Skating on thin ice: the jeopardy of the ‘accidental leader’ in the health and care system

Clinical leadership in the NHS does not always happen by design. It often emerges by accident and is increasingly likely to be something people fall into doing and are not prepared or trained for. We are seeing this across the broad spectrum of clinical roles, from medical and nursing positions to allied health professionals (AHPs) and researchers. 

In our work with clinical leaders, we frequently see people who have stepped into leadership roles not through deliberate career development but through circumstance, organisational need, or simple proximity to a problem that required solving. These ‘accidental leaders’ are becoming a defining feature of today’s NHS leadership landscape. 

The conditions behind this rise are not difficult to trace. Workforce shortages, service pressures, and the rapid pace of operational change mean leadership vacancies often appear faster than formal development and talent pipelines can fill them. As a result, medics, nurses, AHPs, GPs and resident doctors are frequently asked to ‘step up’ on an interim basis, to take ownership of a project, or represent their service in cross-organisational forums. What begins as a temporary or task-based responsibility can quickly evolve into a permanent leadership role – sometimes without adequate preparation, support, or even explicit agreement from the individual. 

Yet despite this unplanned and unsupported route, accidental leaders often bring unique strengths. Their credibility comes from their lived clinical experience and proximity to the daily realities of frontline care. As a result, they have the potential to lead with authenticity, grounded judgment, and a strong sense of purpose.  

However, this informal pathway can also be damaging. Many accidental leaders report feeling underprepared, overwhelmed, or disconnected from the principles, methods and support that colleagues in managerial roles may take for granted. Without structured development, protected time and support such as coaching, the burden of leadership can quickly lead to exhaustion, cynicism, reduced professional efficacy and disillusionment. In some cases, promising leaders retreat back to solely clinical roles, leaving the system without their potential contributions – and leaving the individual feeling they have somehow ‘failed’ at something they never intentionally pursued. Or, sometimes more harmfully, they may stay in the leadership role but become resentful or adopt harmful leadership approaches which can cast a negative shadow on those they lead. 

This raises important questions about how the NHS embeds effective mechanisms to identify, nurture, and support clinical leaders and managers. If the system continues to rely on accidental leadership as a de facto pipeline, it must also accept responsibility for the harm to patients, staff and inefficiency that inevitably flows from poor leadership. The NHS must ensure these individuals have access to the right development opportunities. Leadership is not innate, it is cultivated; and those who step into leadership because ‘someone had to’ deserve as much investment as those who seek it out. 

There is also an opportunity here. Accidental leaders reflect a distributed, inclusive notion of leadership. If the NHS intentionally embraces the development of those who find themselves accidentally leading, it could strengthen clinical engagement, improve service redesign, and foster cultures where leadership is seen as a positive, collective endeavour rather than just a means to ‘get on’. 

Ultimately, the rise of the accidental leader highlights both the pressures and possibilities within NHS leadership and management today. By recognising, supporting and systematically investing in these leaders – not simply relying on them – local systems can turn a challenge into an opportunity, harm into progress and build leadership cultures that are resilient, grounded, and connected to the realities and deeply held values of care.