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ss triple helix - summer 2015,  Problem solving in the NHS

Problem solving in the NHS

  • There are situations where well-established 'command and control' routines lead to a solution.
  • For more complex management puzzles the problem-solving approach will be team-based and democratic.
  • Then there are altogether more complicated problems where there are no a concise and simple answers.
  • Applying the biblical concept of servant leadership may often create a context where stubborn problems can be overcome.

David Pitches says Christian servant leadership can make a difference.

How does someone become a good leader? Some say leaders are born not made, but many disagree, leading to a vast industry seeking to develop potential leaders. Others argue that leaders' success is situational – Churchill might have been an outstanding wartime prime minister but his earlier military adventures left something to be desired. The pressing question for any large organisation such as the NHS is how to ensure that it has good leaders. With so much at stake, we cannot bury our heads in the sand. We can't say we are not cut out to lead or that good leaders' success is merely opportune.

Three types of problem

A useful starting point for defining leadership is 'a process of social influence in which one person can enlist the aid and support of others in the accomplishment of a common task'. (1) Those common tasks essentially boil down to how to solve three types of problem: 'critical', 'tame' and 'wicked'.

Critical problems need military-like command and control – when the cardiac arrest bleep goes off, you do as the leader of the arrest team tells you, following a carefully rehearsed sequence of procedures to resuscitate the patient.

Tame problems, however, are typically perceived as something of a management puzzle; the leader must identify a solution that worked in the past and try to apply it to the current problem. This requires 'transactional leadership'. Rewards, sanctions and democratic participation by teams of professional people characterise this problem-solving approach. This works well when tasks are reasonably clear and outcomes from various scenarios are predictable.

Much of the day-to-day administration of healthcare probably functions at this level.

Unfortunately, part of our problem as doctors in positions of leadership is that we tend to have a scientific mindset which works on the sequence:
problem - diagnose cause - implement evidence based solution - problem solved

When it comes to running health services we have already solved most of the 'easy' or tame problems. What remains are the hard or 'wicked' problems – first categorised by the design theorist Horst Ritter in the 1960s. (2) Wicked problems medical leaders might encounter include how to introduce seven-day working without additional resources whilst ensuring that weekday activities do not suffer, or how to make urgent care sustainable when Accident and Emergency departments are acutely short of new trainees while the workload seems to rise every year.

The sorts of problems NHS leaders face are characterised by there being no clear statement of the problem, with incomplete and contradictory information, changing requirements and constantly shifting goalposts. It is impossible to know if or when the problem has been solved. There are no 'right' or 'wrong' answers, just 'better' or 'worse' options. It is impossible to reverse a solution if it appears not to be working since by definition solutions change the starting parameters. Wicked problems tend to be symptomatic of other wicked problems elsewhere in the system that you probably have no control over.

'Transformational leadership' is needed to identify solutions to these problems. It requires individuals who are inspirational, motivational and charismatic. Transformational leaders communicate well, 'lead when they are not in charge' and possess high levels of emotional intelligence. They appeal to the common good, foster high moral standards and promote cooperation and harmony. In theory, at least.

The failure of NHS leadership

The NHS has long struggled with how to lead such an enormous and complex organisation. Early in Margaret Thatcher's first term as Prime Minister she brought in Sir Roy Griffiths, deputy chairman of the supermarket chain Sainsbury's, to advise how the NHS could be improved. He famously remarked that 'if Florence Nightingale were carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge'. (3) His recommendations led to a series of reforms making the role of managers much more pronounced.

Subsequent decades have seen ever-increasing emphasis on reform and management, at worst resulting in 'top down' leaders who are overconfident, lack insight into their shortcomings and are simultaneously ineffective and bullying. Lately, there has been undue confidence in the ability of 'turnaround teams' and management consultants to solve wicked problems, along with misplaced faith in transformational leaders to achieve the impossible and a distinct lack of humility from the leaders. What a stark contrast with greatness in God's sight, which is measured by how faithfully the leader serves God and others! (4)

Poor leadership, combined with the chaos of organisational and structural upheavals, culminated in the debacle at the Mid Staffordshire Hospital. Many patients, particularly the old and vulnerable, received grossly inadequate and undignified care because patients had become a lower priority than organisational development. The legacy of major failings in Stafford, and the burden of unsustainable increases in demand with no additional funding, means current thinking in NHS leadership has had to do some soul-searching.

Many of the elements of transformational leadership – communication, self-awareness, leading by example – are important to find solutions to complex problems that transcend organisational boundaries. Yet the NHS Leadership Academy is belatedly recognising the value of more muted styles of leadership that take the best attributes of transformational leadership, but have a rather richer heritage (5).

Servant leadership

The principle of leading by example, helping those subordinate to us to flourish and putting the needs of others first, finds its greatest endorsement in the Lord Jesus, who said, 'Whoever wants to become great among you must be your servant, and whoever wants to be first must be servant of all'. (6)

Paul's experience establishing the church in Corinth reveals his approach to servant leadership. He was in Corinth no longer than the typical NHS chief executive is in post – 18 months. He founded a church from a disparate bunch of Jews, God-fearing Gentiles and pagans with no New Testament and limited familiarity with the Old Testament. His congregation tended to degenerate into anarchy as soon as he left. Yet servant leadership was critical to the success of his mission there.

Medical servant leaders will engage with anyone prepared to help achieve excellence in healthcare. Servant leaders have the potential to inspire and influence their organisation and wider society; they want to excel in the way they treat their patients and colleagues, which in turn promotes trust, loyalty and innovation. The servant leader is humble, caring, capable, empowering, ensures that meeting other people's needs is their highest priority (7) and is especially looking out for the weakest in society. (8) They combine the strengths of the transformational leader without their shortcomings.

The new NHS Healthcare Leadership Model is well worth reading. Its nine domains have been shaped by thinking about the inadequacies of existing leadership frameworks and how elements of servant leadership can be taken up by the new generation of leaders who will be required to take the NHS through the very difficult years that lie in the aftermath of Stafford. (9)

A note of caution. Servant leadership is not about only picking the menial tasks – it is about enabling others to do their best. The clue is in the phrase that includes both the word 'servant' and the word 'leader'. (10)

Servant leadership can be bad news for traditional theories of leadership. Some people maintain that being a good leader is a trait you must be born with. Others make their living promoting the idea that good leadership can be taught – yet despite vast sums spent on business training courses we still have many poor examples of leadership in the health service. The really good news is that servant leadership can be successfully practised by any follower of Jesus Christ.

When you lead by serving in humility and loving obedience, God will use your gifts and your attitude to enable you to lead within and across organisational boundaries and solve problems you thought were too complex to begin taking on.

David Pitches is a consultant in public health and currently works for Medair in the Democratic Republic of Congo.

  1. Chemers M. An integrative theory of leadership. Lawrence Erlbaum Associates, Publishers, 1997
  2. Rittel HWJ, Webber MM. Dilemmas in a general theory of planning. Policy Sciences 1973;4:155–169
  4. Luke 22:26
  5. Storey J, Holti R. Towards a new model of leadership for the NHS. The Open University Business School/NHS Leadership Academy, 2013
  6. Mark 10:42–45
  7. Philippians 2:3–4
  8. Matthew 25:40
  9. NHS Leadership Academy. The Healthcare Leadership Model version 1.0. NHS, 2013
  10. John 13:1, 3, 4, 12–15
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