Rule 5: Match the scale of the solution to the problem

Rule 5: Match the scale of the solution to the problem

The six rules of good healthcare management and leadership development.


One of the most common causes of ‘failed’ management or leadership development interventions is a mismatch between the scale of the problem and the solution. Organizations can be susceptible to wild optimism about what is likely to be achieved by very modest investments in development schemes, resulting in disappointment when the anticipated transformation either never arrives or fizzles out.

Attempting to fix huge institutional and cultural problems with a few away days, ‘sheep-dip’ training or course scholarships is clearly not going to work. However, this doesn’t mean that management and leadership is not the right solution – just that the dosage may need to be increased or sustained over a longer period than many leaders’ attention spans.

Evidence from outside the health sector shows organizational behaviors and cultures require effort and time to change and this is rarely initiated by a single person who has been sent away for training. 1 Real change takes perspiration, repetition and an intervention of significant enough scale to overcome the problem to be solved.

One health system that has matched a large-scale, transformational ambition to an equally large-scale solution is the English NHS. It saw a need for system-wide improvement in the quality of its managers and leaders, as similar patterns of missing competencies were observed across all health services around the country. Rather than leave each organization to address the problem itself, a national academy was founded to train thousands of managers and leaders every year. Over time, this will create a substantial cadre of NHS Leadership Academy graduates with consistent approaches. By training staff at multiple levels, the program also helps to create a supportive environment and network for change in each organization.

Symptoms of failure:

  • Uncoordinated, approaches to management and leadership development, with heavy use of individually-focused external programs.
  • Goals of development programs consist of board aspirations that cannot be measured.

Key action for boards:

List the specific behaviours that your management development strategy is designed to change. Ask yourself if the scale of activity and investment is really likely to produce these effects, or is underpowered.

Case study

A whole system effort for whole system impact: NHS Leadership Academy (England).

In 2012, the NHS in England was facing a national crisis of confidence over quality of care following the “culture of blame” and “acceptance of poor standards” reported by the Francis Inquiry – a review into care failures and excess deaths at Mid Staffordshire Hospitals.2

“Leadership which was unable to command confidence” was laid at the heart of the “appalling suffering” of many patients, and the report called for a “fundamental culture change” across the entire English health system, including higher standards of professionalism and skill among managers and leaders.

Fixing a problem of this scale required a substantial policy response, and so one of the largest healthcare management and leadership development programs in the world was initiated. By mid-2016, the NHS Leadership Academy had trained over 45,000 people through the tiered strategy of full-time, part-time and spare-time programs described overleaf.

By operating at such scale, the Academy was able to design tailored programs targeted at the specific priorities and context of the NHS. Some of the distinctive features of the programs that resulted were:

  • Embedding the patient voice at every level, including having teams of patient volunteers participate in discussions and shape course materials.
  • A consistent focus on making immediate and lasting change in participants’ own places of work.
  • Cutting edge learning technologies, including a custom-made ‘virtual campus’ that supported simulations in a fictional local healthcare system, interactive scenarios, professionally produced video presentations, and engagement with other participants and tutors through group forums. This allowed participants to learn anytime, anywhere.
  • A global perspective that broadened participants’ outlook towards truly world-class examples of great care, rather than what was best in the UK.

While the intensity and style of the different tiers varies, each is founded on four consistent aims: to professionalize leadership skills across the system, to broaden leadership styles, to make leadership roles more inclusive and to create a climate in which innovation can flourish.

As for outcomes, the Academy was always geared towards long-term change, but has ended up occurring during the most challenging financial environment in the history of the NHS. Narratives collected from participants have documented a library of examples of the skills and confidence developed throughout the programs in action, from savings, to more engaged staff to patient-led service redesign. In 2016 the Leadership Academy won the European Foundation for Management Development ‘Gold Award’ for excellence in practice.


1 Mintzberg H. Managers not MBAs: A hard Look at the Soft Practice of Management and Management Development. Berrett-Koehler Publishers (2005).

2 Mid-Staffordshire NHS Foundation Trust Public Inquiry, Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry, Stationary Office (2013).

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