminar were amazed at Harvard's change.

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Dan Federman, the charismatic dean of education and an eminent endocrinologist, was chair for the week. He had managed the change to the new curriculum under the deanship of Dan Tosteson. On Wednesday afternoon he ran a session about changing from conservative to innovative curricula. "Hands up all those who have a supportive dean back home," he challenged the group. About one-third sheepishly raised an arm. "Well, for the rest of you, the coffee shop is that way," he said, pointing. "I have nothing further to say to you."

I can't imagine any of the leaders I have known taking on a job without believing that change was important and that they were taking on the leadership mantle to change things. Hence the essay in the Harvard collection I referred to, "A survival guide for leaders," is especially important when thinking about leadership.

"To lead is to live dangerously," Heifetz and Linsky, the two authors of this essay, assert, pointing to the large number of executives who, starting brightly in a new job, soon crash and burn. There is, they say, a dark side to leadership: "The inevitable attempts to take you out of the game."

Change requires people to give up things that are precious to them in favour of a brighter, but indefinite future. So 'adaptive change' – as when a health system is reorganised and requires "wrenching organisational transformation" – is a huge risk factor for leadership.

The sort of leadership required to fiddle around the edges, which they call "technical change" does not lead to threat. I recall talking to a university official who was in charge of research development and asking how he found the job. "Love it!" he said. "In my job what I do is give away little dollops of money to oil the wheels for researchers. They are all happy! I make people happy!"

This is quite unlike the answer from a reforming vice-chancellor, other senior academics or a minister for health who is seeking to effect adaptive change.

When I was dean of a medical school, a colleague asked me how long I had been doing this job. It entailed the introduction of an entirely new curriculum, as had occurred at Harvard a decade before. "Four years," I said. "Goodness!" was his reply (he also had been a dean), "and you can still bend your back?" I replied affirmatively and asked why. "By this stage most deans have so much spinal scar tissue that they can't lean forward," he replied. Adaptive leadership is dangerous.

The essay by Heifetz and Linsky is quite explicit. "To minimise threats to eliminate you," they suggest five protective steps. But the assumption underling all of this is that, if you are the leader, and things are changing substantially, you are in the firing line.

In the language of managerspeak, they first propose that the leader operate "in and above the fray. Move back and forth between the dance floor and the balcony." Become involved in the process of change, but not so obsessively that you never have time to watch and reflect, or avoid hiding in your office 24/7: Get out and about and see what is happening on the dance floor.

Second, they suggest that leaders executing change need to "court the uncommitted," the silent majority who are neither loudly for nor against change. Politicians often overlook this 80% of the community. Accepting a degree of personal responsibility for the need for painful change can be a good move, showing the leader experiencing some of the pain.

A third element of self-protective change management involves living with the ambiguity and discomfort of conflict. "Conflict, is a necessary part of the change process, and if handled properly, can serve as the engine of progress. The conflict needs to be 'cooked," not burned, say Heifetz and Linsky. But, the heat must be high enough for people to sense the need for adaptive change. Short-term heat reduction is sometimes needed and can be achieved by tackling straightforward technical problems or slowing the pace of change.

The fourth attribute of the leader who successfully negotiates adaptive change is the business of delegation – not providing all the answers, not doing all the writing or talking or shifting yourself, but empowering and supporting others to get in on the act. Top-down change strategies, where all the answers have been invented in the sky, frequently fail because there is no local ownership.

Fifth, managing yourself is crucial. "Restrain your desire for control and meed for importance," Heifetz and Linsky suggest. Well, easily said! The value of wise, independent counsel and support for executives leading change is established with several powerful examples.

"The hard truth," they conclude, "is that it is not possible to know the rewards and joys of leadership without experiencing the pain as well. But staying in the game and bearing the pain is worth it, not only for the positive changes you can make in the lives of others but also for the meaning it gives your own."

Good leadership, I once heard said, is the art of helping those you lead to achieve things that exceed their expectations of themselves. That sounds like progress!

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About the Author

Stephen Leeder is professor of public health and community medicine at the University of Sydney, and co-director of the Menzies Centre for Health Policy.

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