Nick Timmins: The practice of system leadership

How do system leaders think? Nicholas Timmins, Senior Fellow at The King's Fund,asked ten system leaders to share their views on the skills needed to lead change and improvement and the barriers that leaders may encounter. Here, he tells Insight what they said.

What did your interviewees think of system leadership?

They all recognised the need for 'system leadership' – which we broadly and very simply defined as achieving change across organisations despite having no direct line management control.

Interviewees felt strong system leadership is needed across the primary, secondary and community divides in health and equally urgently across health and social care – not to say beyond that also.

However, a considerable proportion of the interviewees were reluctant to describe themselves as ‘system leaders’. Some even argued that to do so was counter-productive – it sounded too much like they would be telling people what to do when, in reality, the skills needed were very different. As one interviewee put it, to do that ‘puts you 40-love down before you start’.

So what were those skills?

The skills needed for successful system leadership include being able to 'walk in other people’s shoes’, including understanding the immediate pressures people are under, even as they want to achieve longer-term goals. So finding a way to make the longer-term goal feel very much in the interest of individuals and their organisations – even if it requires an element of short-term sacrifice – is key for a system leader.

Another skill is being able to sow the seeds of an idea, so that it comes back to you as the idea of someone within whom you planted it. Interviewees also described the ability to underline that a change is in a patient’s interest – and to work with, and bring in, patients so that they are the ones explaining it. So that it becomes much harder to say ‘we can’t do that because it is not in my interest, or not in our organisation’s interest’.

Being able to appeal to the higher goals that pretty much everyone in health and social care aspires to, despite the day-to-day pressures. And, crucially, to be able to do that backed by evidence. Being able to help create ‘a coalition of the willing’. Quite often, this means involving clinicians, but also on the wider health and social care front,

local authority staff and members. Finding the people who recognise that what is being provided is far from ideal – and then letting them build, by example and argument, a wider coalition.

If those are the skills, what other attributes do system leaders need?

Time and again, what came back, though often phrased in slightly different ways, was the message that ‘you can achieve almost anything so long as you do not want to take the credit for it’. So a lack of ego is important. The implication is that ‘heroic leaders’ who crave recognition for what they have done, and for what they do, are unlikely to make good system leaders – unless they change their behaviour.

So can system leadership be taught?

Our interviewees were somewhat divided on that. Some thought it could. Some thought it could only really be learnt by people who instinctively have the right skills – learnt chiefly by experience, with experience including being allowed to make mistakes and learn from them. Almost all recognised that there will be some people who are not suited to this role. But all equally recognised that for system leadership to be effective it had to happen at almost all levels of the organisation.

If it’s just seen as a role for those at the top, it is more than likely to fail. So, for many of our interviewees, training mattered, and more support needed to be given to young managers and clinicians who want to do this but who too often feel isolated. They are set up to compete, not cooperate, was one message.

What are the barriers to system leadership?

Unfortunately, our interviewees thought these were myriad.

They included the current financial position, training new system leaders, incentives, and the current system architecture – including, in particular, both regulation and the huge bureaucratic hoops that people have to jump through to do reconfigurations. These often interlocked, which made tackling them difficult.

There is not room here to go into more detail, though the report does. There was a distinct sense among some that something had gone missing with the abolition of strategic health authorities (SHAs). Almost nobody loved SHAs much when they existed. No one wanted to recreate them as such. But the sense that there needed to be a place – at a higher level than the clinical commissioning group – where the disparate elements of commissioning, provision and regulation come together, and come together with the necessary authority to get things done was strong.

Some saw the fact that the NHS five year forward view was a collaboration between so many national health bodies as providing at least some hope of progress on that front.

So should we despair about system leadership?

Far from it. The Forward View, almost by definition, is all about changing the health and care system, and thus recognises the need for system leadership. The interviewees were all system leaders, however reluctant some of them were to claim the mantle. And there are some excellent examples of system leadership around, as well as striking examples of initiatives both to train people and to encourage system working.

That, however, does not mean that in any climate – let alone the current climate – system working is anything other than challenging. Not least because both organisationally and personally it involves give and take. And, quite often, though not always, that can mean, in the patients’ interest, rather more give than take.