Leadership – the difference between ordinary and extraordinary

Mike Chitty, head of applied leadership at the NHS Leadership Academy, outlines his philosophy on leadership in healthcare, looks at mistakes to avoid and the importance of time management and building relationships

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This article was originally published by the NHS Leadership Academy

The first thing to say on this subject is that ordinary leadership isn’t easy – it can be difficult, complicated and demanding – but it’s ordinary in the sense that it’s used to tackle well-understood problems or opportunities using tried and tested methods. For example, to reduce infection on a ward a manager might pull together all the people involved in influencing infection rates and agree a set of principles and procedures. Good, ordinary management is about standard operating procedures and mobilising a known way of operating that is going to produce the desired results. It’s difficult, takes discipline and courage and shouldn’t be overlooked or demeaned.

Extraordinary management

Then there’s extraordinary management, where the challenges are often less well-defined, there’s usually a lot of disagreement about the right thing to do and no guarantee that whatever you do will fix the problem. When you’ve got lots of disagreement and uncertainty it takes a different type of leadership to be able to move things forward. Ralph Stacey called it ‘extraordinary leadership’.

Essentially, what you’ve got to do is build consensus around the uncertain and build support to say, ‘Well, let’s try it.’ And if it doesn’t work this time, we’ll try something else. You’re learning from a very uncertain environment in an iterative way by trying stuff and seeing what happens.

This is an entirely different way of leading because you don’t know what the outcome is going to be, so you have to learn from the action, in the action. What becomes important, then, is to develop the right hypothesis and the actions to try, then try them quickly, learn from them quickly and try again quickly.

Extraordinary leaders need to:

  • Help people work through conflict and disagreement well and gain a sufficient consensus to act
  • Be creative, politically informed and emotionally intelligent
  • Be much more confident in dealing with failure because often what you’re going to try isn’t going to work

One mistake I see being made all the time is to pretend that something that requires extraordinary leadership can be solved by ordinary management principles. We’ll plan our way into a better future as if we know that our plans are going to work, rather than accepting that they might not. We lose that experimental way of working. We choose to look at a complex, messy problem as if it were ‘simple’ or complicated.

Actions speak louder than words

Just by existing, you’re leading and managing at the same time. So if I sit here with my head in my hands looking depressed, that will have an impact on you in terms of how you’re seeing the current situation. It will have an impact on my ability to take you somewhere new as a leader. Whenever we act, whenever we open our mouths, it can have a managerial impact (the here and now, keeping our show on the road etc.) and a leadership impact (how the future’s looking, etc.)

Sometimes leadership and management are presented as if they’re entirely different behaviours and there’s a set of behaviours that address each. For management it’s efficiency, effectiveness and improvement; leadership’s about taking people into a brave new world. I don’t experience that; I don’t open my mouth and lead one minute, then open my mouth and manage the next. Both of these things are happening here in the present, right now. The two are inextricably intertwined.

Sometimes I need to ensure that what I do makes people focus on the future and on change, which you could argue has a strong leadership bias, and sometimes what I do needs to focus on the here and now which you could argue has a strong management bias. If all you ever get from me is the here and now I look very managerial and very operational; if all you ever get from me is where we’re going to go and where we’re going to be in the future I look very visionary and leaderful but perhaps a bit disconnected.

Basic management processes with big leadership impact

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There are some basic processes that would typically be described as management but can have a big leadership impact. These give us the solid foundation from which to move into extraordinary management/leadership. They are:

We don’t value enough the time where we sit and talk to each other about what drives and motivates us. We need to teach people that of the hours a week they give to the NHS, a significant percentage ought to be spent on consciously building trust and agreement and building a relationship.

Hierarchies are still alive and kicking in the NHS. If you’re a doctor and I’m a nurse, what will define our relationship is our label, not us connecting as human beings. If we talk about what we’re here to do, now and in the future, our labels can disappear and we can do some interesting work together.

It’s through relationships that we can manage well or lead well. If I work with you to build trust and a relationship, I’ll be able to lead you better and you’ll be able to lead me better too. If I don’t, we won’t able to do either.

Giving feedback

We’re not always good at taking the time to give feedback in the NHS because we’re so results-focused. Whether given ‘in the moment’ or through planned appraisals, delivering feedback that’s useful and constructive needs to become part of the fabric of a leader’s regular responsibilities. It’s crucial in supporting everyone’s development and performance. Equally as critical is ensuring that colleagues have the opportunity to – and feel able to – give you feedback about any help and support you can give them. 

Delegation

The reason why some people are working 60-hour weeks is because they don’t know how to do their 40 hours and then delegate the rest. If we don’t delegate appropriately, we can’t get

our jobs done so we end up recruiting another assistant director, for example, which means we have top heavy organisations and not enough people at the frontline.

Time and priority management

How can you transform the NHS in your 60-hour week if you spend 59 of them maintaining the current operation and one looking at the future and one day a month at a meeting to look at future strategy? Our practice doesn’t reflect what we say our priorities are – if you want to transform the NHS, spend 59 hours transforming it and one hour maintaining it. The best leaders can do both things at the right time.

Extraordinary leadership doesn’t always make things better for patients

Extraordinary leadership doesn’t always lead to better care; quite often, it leads to worse care in the short term. Remember the Mental Health Act when we shut down the large asylums to care for people in communities? Some dreadful things happened because we didn’t know how to do it well. But, 30 years on, most people would say mental health provision is significantly better than it was. From caring for 97% of mentally ill people in asylums and three per cent in the community, it’s now the other way around.

Suppose we’ve got a large rural health economy with five community hospitals, all small and expensive to operate. So we shut them and build one world class hospital because it makes more financial sense and is more efficient. But when we’ve shut the hospitals down, the people who’ve used them will have worse care for the next three to five years. With something like that it’s very rare to make a step change from good to better. Seth Godin calls it ‘the dip’ and it can be long and expensive. With mental health, it’s probably taken a decade for people to say ‘Yes, that was worth it.’

Courage is the main thing we need to bring about this change. We need to face up to these big, and sometimes seemingly overwhelming, challenges and acknowledge them rather than only working with what we feel is in our control. Extraordinary can make people hold their nerve and believe that what we’re going through is worth it and that what we’ll go through will get us to a better place.