Being a servant leader in the NHS

Nick Land on how the Christian faith informs attitudes to work and leadership.

When I became medical director the response of some colleagues was 'So, you've gone over to the dark side.' Some of this came from within the Trust; a lot more came from Christian doctors I knew. I thought that was strange because when I became Chair of CMF no one asked if I'd gone over to the dark side. Nor did they ask this when I became Lay Chair of the York diocesan synod. So why was it that when I took up leadership in a National Health Service organisation, people thought I was doing something not in line with the gospel?

Those 'dark side' comments reveal an unhelpful division about what it means to be a doctor and what it means to be a Christian; that somehow these two things live in different worlds – that the Sunday world was different from the weekday world. In an earlier Triple Helix article I looked at the themes of work throughout history and how God views work. (1) I pointed out that for many Christians, our ideas about work are informed not by Scripture but by contemporary culture.

If the work we have been given is God's work, then surely we should be involved in its leadership and its organisation. The Bible gives reasons why Christians should seek leadership roles in any organisation. From Romans (2) we see that government and leadership are part of God's 'common grace'. Then, all life is God's and we are called to be salt and light. That may be involvement in healthcare, it may be as a school governor, or local politics or organising a foodbank.

Servant leadership

Nehemiah is one of the great biblical models of the servant-leader. Nehemiah hears of a need, he prays, acknowledges God's greatness, he repents of his sins and those of his community. (3) Then having seen a need he hears a call; he takes the risk of moving back to Judah to rebuild the walls of Jerusalem and faces lots of mockery. There are strong parallels in some areas of the Health Service today.

There are many other biblical examples. Jeremiah, prophet to the exiles, tells them to work for the prosperity of the city where God has placed them. (4) There are models of good practice, eg when Moses' father-in-law visits, finds him snowed under with work and teaches him principles of delegation. (5) Esther: a young woman who suddenly has to step up to courageous leadership. Joseph: apprenticed as Potiphar's steward; wrongly accused; sent to prison. God lifts him up and his skilful leadership saves the entire nation of Egypt from famine.

You may be a first class clinician, but there may come a time when you're called to speak up as Esther was because there are problems, because people are suffering, because what has been done is not right.

So government, leadership and management are a means of common grace, given by God to deliver justice and to limit evil.

Leadership in our times

So, why is it so important now that people step up to the mark to be leaders in the NHS? First, there is the QUIP Agenda. This means every NHS organisation needs to find 4% saving year-on-year for the next five whilst improving quality. This is causing a lot of strain and requires considerable leadership. The Health and Social Care Act means massive structural change, huge uncertainties during transition, and increasingly complex management structures on the commissioning side. A huge number of people with a great deal of experience in the NHS are suddenly finding themselves unemployed or dislocated. People in public health now find themselves no longer in the NHS but employees of the local authority; huge changes. Next we have the Francis Report. No-one who has read even extracts cannot feel other than angry and distressed, but also wonder if they'd have done something different in the same situation.

There are broader issues. Big changes in the clinician-patient relationship, consumerism, postmodernism, bringing fundamental changes, massive ethical issues. I want to pay tribute to a small cadre of people in CMF who get involved with the BMA in order to ensure, for instance, that the BMA doesn't go neutral on euthanasia. Then there is the issue of unhappy doctors where the entire doctor-patient compact is changing. (6)

So big changes and great opportunities for Christian leadership. But there are dangers, real temptations to 'go over to the dark side'.

• Selfish ambition. Philippians 2:3 warns against 'selfish ambition or vain conceit'. It's very easy to become either very personally ambitious, or ambitious for your organisation. You can end up in some kind of unholy competition that's not about the best for the community or the patient.
• Idolatry. It's easy to let your trust or practice become an idol. Exodus 20:3 says, 'You shall have no other gods before me.' It's very common for doctors to be so committed to medicine, that everything else...their family, their faith…begins to slip away.
• Dishonesty. Proverbs is full of verses like 'God detests dishonest scales.' (7) John the Baptist tells tax collectors, 'don't cheat'. (8) God wants integrity in our financial dealings. It's so easy to slip into half-truth. It's even easier as you rise in seniority.
• Anger. If you really care about patients then you can get very angry. Of course there is such a thing as righteous anger. Jesus got angry with the moneychangers in the temple. But James says, 'Everyone should be quick to listen, slow to speak and slow to become angry.' (9) Lots of people come and give me accounts of things that on first hearing make me very angry. Don't get angry until you've got to the facts. Ephesians says, 'In your anger do not sin.' (10) Wait until the next day before you send that angry email.
• Over-work. It's easy to get so involved in our medicine, our leadership, that we stop going to our Bible study group, or begin to skip church. The chances are, if this becomes a regular habit, then we may have got the balance wrong.
• Cynicism. The dictionary definition: 'a distrust towards others' motives. A general lack of hope in humanity or social and ethical values; ridiculing other people's aspirations and motives'. In my view this is one of the greatest dangers in healthcare today.

Christian leadership in the NHS

I find I need read Philippians 2:3-7 every week: 'In your relationships with one another, have the same mindset as Christ Jesus: who, being in very nature God, did not consider equality with God something to be used to his own advantage; rather, he made himself nothing by taking the very nature of a servant'.

We are called to serve others and to be radical in our service is to be a servant-leader. I try to teach this to senior registrars.

Quality improvement

Let me share something about how our trust's quality management system which is based on the Toyota production system. It's called the Kaizen system of continuous improvement developed by Toyota. Cars are not people but this system centres on adding value to the customer or patient. If what you're doing doesn't add value you need to ask why you're doing it.

We involve everyone – patients, doctors, nurses, carers, porters – to look at a particular part of the service. They are freed up from all other work for a week. They redesign that service, going through a series of PDSA cycles where you plan it, try it, assess and do it again. By taking the waste out of the system you can both reduce costs and improve quality.

If we are servant-leaders; if we work with integrity and enthusiasm; if we have God's wisdom and we pray, we will bring hope into our practices and hospitals, our patients and our colleagues because we know we are grounded in the love of God and we have an inheritance that can never spoil of fade.

Nick Land is Medical Director to the Tees, Esk and Wear Valley NHS Foundation Trust, providing Mental Health and Learning Disability Services. Based on the 2013 Rendle Short lecture: to hear an audio recording go to cmf.li/15dpWeo