Good leadership can improve diabetes care for older people with diabetes

The NHS is currently facing spending cuts, change and uncertainty as never before. In addition, diabetes is becoming more prevalent, with the largest age group in this population being older people (Sinclair, 2009). With the increasing numbers of people being diagnosed with diabetes, it is inevitable that financial costs will continue to rise for care, education and prescriptions, in addition to that associated with diabetes-related complications.

How can a service of good care be maintained, ensuring access for all people with diabetes in the face of diminishing expenditure, while keeping the person with diabetes at the heart of care? The Quality, Innovation, Productivity and Prevention strategy (see http://bit.ly/eOSk5b) suggests this is possible; good leadership is required to ensure services are reviewed and developed rather than just accepting the “we have always done it this way” mantra. Apportioning scarce resources fairly can be difficult but necessary to ensure that older people, who may not be able to communicate their needs, have a fair access to services. 

As senior clinicians, we need to develop the skills required to enable us to lead in different situations. Commissioning Diabetes Without Walls (NHS Diabetes, 2009) proposes a closer partnership between health and social care to improve quality of care for people with diabetes. The greater the number of professional groups represented in the team, the higher the levels of  innovation in patient care (Borrill and West 2000). 

Types of leadership
Among the different styles of leadership, autocratic management – where the leader dictates to the team – has been common within the NHS. However, leadership in such a complex organisation requires more skills than this to be able to meet its demands. Mullins (2007) has described leadership as a relationship through which one person influences the behaviour or actions of other people. It is associated with the concept of inspiration, collaboration and creating a vision with which others can identify. Providing multidisciplinary services in which the older person is at the heart of care requires effective leadership. 

Health and social care have not historically provided collaborative services, as is recommended in Commissioning Diabetes Services for Older People (NHS Diabetes, 2010). One group will not have authority over another; therefore, inspiring and creating a vision of how services should be provided collaboratively appears the only way forward. 

Transactional and transformational are two types of leadership that are more appropriate than autocratic leadership in a competitive marketplace where quality and innovative patient care are required in a changing environment. Transactional leadership is a style in which the leader gives responsibility and authority to the team member to undertake a task. This style is flexible and can adapt to changes quickly (Wedderburn-Tate, 1999). 

Transformational leadership is recognised as a newer style of management in which leaders are considerate of their team members, providing opportunities for them to learn and develop. This provides the opportunity for both innovation and increased productivity as staff are motivated and encouraged to take responsibility for a task. In a multidisciplinary team, different groups may learn from one another and develop innovative care. 

Kouzes and Posner (2007) have identified the five key skills required in a transformational leader. They suggest that the leader needs to:

• Inspire the team to have a shared vision, thus motivating them to work towards their goal.
• Model the way.
• Challenge processes along the way. If there are difficulties or delays, they should seek solutions from the team or outside the team, if assistance is required.
• Encourage the team to continue working towards their goal.
• Enable others to act, ensuring the team are all progressing on the journey towards the overall goal.

In providing quality care for the older population, it is key to work collaboratively across the health and social care providers and identify a vision of what care and service can be provided using currently available resources. 

Qualities of leadership
Wedderburn-Tate (1999) suggests that many of the qualities required to make good decisions, such as information, freedom of thought and freedom to act, are not luxuries afforded to leaders working in healthcare. In addition, there is infrequently adequate time to contemplate decisions that need to be made (Wedderburn-Tate, 1999). Leaders need to be able to manage unclear situations, to remain optimistic and to be quick in acting when required (Lucas, 2010). As in team working, the leader does not need to possess all the skills, but needs to recognise these skills in others and empower and enable others to lead. 

Within the scope of leadership is enabling others to act by giving them power and authority. Delegation is poorly implemented within the NHS (Lucas, 2010). Implicit within the role of leadership is the responsibility of self-leadership, which includes life-long learning and reflection to enable the transformation of oneself (Kouzes and Posner, 2007). Transformational leadership leads to an environment in which individual team members can develop their leadership potential in a milieu of change. 

Older people need leaders who can bridge the traditional divide between health and social care to provide them with access to the quality services they deserve. DSNs are well placed to know what diabetes care this population require given the complexity of caring for these individuals who frequently have comorbidities and disabilities. In addition, the leader needs to have good networking skills to enable collaborative multidisciplinary working across the boundaries of primary, secondary, social and often residential care to provide seamless care. A transformational leader will not only be passionate about providing the best care for this population, but will also inspire the team with the same vision of providing best services while encouraging the team to achieve their goal.

Problem solving
Leaders in the NHS require different approaches to management in different situations. Many problems encountered have been met before and solutions are known. The DSN network is good at sharing solutions and best practice, as evidenced by the variety of articles in past issues of the Journal of Diabetes Nursing. 

These previously encountered situations have been described as “tame” problems (Hartley and Benington, 2010). A “wicked” problem has no agreed solution, different people have a variety of views and there is a large amount of uncertainty about the problem. An example of this might be how services will be commissioned for older people living in residential care. An “adaptive” style of leadership is required here, where the leader asks the right questions and engages a range of people to try to solve the problem. “Critical” problems are those for which immediate and urgent action is required such as in treating hypoglycaemia. Here a “command and control” style of leadership is more appropriate (Hartley and Benington, 2010). Therefore, different styles of leadership are required in different situations.

Differences between leaders and managers
The roles of the leader and the manager differ but may overlap. The manager must focus on tasks and achieving them; the leader must oversee and direct the whole operation, be the strategist, directing the team, anticipating future change and organising the team (Heller, 1999). Leaders are required in times of change; managers are required in times of stability.

Organisational culture
Healthcare organisations have a responsibility to ensure that staff can use their skills and expertise to offer the best possible care to patients. Poor leadership leads to a high staff turnover and a reactive style of management in which there is failure to anticipate problems. 

The NHS is a highly complex organisation. There are daily challenges in healthcare such as government targets and directives, increasing patient numbers, restructuring of organisations and anticipating future changes. In addition, conflicts are common such as those between managers wanting resources for maintaining services and buildings and healthcare practitioners wanting more staff and equipment.

Political awareness
Poorly led teams lack the political influence to be able to attract the resources required, thus compromising patient care. Conversely, well-led teams can provide a more innovative quality service with a more efficient use of resources (Da Costa, 2007). Collaborative services can reduce waste through duplication of tasks and improved communication can highlight and bridge gaps in care or service.

Meeting the needs of those outside health care
Meeting the needs of those who are house-bound or living in residential or nursing homes is a challenge. This group has been excluded from routine care, such as annual reviews, if they are unable to attend the GP surgery. A leader representing them can pioneer alternative ways of ensuring they have access to appropriate care. 

NICE (2003) recommends structured group education for people with diabetes; this may be appropriate to be undertaken in a group in the residential or nursing home setting. Educating older people with diabetes may require more time than for younger people due to their impaired cognitive function, vision and hearing. The pace should be slowed to allow time for the residents to assimilate information without feeling rushed. As the residents have little control over their diet, it would be appropriate to include carers, cooks and managers to ensure residents are offered a suitable diet. It is imperative for these staff to be educated about the risks of hypoglycaemia and to be aware of how to avoid and manage such risks. Time spent in providing education for residential care home workers has the potential to leave a legacy of providing indirect diabetes care to a greater number of individuals than would be seen in one clinic visit. Transformational leadership can inspire carers and healthcare professionals in residential settings to provide excellent diabetes care for their older residents and work collaboratively to support them in implementing their learning.

Retinal screening may be denied to older people if they cannot attend the ophthalmology centre, thus increasing their risk of blindness, which would further contribute to their social exclusion. An alternative could be for the GP to examine the older person’s eyes using an ophthalmoscope. 

The National Service Framework for Older People (DH, 2001) recommends that older people should be treated as individuals by health and social care services to enable them to make their own choices about care. Patients and their carers should contribute to the design and provision of services. The DSN can take a lead in working with the older people by giving them the opportunity to experience shared care planning. 

Next steps to leadership
The NHS Leadership Qualities Framework website provides advice on leadership (www.nhsleadershipqualities.nhs.uk/coaching). Leadership requires personal commitment and discipline, not a financial commitment (Kouzes and Posner, 2007). These authors challenge us to accept the responsibility to be a role model for leadership. Wedderburn-Tate (1999) recognises how we can forget to have fun, to dream and to be optimistic. She describes how the NHS has become charmless, dispirited and dull because of the increasing workload and decreasing resources. Therefore, celebrating success is very important to redress this balance. 

Conclusion
It is important to remember that leaders are human beings and so will not always get things right but will learn from mistakes and failures. DSNs should lead the planning of an integrated service for older people with diabetes working across the interface of health and social care. A DSN with a transformational leadership style has the ability to lead and develop a motivated team to provide a quality, innovative, integrated, multidisciplinary service, while being a good steward of scarce resources.