Flies on our Heroes | Followership in the NHS

‘Followership’ represents a slightly odd word, one which doesn’t quite sit right—like that packet of unopened digestives in the crowded theatre coffee room. It almost seems like a word of inflated grandeur, intended to give some importance to something which may be seen as unglamorous, unimportant, a frankly subordinate concept.

Defining followership can be tricky. Taking it as a way to describe one who would follow, a ‘follower’ would be any person who supports and admires a particular person or set of ideas. However, defining the characteristics necessary for followership is much more difficult. Mary Uhl-Bien et al. recently published a large review of followership literature (2014) in which they suggested that followership was ‘…the characteristics, behaviours and processes of individuals acting in relation to leaders’. They also proposed that followership involved ‘…the study of the nature and impact of followers and following in the leadership process’.1

Using the concept of leadership within a definition of followership suggests that followership is an integral part of the leadership process. But followership should not just be thought of as a special type of leadership; it is its own distinct concept. Certainly Uhl-Bien et al. firmly held that followership and leadership should be treated with a degree of separation. Perhaps one reason that we might not be right in treating followership simply as the opposite of leadership (NB I say, you should) is that the characteristics used to define and measure each are quite different. The incentives and motivations of a leader may be quite removed from those of their followers.

It is also important to recognise that individuals within an organisation are not necessarily always followers. Conversely, it might be tempting to suggest that organisations operate in a dichotomy of leaders and followers, however this is also too simplistic a concept—being a follower is not synonymous with being an employee. Followers have specific characteristics, behaviours and processes which are different to that of an employee. Personally, I would suggest that followership needs to be treated as a separate and distinct entity, but always in relation to the process of leading and becoming a leader.

Whilst a definition of followership is helpful, it is also important to consider how it might work in practice. The King's Fund recently published a framework by which we might think about the practical aspects of followership. As a brief summary, it represents a relatively simple triangulation between a ‘problem’ being solved by a ‘leader’ as actioned by a ‘follower’. Here the crux of both following and leading is the set of mutually faced problems, and that each need to adapt accordingly. This may seem an obvious sentiment, but further interest arises from the way we can see followership interacting with what we already know about leadership.

It will come as no surprise that healthcare consists of many dazzingly complex problems, which may often be difficult to solve using what we might call ‘standard procedures’. The King’s Fund termed these problems ‘wicked’, problems that tended to be the most difficult to solve because they required high levels of energy intensive leadership, the kind that is relational, constantly evolving and requiring ample thought. Importantly, they suggested that ‘wicked’ problems required a specific type of followership in support of their leader: a follower who is able to analyse problems and also willing to add to the leadership process.2 It is therefore important to consider not only the style of leadership required for a certain problem, but also the style of following. This changes the focus of leadership somewhat by devolving total responsibility from the leader to be shared with expert followers, particularly in certain circumstances such as these ‘wicked’ problems.

To echo this, one of their most poignant thoughts is that ‘…leadership is the property and consequence of a community rather than the individual’. A greater focus on followership, being a product and a process of leadership, puts a greater emphasis on a community of followers and leaders rather than a focus on one individual leader. This may represent a move away from a worrying trend of the 'heroic leader' status which seems to have blossomed in healthcare where it has shrunk away in many other sectors.

A recent healthcare article from the BBC highlights this point pertinently. The article talks about the recently appointed leader of NHS England and the challenges ahead of him.3 Tellingly, it finishes with the sentiment that if he were to succeed in turning around the fortunes of our groaning NHS, he would become the greatest leader of his generation. Whilst this may be true, it represents an unspoken craving for a heroic leader rather than relying on the wealth of experience and skill we currently possess in the expert followers of the NHS.

The art of followership is not, therefore, simply being able to follow, but it must be more to do with knowing how to follow in appropriate circumstances—the aforementioned ‘characteristics, behaviours and processes’.

It is not just academic writing where we can find followership; it is there in many classic story lines too. Ideas stemming from both fantasty and real world stories are often the most potent. Re-thinking well trodden story lines through the looking glass of followership, we see that many of the problems arise from the lack of quality following, rather than the lack of quality leadership.

The gruesome plot of the Lord of the Flies, which begins with a group of school boys marooned on a paradise island, soon turns into a serious and deadly game of revenge and bloodthirsty hatred. Of course Ralph, the appointed leader, is pretty accurate in his estimation of what needs to happen for the boys to have even a slim chance of survival. They need food and they need a signal fire. He rightly realises that separate teams, one to man a large signal fire, the other to hunt wild pigs for food, would be the answer. What follows is simply a lack of fundamental levels of ‘follow the leader’. Some resent Ralph as their leader, others are simply more interested in splashing in the water. Whilst Ralph's leadership may not be ideal, the real failure on the island was a lack of quality followership.

In another classic story, The Lion the Witch and the Wardrobe, we see how followers can undermine the authority of the person leading; much in the way that the King's Fund report describes ‘restrictive’ followers. When Lucy finds an amazing parallel universe at the back of an old wardrobe, Edmund, her older brother, fails to acknowledge that it is real, even after experiencing it for himself. He even goes as far as ridiculing and bullying her in front of their other siblings. Edmund is reluctant to let Lucy be the one to make such an amazing and magical discovery; he is jealous of what she has discovered and wished it was him.

This well-known fragment of the classic storyline closely echoes situations which occur all the time in healthcare. Many times I have witnessed people bring forth simple, beautiful, perhaps even genius suggestions for improvements, only to be thwarted by others who cannot envisage their idea, who may be resentful or resistant to change. Is this a case of poor leadership? I would argue not, in fact I think this is just the sort of leadership that we would want in our healthcare system. This is a case of poor followership which has an altogether stronger impact. If Lucy comes to you, Edmund, follow her! What you find might surprise you.

Once you begin looking, its clear that followership goes pretty much everywhere leadership does. However, when you tie up these assorted thoughts on followership, you may conclude either that it represents an interesting vantage point on both the skill and importance of leadership, or rather an abstract concept of which we know little. It may even make you evaluate your followership skill. Of course, you may just conclude that it represents an interesting topic for the coffee room, between cases, over one of those unopened biscuits.

References:

1 www.sciencedirect.com/science/article/pii/S1048984313001227

2 www.kingsfund.org.uk/publications/articles/followership-nhs

3 www.bbc.co.uk/news/health-26821064

There are, of course, some books on the subject of followership which we have not yet reviewed in the Bookclub listed below. It would be great if you could review one of these and add to our thoughts on followership. Also, what are your thoughts on classic story lines involving followership?

If you would like to get involved in this or any other way get in contact with us at bookclub [at] fmlm.ac.uk. Finally, let us know your thoughts on the topic of followership by posting a comment on this page. We'd love to hear your thoughts. 

Suggested reads:

http://www.amazon.co.uk/Followership-Followers-Creating-Changing-Leadership/dp/1422103684

http://www.amazon.com/The-Art-Followership-Followers-Organizations/dp/0787996653/ref=pd_sim_b_3?ie=UTF8&refRID=03HX006V4GX42RWSAWW1

http://www.amazon.com/Power-Followership-The-Robert-Kelley/dp/0385413068