What does it take to lead in the NHS?

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Nish Manek is a GP trainee and clinical fellow who took part in a leadership 'open space’ event earlier this month. The event brought together previous participants of The Kings Fund’s clinical leadership programmes. Here Nish reflects on what she learned from the day about the challenges and opportunities of taking on leadership roles in the NHS.

It was a day of firsts for me. It was the first time I'd been invited to an open space event in which the participants decide the agenda. I had no idea what I could contribute or expect. It felt uncomfortable.

But I was reminded of a quote from Roy Griffiths’ famous report 25 years ago: ‘if Florence Nightingale were carrying her lamp through the NHS today, she would be searching for the people in charge.’ This was an opportunity for another first - to be a fly on the wall in a room full of those very people, observing a fascinating series of conversations.

The clinical leaders in the room ranged from new consultants and departmental leads to medical directors, clinical commissioning group chairs and chief executives. As a junior doctor, I don’t pretend to fully connect with the complexities they described that day. However, three observations stood out for me.

First, the day brought to life the sheer weight of the challenges that came with their leadership roles. The sense of pressure, personal cost, and political intrusion was palpable. I was unnerved by the consistency of the commentary on their daily tensions: the need to deliver data-driven outcomes while building compassionate cultures; the need to drive internal performance while investing in system-wide relationships; and the need to empower staff while asking them to do more with less.

Second, simply voicing these tensions appeared hugely valuable. Whether participants were drawing on volumes of experience or opening the first chapter of their leadership story, they held similar fears and ambitions. They shared concerns on battling their ‘imposter syndromes’, the lack of meaningful feedback, and the instability of roles at the top, alongside earnest ambitions to improve patient care, protect staff morale, and seek support on their leadership journeys. The importance of holding on to that humble curiosity to learn from each other was clear.

Finally, it struck me that the challenges of these clinical leaders could often be stripped down to one core factor: people. I was acutely reminded that, like all complex systems, the NHS is a social organism. Even the biggest hurdles could be unravelled to reveal the human element - dealing with conflict, managing diplomacy, flattening hierarchies or improving relationships between teams. And that rang true across all levels of seniority.

I was also surprised by how many of these interpersonal issues resonated with me. While on a different scale and degree of complexity, I encountered similar sticking points in my first years as a junior doctor – in untangling team dynamics, trying to implement changes on a ward, or working out how to motivate medical students. Given the parallels, I think that training our workforce in the art of influencing and managing relationships from the outset would be a worthwhile investment.

In preparing for the complex and technical business of providing health care, it’s easy to forget that, working in the NHS each day, we’re in touch with existential anxieties that trigger our most primitive feelings. Bearing witness to the physical messiness of disease, the highly-charged emotions of patients, and the vulnerabilities that come with illness, can sometimes give rise to a harrowing working environment. In this context, I think it’s the simple, human acts – such as being kind, ‘listening with fascination’ (in the words of Michael West), staying mindful of our language, and taking the time to show empathy and gratitude – that offer the most potential for leading effectively. As I heard Mark Britnell comment recently: 'Change is a human contact sport'.

Overall, I left that day with a renewed sense of admiration for clinical leaders. As someone new to leadership in the NHS, I was energised to see that we have some exceptional individuals at the helm, nurturing their visceral ambitions to improve patient care. I was buoyed by their shared belief that the secret of success lies not in leading through power, but through people.

Going forward, I think the real challenge lies in creating cultures that support such clinical leaders to be the role models they wish to be. We mustn’t forget that the signals they send are influencing the next generation.

Because, for me, a bigger question remains: in future, if Florence Nightingale were to carry her lamp through the NHS, will she find a new cadre of leaders feeling emboldened and equipped to follow suit?