Evidence for leadership in health care

The delivery of clinical care is based on careful research to determine the most effective way of providing care for patients. At the same time the NHS spends huge amounts on leadership development without a clear understanding of what kind of leadership and leadership development has most impact on patient outcomes.

I have spent the past two years undertaking a review of the evidence on leadership and outcomes, with a particular focus on what is known about leadership in health care. The findings are published today as Leadership and leadership development in health care: the evidence base.

One observation to come out of this work is that much of what is written about leadership and much effort on leadership development in the NHS is based on fads and fashions rather than hard evidence. Moreover, successive reviews often fail to draw on the evidence base, only adding confusion via strong opinion to the vast body of writing on what constitutes good leadership in health care. 

The evidence is clear though: leadership at every level – from frontline leadership in wards, primary care and community mental health teams to board leadership in trusts to national leadership in overseeing bodies – is influential in determining organisational performance. 

The task for leaders at every level is to ensure direction, alignment and commitment within teams and organisations. Direction ensures agreement with and pride in what the organisation is trying to achieve; alignment means effective co-ordination and integration of the work; and commitment means everyone in the organisation makes it a personal priority to ensure the success of the organisation as a whole, rather than focusing only on their individual or immediate team’s success in isolation. 

Previous research showed that leadership is required not just to develop inspiring visions but to make these visions a reality for staff at every level by: agreeing clear aligned objectives with all teams, departments and individual staff; offering supportive, compassionate and enabling people management; encouraging and supporting learning, innovation and quality improvement; and nurturing effective team-working. 

The evidence shows that such leadership embodies honesty, kindness, altruism, fairness, accountability and optimism. It is not preoccupied with target-setting, rules, regulations and status hierarchies.

The evidence points towards what we call collective leadership. Such a culture is characterised by shared leadership where there is still a formal hierarchy but power is more dependent on who has the expertise at each moment. Leadership is most effective when all staff – especially doctors, nurses and other clinicians – accept responsibility for their leadership roles. Collective leadership is characterised by leaders working together to nurture a shared culture, adopting leadership styles that are consistent across the organisation, and co-operating and supporting each other across boundaries within the organisation. 

Integrating health and social care services will also require leaders to co-operate between organisations, prioritising overall patient care rather than the success of their component of it. That means leaders working collectively and building a co-operative, integrative leadership culture – in effect, collective leadership at the system level.

Developing such collective leadership for an organisation depends crucially on local contexts and is likely to be best done ‘in house’ with expert support, integrating both organisational development and leadership development. The NHS needs to use evidence-based approaches to leadership development in health care to ensure a return on the huge investments made. In particular, we know that experience of leadership is the most valuable factor in enabling leaders to develop their skills, especially when they have appropriate guidance and support. A focus on how to enhance leaders’ learning from experience should be a priority.

National-level leadership needs to embody developmental, appreciative and sustained approaches, with NHS organisations seen as partners to be supported. Organisations including Monitor, the Care Quality Commission, NHS England and the NHS Trust Development Authority need to demonstrate collective leadership and positive cultures, and support the health service to do the same by the way they interact with NHS organisations.

The challenges that face health care organisations are too great for leadership development to be left to chance, to fads and fashions or to piecemeal approaches. Our review suggests that approaches to developing leaders, leadership and leadership strategy can and should be based on robust theory with strong empirical support and evidence of what works in health care. Organisations need to develop and implement leadership strategies that will create cultures that deliver high-quality, compassionate care to meet the health care needs of the populations they serve. 

Keep up to date

Subscribe to our email newsletters and follow @TheKingsFund on Twitter to see our latest news and content.


#542991 George Coxon
Various inc chair of MHNA, independent commissioning advisor

Really excellent stirring piece. I will use this report on my travels and in my various roles. I do try to lead well as a care home owner as well as as chair of our sizable residential care kitemark movement in Devon. But as to the debate re evidence based leadership!! Well I totally agree with the fads and fashions comment. I spoke up at several times recently about 'culture shapers', decision making, giving direction, being credible, enthusing as much as being reflective. However most vital for me will be leading from the front. I'd be keen to see the compendium of evidence on leadership essentials where trust and respect are drawn from inspired staff seeing managers really working close up with their teams. Much food for thought for me as us for sure. So thanks for this very topical tool.

#543009 June Girvin
Oxford Brookes University

It's good to see these reports. I've been talking about leadership in these terms for over 20 years and used to write about it too. When the fads and fashions rise it's so annoying - people earning a fortune for bells and ribbons when the evidence of what works is in plain sight and has been available for a long time.
The one element that I think makes most difference is the notion of taking responsibility - something that seems to be more and more rare, at all levels. It's scary and people need support to develop their sense of responsibility.
I will use these papers. Thank you.

#543286 Paquita de Zulueta
GP, Coach, Therapist and clinical ethicist
Imperial College

Thank you for this succinct and illuminating piece which confirms what I have thought for some while. I have to say that I prefer collaboration or shared values to 'alignment' as this word gives a conformist, mechanistic tone. We need to move away from the view of the organisation as a machine to the organisation as a complex living human system (ref Laloux and the AI literature etc) because the former - still so prevalent, alas- stifles creativity and humanity. I shall be writing a commissioned article with John Ballat (co-author of Intelligent Kindness, reforming the culture of healthcare) on developing compassionate leadership in healthcare. We share your views on collective leadership vs 'heroic' leadership from the top and that many leadership initiatives lack an evidence base. But we cannot ignore the zeitgeist and the impact of 'negative organisational receptivity' (Stordeur, Vanderburghe and d'Hoore, 2000) on leadership and flourishing. I have already written about the sustainability of compassion in 21st century medicine. I look forward to reading your report in depth. I hope that we can have a dialogue sometime if you had the time and inclination? Best wishes. Paquita

#543290 michael west
Senior Fellow
The Work Foundation

Thanks George - and there is so much evidence of the connections you make in the national staff survey data and patient outcomes

#543291 Michael West
Senior Fellow
The King's Fund

Very helpful comments Paquita - thank you. I hope we meet at some point to share ideas.

#543292 michael west
Senior Fellow
The King's Fund

I agree - a fear culture has driven out the desire of leaders to take responsibility.

#543310 Paquita de Zulueta
GP academic
Imperial College

Thank you so much. I do hope that we can meet. I do not wish to be nit-picking re words but I am mindful how they generate metaphors, which in turn can affect how we think (George Lakoff) so I prefer 'harmonisation' or 'concordance' vs 'alignment'. Kind regards. Paquita

#543575 Anytime Doctor

Leadership qualities are evident in once growth and in healthcare its significant contribution can help both people and person belong to the same. Keep writing. Excellent stuff!!

Add new comment