There has been significant work in better managing health-care services as costs in service delivery escalate due to advances in science and technology, an ageing population, and new and emerging diseases requiring increased access to health care. This has occurred without the expected reciprocal increase in quality and safety of care. In addition it has been recognised that the traditional approaches to health-care planning and delivery do not necessarily meet the needs of consumers, are often fragmented, result in waste within the health-care system and do not reflect best practice. A risk when seeking to provide affordable, responsive health care is to work primarily through the lens of cost reduction to meet efficiency targets, rather than efficiency targets being the outcome of improved quality and safety. Spurgeon et al. (2011) identified the need for increased medical engagement in supporting changing health-care delivery models, and there is evidence of a more positive impact on the quality of care delivery where there is high-level medical engagement. The importance of inter-professional work in the development and implementation of health-care strategy is well recognised (Carney 2007.) The role and functions of the nurse are essential to both the patients’ experience of care and the care outcomes, as is the link between person-centred care provision and staff job satisfaction (Lehuluante et al. 2012). Staff leadership development, to build the capacity of an organisation to respond to challenges and capitalise on opportunities, needs to be linked to the organisation’s strategic plan, as change is as much about culture as it is strategic outcomes (Dinwoodie et al. 2014).

There are recent examples in health where the focus of care was not through the lens of person-centeredness resulting in poor outcomes for patients, staff and families. The Independent Inquiry into care provided by Mid-Staffordshire NHS Foundation Trust between January 2005 and March 2009, known as the Francis Report, is such an example (Francis 2013). In his letter to Hon. Jeremy Hunt MP, 5 February 2013, Francis emphasised ‘the extent of the failure of the system shown in this report suggests that a fundamental culture change is needed’ (Francis 2013, p. 5). The Person-centred Nursing Framework (McCormack & McCance 2010) outlines the prerequisites of person-centred care, the focus on the care environment and the care processes that can be used, in conjunction with other management processes. This framework can inform the development, implementation and evaluation of strategy in supporting person-centred practices. Parlour et al. (2014) undertook a study that identified statistically a relationship between care delivery that is person centred and a positive patient experience of care, which we know in our own experience of health care delivery to be true.

Strategy is about planning to meet the organisation’s vision for the future in health-care delivery. Health-care strategy is influenced by:

• political imperatives;
  
• social determinants that are currently or predicted to impact on health-care delivery;
  
• emerging disease processes;
  
• advances in science and technology;
  
• the population that it serves; and
  
• the aspirations of the health entity developing the plan.

With so many factors at play it is important to ensure that the patient is at the centre of decision-making.

The intent of strategic planning in health is to provide high-quality, safe care to patients and to support the workforce to meet service delivery needs. A strategic plan is essentially a high-level road map of where the organisation would like to be in 5–10 years’ time from a service provision perspective.

A strategic plan will strive to include strategies to enable the organisation:

• to meet the health-care needs of patients;
  
• develop the workforce capabilities;
  
• encourage innovation;
  
• lead medical science and research translation to practice;
  
• support technological advancement; and
  
• build financial sustainability.

Realistic and successful strategic plans are developed to align with current health policy, emerging and current health-care challenges and social imperatives. To be realistic and relevant these plans are developed in consultation with the workforce and other key stakeholders, which include patients and their families. They are enacted through operational plans that are generally focused on one key area of the strategy. This approach of distinct operational plans runs the risk to the organisation of not meeting the goals of the strategic plan, due to fragmentation and the potential of oppositional work occurring unintentionally. The risk can be minimised by the operational plans being explicitly linked back to the strategy document as well as across to all other operational plans that are in place to support achievement of the strategic plan. A regular review of the progress of the strategic plan implementation and review of the operational plans through the lens of being person centred:

• supports meeting the strategic imperatives; and
  
• is a gauge to identify the extent to which the people of the organisation and service users are on board and satisfied with the direction and changes that are occurring.

Monitoring of the effectiveness of the strategic plan in meeting the goals is supported when the plan elements are cascaded down into the organisation through to the clinical interface. This approach places the ownership of the strategy at different levels within the organisation and creates meaning and momentum in achieving the best for patients and their families along with a capable and responsive workforce. It supports feedback in a timely way of what is not working and what is working well within the practice domain for patients, their families and the staff.

Complexity in health-care planning and delivery has increased over the years and requires a changing and evolutionary set of leadership skills to meet and respond to these complexities. Kegan and Lahey Laskow (2009) write about the impact of our personal values and beliefs, coupled with organisational culture, in creating immunity to change. They propose that this immunity to change can be overcome through an investment in adaptive leadership development with staff.

Leadership capability development is essential within the workforce as leadership occurs at all levels within health organisations. A cascade approach to leadership development assists in further developing and creating the necessary skills, energy and impetus to continue to grow and develop the self and others to meet the ‘wicked problems’ we face within the provision of modern health care. An example of a wicked problem in health would be trying to change a large population mindset and behaviour (Conklin 2006), therefore the culture or attitude. An example we are currently working through in our organisation is how to:

• meet the current and increasing demand for access to health care;
  
• minimise unnecessary wait times for patients;
  
• best utilise our inpatient beds to meet service demand;
  
• explore new models of care including hospital in the home and ambulatory care; and
  
• ensure evidence-based care practices with the elimination of unnecessary clinical variation.

To meet these challenges requires the staff to think and behave differently in the way they engage with their work, each other and the patient; this would mark a cultural shift from the present situation.

What we need now and into the future are approaches and solutions to respond and plan for the future, not merely to deal with current complexities. Investment in human capital is critical to organisations meeting person-centred sustainable health care.

To enhance the leadership development capabilities of staff in the health-care organisation required a multi-pronged approach. To focus on the most pressing ‘wicked problems’ of the organisation we are engaged in a multi-professional programme that focuses on adaptive leadership development capability. Much has been written about the transformational leader in inspiring a shared vision and working with staff to achieve the organisation’s key objectives, through leading the way and using charismatic approaches to staff engagement within a framework of transformation of processes, systems, culture and work practices (Kouzes & Posner 2002). The transformational leader requires the additional skills of adaptive leadership to be truly effective within the context of a changing health-care environment and to meet consumer expectations.

Adaptive leadership within the transformational leadership capabilities is not well documented in the literature. We believe that the transformational leader must have the capabilities of adaptive leadership to truly transform the health-care system’s ways of working and thinking about health care (Box 5.1).