Strategic clinical leaders

Transcription

1 The current issue and full text archive of this journal is available at wwwemeraldinsightcom/ htm The development of strategic clinical in the National Health Service in Scotland John Edmonstone MTDS Consultancy, UK; School of Public Policy and Professional Practice, University of Keele, Keele, UK, Institute for International Health and Development, Queen Margaret University, Edinburgh, UK, and Centre for Innovation in Health Management, University of Leeds, Leeds, UK Strategic clinical 337 Abstract Purpose The paper seeks to describe a national strategic and multi-professional clinical hip programme designed and developed for the National Health Service in Scotland It addresses the policy imperatives behind the programme, the local and national processes for identifying future clinical and their preparation through the programme Design/methodology/approach The background context and case for the programme are considered against international and local contexts The programme s roots are explored, drawing upon the extensive consultation process used The programme design is explained and the evaluation methodology and results are described Findings Key learning related to programme design and delivery issues is highlighted, as is that relating to hip itself Research limitations/implications This is a one-country case study but draws upon recent international good practice Originality/value The case study identifies how a small (five million population) country can devise a strategic clinical hip programme which reflects the distinctive direction adopted at policy level of working closely with clinical Keywords Clinical hip, Scotland, Development programme, Leadership, Development Paper type Research paper This paper focuses on a national strategic and multi-professional clinical hip development programme designed and developed for the National Health Service (NHS) in Scotland It addresses the policy imperatives which stimulated the need for the programme, including the impact of devolution and the resulting distinctiveness of clinical hip in the Scottish system It describes the local and national processes for identifying future strategic clinical and the preparation for future clinical hip roles through the Delivering The Future programme, including both programmatic and work-based elements The methodology and outcomes of the external evaluation of the programme are described, as are the resulting changes to the programme design and delivery, which have included closing the feedback loop from the programme into health policy development Major learning from the programme experience is identified Leadership in Health Services Vol 24 No 4, 2011 pp q Emerald Group Publishing Limited DOI /

2 LHS 24,4 338 Background and context The case for clinical hip Clinical hip is increasingly seen as vital in ensuring that patients receive effective, high-quality and cost-effective care (Millward and Bryan, 2005) It has increasingly become seen to be important both within uni-professional and multi-professional health care teams and across a range of professional groups in order to foster creative solutions in providing seamless care across professional, geographical and organisational boundaries This perception is one shared both by clinical professionals themselves and by health care managers (Hardacre et al, 2010; Miller and Balint, 2010; Pearson and Machin, 2010; Stoll et al, 2010) Working in uni-professional silos is seen as hampering the delivery of safe and effective care and as impacting adversely on the patient s journey The Picker Survey (Picker Institute Europe, 2005) involving over a million patients identified the following aspects of care that patients considered most important: Fast access to health advice Effective treatment delivered by trustworthy staff Involvement in decisions and respect for patients preferences Clear, comprehensible information and support for self-care Physical comfort and a clean, safe environment Emotional support and alleviation of anxiety Involvement of family and friends and support of carers Continuity of care and smooth transitions The survey was carried out in NHS England but there is little reason to believe that the priorities for patients in Scotland (or indeed anywhere) would be different In terms of delivering such a patient-focused service, the role of clinical working together to meet these needs appears fundamental and apparent This focus on clinical hip at every level of the organisation is highlighted in the Scottish Executive s National Framework for Service Change (SEHD, 2005a) which highlights the role of front-line staff in contributing to service change and the concomitant need to empower them as That report focused on strategic clinical hip, suggesting that one way of building on clinical commitment would be to identify clinical leads in each NHS Board charged with driving forward the actions identified here as key to the future of the NHS in Scotland The importance of local clinical hip in ensuring effective organisational functioning matches findings from a study by the former NHS Leadership Centre in England, which sought to identify the contribution made by Chief Executives to their organisations star ratings This suggested that Chief Executives were not significant in changing the performance of their organisations and implied that they had little to do with how their organisations functioned as a whole (Dawes, 2002) This research shifted the focus of hip thinking away from a focus on individuals towards that of organisational capacity Edmonstone (2005) suggested that these findings propose that hip is not something that rests in a few talented individuals, but is an aspect of the whole organisation and thus reflects how teams support each other, learn from mistakes and instigate service change This notion of shared hip

3 has become increasingly seen as necessary in health care (AMRC/NHS Institute, 2009) Rather than concentration on the few talented individuals the emphasis is increasingly rather on collective capacity or efficacy the social capital rooted in the quantity and quality of the connections and relationships in an organisation, network or system and evidenced in mutual understandings, shared values and trust The emphasis is on the relationships between individuals rather than the qualities or competences within them In considering hip styles Trofino (1995) argued that the present health care context required who develop people committed to action, convert followers into an empowered workforce and transform into change agents Other writers (Faugier and Woolnough, 2002; De Geest et al, 2003) also concurred that a shift in hip away from command-and-control styles and towards more transformational and facilitative styles was what was required and this conclusion that a transformational and facilitative approach was most appropriate for hip of clinicians was strongly echoed by a summary of recent research findings backed by the UK s medical Royal Colleges (AMRC/NHS Institute, 2009) and is further embodied in the creation of a shared clinical hip competency framework covering all clinical professions (NLC/NHS Institute, 2010) Further evidence supporting this conclusion is drawn from research into the links between hip behaviours and service improvement (Hardacre et al, 2011) A recent major survey (Alimo-Metcalfe and Alban-Metcalfe, 2003) of public sector managers revealed a clear conjunction of the hip qualities deemed important by staff with those that resonate with the literature on transformational hip The most important characteristics were concern for others and the ability to communicate and inspire The authors concluded that while the transactional competencies of management were crucial, they were insufficient on their own Organisations therefore had to be willing to adapt and be truly committed to incorporating transformational hip into their recruitment, selection, promotion, performance management and development processes for all staff, whatever their area or level of work Such conclusions were subsequently reinforced by further work in the employee engagement field by the same authors (Alimo-Metcalfe and Alban-Metcalfe, 2008) The relationship between high-quality hip and high-quality patient care is increasingly apparent in the literature (Chiok Foong Loke, 2001; Donaldson, 2001; Firth-Cozens and Mowbray, 2001; Edmonstone and Western, 2002; Cunningham and Mackenzie, 2005) Mannion et al (2005) compared and contrasted the cultural characteristic of high and low-performing hospitals in the NHS in England and found that while each location possessed its own unique character, significant patterns were observable The key points of divergence were groupable under four headings, one of which was hip and management orientation Key features of such an orientation were low turnover of senior management team members (a feature particularly attractive to clinicians), strong and empowered middle management, clear accountability and performance management as a high priority Similarly, West et al (2002) found a significant association between the management of employees in acute hospitals and the levels of patient mortality within those hospitals Human resource management practices predicted a significant proportion of variation in patient mortality regression analyses, controlling for hospital size, number of doctors per bed and local health needs Specifically, the Strategic clinical 339

4 LHS 24,4 340 sophistication and extensiveness of appraisal and training for employees and the percentage of staff working in teams in the hospital were all strongly associated with measures of patient mortality Such conclusions were further endorsed by further related research (Shipton et al, 2005) The Scottish context Under the devolution arrangements for Scotland and Wales implemented in the late 1990s (and later in Northern Ireland) health care is a devolved area of policy and practice and it has become increasingly obvious that there are four health care systems emerging within the UK, each marked by a different set of values (Greer and Rowland, 2007) The distinctive nature of these systems has been identified as managers and the market for the NHS in England, localism and collaboration for the NHS in Wales and working closely with clinical professionals for the NHS in Scotland (Greer, 2004) Northern Ireland has experienced devolution later than the others and a distinctive profile has yet to emerge there Thus the Scottish context is one which quite clearly signals the centrality of clinical hip and indeed did so in advance of the emerging similar emphasis in England (DoH, 2008) The roots of the programme In 2005 the Scottish Executive (the devolved administration) published Delivery Through Leadership: A Leadership Development Framework for NHS Scotland (SEHD, 2005b) which recognised that improving the health of Scotland and reforming how health care was delivered depended upon effective hip and that developing future would be crucial in delivering NHS goals The framework summarised the policy drivers (shown in the list below) and set out the hip qualities seen as essential in translating the policy agenda into meaningful actions (Table I) It emphasised the key role that clinical had in making this a reality and identified the priorities for action Leadership context in NHS Scotland: Developing and implementing sustainable service strategies to improve health and health care delivery Delivering excellence in service quality consistently through staff, with a stronger patient focus and greater public involvement Using resources to maximum effect and accounting for their impact on health improvement and service performance Aligning service needs and the current and future workforce Moving from a focus on institutions to a focus on networks and the continuum of patient care, and to a focus on health as well as health care Working more effectively in partnership across the wider public sector and other agencies Developing effective single-system arrangements and regional planning processes which support devolved responsibility and accountability, together with career development across the local public sector Creating an infectious can do culture (Scottish Executive Health Department (2005b) q Crown Copyright)

5 Qualities Personal qualities Personal governance Personal management Knowledge management Service excellence Ensuring focus Delivering governance Achieving results Future focus Identifying goals Descriptors Commitment to service excellence Integrity and probity Account for performance Engage with others in decision-making Develop team and self Self-awareness Emotional competence and consistency Articulate and live by values ( being-the-talk ) Asking the hard questions proactively Listening empathetically to understand Maintaining a contemporary knowledge of best practice Directing attention to the key issues Regulating the temperature (managing pace and stress) Looking after the needs of patients, staff and the public Balancing risks Creating a climate of performance delivery and accountability Resolving complex problems through a win-win approach Creating purpose with a focus on outcomes Shaping and articulating the future with passion Creating and making choices Thinking flexibly and innovatively Making choices in uncertainty and ambiguity Taking risks with political astuteness Developing capability and Building relationships and partnerships which recognise capacity with partners interdependency and which share learning Instilling a staff, team and organisational development culture Leading change Aligning people, structures, systems and processes to secure goals Seizing technological solutions to improve healthcare Inspiring others and unleashing energy to change Source: Scottish Executive Health Department (2005b); q Crown Copyright Strategic clinical 341 Table I Leadership qualities framework Scoping and consultation From 2004 attention began to be paid to the development of clinical hip in NHS Scotland While there was existing work being pursued, clinical hip development was typically patchy, not sustained or was based solely on uni-professional approaches There was no coherent approach to succession planning for the most senior strategic clinical and a great deal of concern expressed by chief executives and senior clinicians about where the next cohort of medical directors, nurse directors and allied health profession leads would come from A scoping exercise was undertaken (November, 2004-January, 2005) This involved a literature review of international best practice in clinical hip which was strongly influenced by Vance and Larson s (2002) earlier study which noted that only 44 per cent of 6,628 articles reviewed were data-based; that the largest proportion (414 per cent) were purely descriptive of demographic characteristics or personality traits of, and that only 152 per cent included any correlation of qualities or styles of hip with measurable outcomes for service users or positive changes in

6 LHS 24,4 342 organisations There was also a series of 20 formal and informal meetings with a range of uni-professional and multi-professional groups and with key individuals, including existing strategic clinical, organisation development (OD) leads in NHS boards, chief executives, participants on an existing programmes, external consultants and experts in the field of hip development The exercise was also informed by outcomes from other work on workforce design, partnership working, etc From the exercise a number of recurring themes emerged representing the key challenges perceived by strategic clinical These are presented below: Clarifying clinical hip and establishing it as a legitimate career path Managing tensions between strategic hip role and operational management/clinical service delivery role Aligning professional and organisational agendas Balancing the need for transactional management with transformational hip Breaking-down organisational silos, both vertical and horizontal Consistency of hip behaviours, being corporate Developing self-awareness and self-management strategies Managing complex change Resolving conflict, negotiation and mediation Working in virtual teams across professions and across organisations Strategic influencing and influencing at all levels (3608 influencing) Understanding high-level political processes and the political/service interface Managing local politics Shaping clinical strategy and redesigning services to improve health and health care delivery Engaging in policy formation Leading cultural change Meaningful patient focus and public involvement including consulting with communities Clarifying accountabilities and ensuring processes are in place to effect real change for patients Opportunities for sustained development programmes Following the scoping exercise, a discussion paper highlighting the challenges and suggesting a programme outline was circulated to all key stakeholders and extensive written feedback was obtained Four regional focus groups were also held, the membership of which reflected the major stakeholders mentioned above a mixture of policy-makers, strategic, clinical professionals and those with local and national responsibilities for personal and organisational development There was much support for the programme and feedback from stakeholders was built into the programme design A high-level steering advisory group representing stakeholders was also established Members included the deputy chief medical officer, a nurse

7 director, a human resource director, together with academic input The extent of the scoping exercise, consultation, and the advisory group were all seen as key to ensuring that a programme emerged which had a resonance with, and buy-in from, stakeholders Strategic clinical The programme Programme design In terms of programme design a number of guiding principles were seen as key: The programme was not intended as a single catch-all in terms of clinical hip development, rather it focused on succession planning for high-level clinical hip roles It was recognised that the development of clinical was also being pursued by many health care organisations within NHS Scotland Due to the nature and complexity of these high-level posts and a shared concern that a sufficient and appropriate hip pool to recruit from in the future was available, this warranted a national approach that would provide participants with opportunities which they would find difficult to access locally The initiative needed to be seen within the wider context of the national hip development framework and local NHS board development plans The programme was developed as a national initiative and was largely funded centrally Working in partnership with local systems to ensure local ownership of the programme was deemed essential and was therefore reflected in the approach taken in developing the programme While the programme would help develop for the future, it needed to be complemented with a range of local experiences to ensure that potential benefits for individuals, organisations and NHS Scotland were realised Local systems were therefore asked to consider opportunities that would be available during and following the programme to sustain participants hip development The programme was designed to address the common themes that emerged during the scoping and consultation exercise This was balanced by the need to address individual participants emerging needs The experiences offered locally would also be central to achieving this balance The programme aimed to be as inclusive as possible and was designed on a multi-professional basis for clinical from a variety of settings 343 The aims and outcomes of the programme are presented in the list below The programme was designed to be delivered over a 12-month period with up to 24 participants from across the NHS board areas in Scotland Aims and outcomes of the programme: (1) Aim To identify senior clinical from across the clinical professions and prepare them for future roles at NHS Board, regional and national levels (2) Outcomes To provide a cadre of senior clinical across NHS Scotland who: Exhibit hip behaviours consistent with the hip qualities framework and who create an enabling culture for managing complex change

8 LHS 24,4 344 Provide strong clinical hip across professional and organisational boundaries focussed on service excellence, driving reform and delivering strategic change to improve health and heath care Think creatively and work collaboratively to overcome obstacles to the change process Understand the national context for health (political, policy, economic) and the supporting strategies and processes Are able to operate at NHS board and national levels to drive improvement in health and health care delivery Clinical hip structures varied between organisations and it was difficult to prescribe exactly the roles that potential participant might be in Applications were encouraged from from all clinical professions who were currently in senior posts with a strategic focus or who were aspiring to future roles at NHS board, regional and national levels within the next two years Reflecting the local ownership principle, guidance for NHS boards on recruitment and selection followed consultation with the board OD leads who were central to the local recruitment and selection processes NHS board chief executives were important in taking on a sponsorship role for the successful participants In addition to written guidance, there was close working with organisations to support the recruitment and selection process While a fixed number of places were allocated for territorial boards based upon population size, other places were reserved for applicants from national boards The intention was to pursue local selection against national criteria The programme themes (presented in Figure 1) were derived by mapping the key clinical hip challenges that emerged during the scoping exercise against the headings of the hip qualities identified in the hip development framework A more detailed model of the programme demonstrating the relationship between the aims and outcomes, programme themes and interventions is presented in Figure 2 In order to address the key themes a variety of development methods were selected that targeted participants knowledge, skills and attitudes within their organisational context A blended learning approach was adopted to combine structured input with experiential learning approaches that were grounded in the participants day-to-day context Programme elements The programme that emerged from the scoping and design stage was complex and based on best practice in hip development The elements were both programme-based and work-based and included: Programme-based A three-day residential development centre intended to introduce participants to the programme and review their individual strengths and development needs Tools that were employed included: 3608 feedback using the NHS Scotland hip qualities framework tool Myers Briggs type indicator (MBTI) Learning styles questionnaire (LSQ) Thomas Kilman conflict mode instrument Observed case study exercise

9 Strategic clinical 345 Figure 1 Programme themes Figure 2 Programme model

10 LHS 24,4 346 The development centre also introduced the participants to each other, to the programme, the coaching/facilitating team and to the interventions Participants were encouraged to produce a challenging personal development plan (PDP) to develop their hip capability during the programme and this required participants to negotiate locally with key stakeholders The rationale for holding this event prior to the launch of the programme was to ensure that participants were focused on their development needs and had a personal development plan in place from the start of the programme Participants came together for a total of nine two-day residential events held every six weeks These events consisted of masterclasses designed around the programme themes and consisting of whole-day events facilitated by experts in their field, each masterclass being commissioned individually The aim was to introduce participants to leading-edge thinking on relevant issues and to challenge participants own thinking, as well as providing both knowledge and skills for the participants The masterclasses also provided opportunities for the group to network and share good practice across the NHS in Scotland and to invite key individuals to attend On the second day of the residential event participants were members of an action learning set Three action learning sets of eight participants each focused on the challenges faced by individual clinical in their roles, the project work (see below) and the embedding of the learning from the masterclasses Participants self-selected their action learning sets after receiving guidance about relevant factors to consider Sets were mixed in terms of professional background and this provided richness to the experience Each participant had access to six two-hour individual coaching sessions with their action learning set facilitator over the twelve months of the programme The purpose was to improve the performance of individuals by focussing on their PDP and to ensure that they were supported and challenged to identify experiences that would help in meeting their goals activities such as shadowing, organisational visits, etc Work-based Sponsoring chief executives were instrumental in supporting the participants to identify a substantial and stretching service development through hip project undertaken across the programme This improvement project aimed to build hip capabilities and required development of the full range of hip qualities The nature of the projects varied and they were located at both local and national levels All projects were focused on service improvement and examples of successful work include: Development of a managed (health and social) care network for older people s services Development of national radiology information to support performance-managed waiting time targets Service redesign from fracture treatment to falls prevention Development of a community dermatology referral management and treatment service Piloting and roll-out of an electronic palliative care summary Each year abstracts of all projects were supplied to chief executives and medical and nursing directors of all health care organisations in NHS Scotland

11 Participants were expected to identify a mentor to provide support during the programme and guidance on selecting a mentor was provided during the development centre Not all of the participants initially selected a mentor but as the programme developed, the importance of mentoring to help sustain development was increasingly evident to participants Opportunities for shadowing senior people at national and local level for anything from a day to a week were encouraged and many programme members took advantage of this Participants also took the opportunity to visit key bodies (like the parliamentary health committee) and to network with each other and with members of other cohorts of the programme Strategic clinical 347 Evaluation Five cohorts have passed through the programme Table II shows the make-up of these cohorts: The first two Cohorts of the programme were the subject of external evaluations by the Institute for Clinical Leadership at the University of Warwick The evaluation methodology included questionnaires seeking participant views on the masterclasses and action learning sets; comparison of 3608 assessment results prior to and after the programme; the use of the Q-Sort technique (Stephenson, 1953); stakeholder reports based upon personal development during the programme and project implementation, and qualitative material based upon a summary of participant reflective reports (see below) These evaluations identified that: All elements of the programme were positively rated by participants with ratings becoming more positive as the programme progressed Positive feedback was also offered by those around the participants in their employing organisations In responding to telephone interviews and questionnaires, these colleagues, managers and staff of participants reported significant behaviour change Successful completion of significant service development through hip projects had made significant impact locally and nationally Nationally this included the creation or adoption of, for example, a nationally-coordinated nurse bank arrangement as part of a project on nursing and midwifery workforce planning, which led to significant cost-savings A local example featured the use of demand and capacity measurement and standard- setting to improve performance against national cancer targets Symbolically, each cohort of the programme met with the continuing presence and support of the national director general, health and social care and NHS board chief executives were regular visitors and supporters of their nominees during the residential aspects of the programme The programme completion rate was very high Some 80 per cent of participants had either increased significantly their range of responsibilities or had achieved promoted posts within two years of attending the programme The programme had also contributed to the development of policy through a number of processes, including masterclasses focussed on providing feedback on policy developments, and through the directly increased involvement of participants in policy-making forums Due to the programme design, a flexible

12 LHS 24,4 348 Table II Make-up of programme cohorts Clinical psychologist Dentist Ambulance Allied health professional Pharmacist Public health doctor Nurse Primary care doctor Hospital doctor Cohort Cohort Cohort Cohort Cohort Total Total (%)

13 response to developments in policy could be incorporated, thereby ensuring value was added nationally as well as locally The commitment of previous participants in the programme had been outstanding, through assisting at the recruitment and selection phase, the development centre, masterclasses and local mentoring Participants had continued to contribute to a community of practice/network at the end of the formal component of the programme Strategic clinical 349 The external evaluations concluded that the programme had been a very successful programme and experience and that participants appear to have gained tremendous personal benefit which focused on confidence to operate outside their initial comfort zone; greater clarity about their hip role; greater assurance about their own hip capability and sense of empowerment; greater awareness and knowledge of policy issues and the need to develop skills in the areas of strategic influence (Spurgeon and Flanagan, 2007, 2008) The internal evaluations (Edmonstone, 2009, 2010) identified the development of both personal and organisational capacity The former emphasised increased self-awareness and insight, greater personal resilience and improved motivation The latter highlighted improved relationship-building and networking skills and the development of improved influencing ability Key learning Changes to programme design and delivery The experience of running the programme produced some major changes to design and delivery For example, the coaches/facilitators became closely involved in the local and national selection processes This did not change the participant mix significantly but improved the level of local understanding and support for programme members From cohort 4 onward participant data gathered prior to the programme was consolidated into a yearbook and made available to participants at the development centre, as an early means of encouraging networking The external evaluations highlighted some ambiguity over the role of the project whether the purpose was local improvement or personal development and the guidance made available to participants and their organisations was improved Participants were also asked to produce a reflective report after the final masterclass and action learning set on the programme as a whole and this provided useful evaluation material Six months after the completion of the programme a consolidation event was instituted to support the transition of participants to the next stage of their development Programme participants also set up local support groups within their territorial area to facilitate their on-going development and these have been supported by NHS Boards The evaluation of the programme has been taken in-house and the results have served to confirm the results of the external exercises Finally, each cohort has been able to significantly influence the development of health policy through engagement with key policy-formers as the programme progressed Burgoyne (1988) posited six levels of hip and management development policy: Level 1 There is no planned or systematic hip development and total reliance on chance Level 2 Leadership development is isolated, piecemeal and tactical, to meet reactively local crises and problems

14 LHS 24,4 350 Level 3 At this level specific hip development initiatives are coordinated, integrated and formalised Level 4 Here hip development strategy supports the implementation of corporate policy and planning Level 5 Corporate decision-making processes are informed by hip development at this level Level 6 Here hip development processes inform and provide a framework for the formation of corporate strategy Examples of influence on health policy development through the programme include: Between the publication of the Scottish Government s policy document better health, better care (Scottish Government, 2007a) and the emergence of the resultant detailed action plan (Scottish Government, 2007b) important changes were made as a result of consultation with cohort 3 participants In 2009 cohort 4 were consulted at an early stage in the production of a quality strategy for NHS Scotland and were able to contribute significantly towards a change of emphasis from acute hospital provision to primary and community care and mental health in the final published document (Scottish Government, 2010) Leadership development in NHS Scotland was clearly operating at Burgoyne s level 4, but the programme also provided opportunity for influence at levels 5 and 6 Learning about hip There are four major areas where, as a result of the programme, there has been learning about, hip and hip development The first is that the programme is specifically designed to develop clinical and, although this is a field attracting increasing attention (Millward and Bryan, 2005) there remains a high degree of conceptual fuzziness One outcome of the programme has been work to define and map clinical hip and its relationship to corporate (organisational) hip (Edmonstone, 2008) The second area of learning relates to the issue of competence While the hip qualities framework is one of the underlying elements of the programme, such competency frameworks have generated increasing criticism (Edmonstone, forthcoming) as fragmenting hip, undermining the importance of context and focusing on measurable behaviours at the expense of more subtle qualities Moreover, they tend to address the what of hip and ignore the how (Alimo-Metcalfe and Alban-Metcalfe, 2008) A practical example of this is the difficulty (in some cases impossibility) of repeating use of the 3608 tool when the role set of participants has changed due to staffing churn Recent work (Walmsley and Miller, 2008; Anderson et al, 2009) has focused on the essentials of good design for hip development programmes Such principles include: Starting with what is Shared agreement about the reality of the hip situation between participant, local stakeholders and coaches Focusing on an end-point Explicitly linking the programme to service improvement for service users

15 Real-time, real work, real people Co-design of the programme in collaboration with participants and their organisations Clarity of values Underlying programme values are explicit Addressing system-wide issues Going beyond the local to engage more widely Embracing diversity Encouraging understanding about other professions, organisations, sectors Addressing sustainability Considering how development can endure and extend beyond the programme Embedding within core business Leadership development is seen as a vehicle for addressing policy issues and local organisations use programme alumni Strategic clinical 351 While the delivering the future programme embodies several of these principles (such as embracing diversity, clarity of values and starting with what is ), there is also scope for further improvement in several areas Finally, while the evaluation studies revealed that, as a succession-planning exercise, the programme is indeed fit for purpose, current thinking in the field makes a distinction between such programmes as an expression of leader development, developing individual human capital and hip development programmes dedicated to increasing social capital through greater emphasis on relationships between people, professions, organisations, etc The challenge may be to rebalance the individual emphasis with one which addresses the whole system (Edmonstone, 2011) References Alimo-Metcalfe, B and Alban-Metcalfe, J (2003), Stamp of greatness, Health Service Journal, Vol 113 No 5861, pp Alimo-Metcalfe, B and Alban-Metcalfe, J (2008), Engaging Leadership: Creating Organisations that Maximise the Potential of their People, Chartered Institute of Personnel and Development, London AMRC/NHS Institute (2009), Shared Leadership: Underpinning The Medical Leadership Competency Framework, Academy of Medical Royal Colleges and NHS Institute for Innovation and Improvement, London and Coventry Anderson, L, Malby, B, Mervyn, K and Thorpe, R (2009), The Health Foundation Position Statement on Effective Leadership Interventions, Centre for Innovation in Health Management, University of Leeds, Leeds Burgoyne, J (1988), Management development for the individual and the organisation, Personnel Management, June, pp 40-4 Chiok Foong Loke, J (2001), Leadership behaviour: effect on job satisfaction, productivity and organisational commitment, Journal of Nursing Management, Vol 9 No 2, pp Cunningham, G and Mackenzie, H (2005), The Royal College of Nursing clinical hip programme, in Edmonstone, J (Ed), Clinical Leadership: A Book of Readings, Kingsham Press, Chichester Dawes, D (2002), Stars of wonder, Health Service Journal, pp 26-7, 12 September De Geest, S, Claessens, P, Longerich, H and Schubert, M (2003), Transformational hip: worth the investment, European Journal of Cardiovascular Nursing, Vol 2, pp 3-5

16 LHS 24,4 352 DoH (2008), High-Quality Care For All: NHS Next Stage Review Final Report, Department of Health, London Donaldson, L (2001), Safe high-quality health care: investing in tomorrow s, Quality in Healthcare, Vol 10, pp 8-12 Edmonstone, J (2005), What is clinical hip development?, in Edmonstone, J (Ed), Clinical Leadership: A Book of Readings, Kingsham Press, Chichester Edmonstone, J (2008), Clinical hip: the elephant in the room, International Journal of Health Planning and Management, Vol 21 No 1, pp 1-16 Edmonstone, J (2009), Evaluation of Cohort 3 of Delivering the Future: The National Strategic Clinical Leadership Programme for NHS Scotland, MTDS, Ripon Edmonstone, J (2010), Evaluation of Cohort 4 of Delivering the Future: The National Strategic Clinical Leadership Programme for NHS Scotland, MTDS, Ripon Edmonstone, J (2011), Developing and hip in health care: a case for rebalancing?, Leadership in Health Services, Vol 24 No 1, pp 8-18 Edmonstone, J and Western, J (2002), Leadership development in healthcare: what do we know?, Journal of Management in Medicine, Vol 16 No 1, pp Faugier, J and Woolnough, H (2002), Valuing voices from below, Journal of Nursing Management, Vol 10, pp Firth-Cozens, J and Mowbray, D (2001), Leadership and the quality of care, Quality in Healthcare, Vol 10, pp 3-7 Greer, S (2004), Four-Way Bet: How Devolution Has Led to Four Different Models for the NHS, Constitution Unit, University College London, London Greer, S and Rowland, D (2007), Devolving Policy, Diverging Values, Nuffield Trust, London Hardacre, J, Cragg, R, Flanagan, H, Spurgeon, P and Shapiro, J (2010), Exploring links between NHS hip and improvement, International Journal of Leadership in Public Services, Vol 6 No 3, pp Hardacre, J, Cragg, R, Shapiro, J, Spurgeon, P and Flanagan, H (2011), What s Leadership Got to Do With it?: Exploring Links Between Quality Improvement and Leadership in the NHS, The Health Foundation, London Mannion, R, Davies, H and Marshall, M (2005), Cultural characteristics of high and low performing hospitals, Journal of Health and Organisational Management, Vol 19 No 96, pp Miller, S and Balint, S (2010), Summary Report: Independent External Evaluation Of KSS Deanery s Leadership Fellow Programme, University of Westminster Business School, London Millward, L and Bryan, K (2005), Clinical hip: a position statement, Leadership in Health Services, Vol 18 No 2, pp xiii-xxxv NLC (2010), Clinical Leadership Competency Framework Project: Report on Findings, NHS National Leadership Council/NHS Institute for Innovation and Improvement, London Pearson, P and Machin, A (2010), Clinical Leaders for the Future?: Evaluation of the Early Clinical Careers Fellowship Pilot Programme, Northumbria University, Newcastle Picker Institute Europe (2005), Is the NHS Getting Better or Worse?: An In-Depth Look at the Views of Nearly a Million Patients Between 1998 and 2004, Picker Institute Europe, Oxford Scottish Government (2007a), Better Health, Better Care, Scottish Government, Edinburgh

17 Scottish Government (2007b), Better Health, Better Care Action Plan, Scottish Government, Edinburgh Scottish Government (2010), The Healthcare Quality Strategy For NHS Scotland, Scottish Government, Edinburgh SEHD (2005a), Building a Health Service Fit for the Future, Scottish Executive Health Department, Edinburgh SEHD (2005b), Delivery Through Leadership: A Leadership Development Framework for NHS Scotland, Scottish Executive Health Department, Edinburgh Shipton, H, Borrill, C, West, M and Dawson, J (2005), The Relationship Between Leadership, Trust Performance and Staff Job Satisfaction, Aston University Business School, Birmingham Spurgeon, P and Flanagan, H (2007), Delivering the Future: Evaluation Report (Cohort 1), Warwick University Institute for Clinical Leadership/ORCNI Ltd, Coventry Spurgeon, P and Flanagan, H (2008), Delivering the Future: Evaluation Report (Cohort 2), Warwick University Institute for Clinical Leadership/ORCNI Ltd, Coventry Stephenson, W (1953), The Study of Behaviour: Q-Sort Technique and its Methodology, University of Chicago Press, Chicago, IL Stoll, L, Foster-Turner, J and Glenn, M (2010), Mind Shift: An Evaluation of the NHS London Darzi Fellowships in Clinical Leadership Programme, Institute of Education, University of London, London Trofino, J (1995), Transformational hip in health care, Nursing Management, Vol 26 No 8, pp 42-7 Vance, C and Larson, E (2002), Leadership research in business and healthcare, Journal of Nursing Scholarship, Vol 34 No 2, pp Walmsley, J and Miller, K (2008), A Review of the Health Foundation s Leadership Programmes: , Health Foundation, London West, M, Borrill, C, Dawson, J, Scully, J, Carter, M, Anelay, S, Patterson, M and Waring, J (2002), The link between the management of employees and patient mortality in acute hospitals, International Journal of Human Resource Management, Vol 13 No 8, pp Strategic clinical 353 Corresponding author John Edmonstone can be contacted at: johnedmonstone@btinternetcom To purchase reprints of this article please reprints@emeraldinsightcom Or visit our web site for further details: wwwemeraldinsightcom/reprints