Developing collective leadership for health care

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With the NHS facing bigger challenges than ever before, leaders must ensure that cultures within health care organisations sustain high-quality, compassionate and ever-improving care. Key to shaping these cultures is leadership.

This paper argues that collective leadership – as opposed to command-and-control structures – provides the optimum basis for caring cultures. Collective leadership entails distributing and allocating leadership power to wherever expertise, capability and motivation sit within organisations. NHS boards bear ultimate responsibility for developing strategies for coherent, effective and forward-looking collective leadership.

This paper explains the interaction between collective leadership and cultures that value compassionate care, by drawing on wider literature and case studies of good organisational practice. It outlines the main characteristics of a collective leadership strategy and the process for developing this.

Key messages

  • Collective leadership means everyone taking responsibility for the success of the organisation as a whole – not just for their own jobs or area. This contrasts with traditional approaches focused on developing individual capability.
  • If leaders and managers create positive, supportive environments for staff, those staff then create caring, supportive environments for patients, delivering higher quality care.
  • Where there is a culture of collective leadership, all staff members are likely to intervene to solve problems, to ensure quality of care and to promote responsible, safe innovation.
  • Organisational performance does not rest simply on the number or quality of individual leaders. Research shows that where relationships between leaders are well developed, trusts will benefit from direction, alignment and commitment.
  • Vision and mission statements must be translated into clear, aligned, agreed and challenging objectives at all levels of the organisation, from the board to frontline teams and individuals.

Policy implications

  • The process of developing a collective leadership strategy must begin with the board since the scale of the change process and resources required demand complete commitment from the most senior leaders.
  • A collective leadership strategy focuses on the skills and behaviours that leaders will bring to shape the desired culture, including generic and specific behavioural competencies. It also designs systems for ensuring leaders act together.
  • Collective leadership implies all staff welcoming feedback, treating complaints and errors as opportunities for system learning rather than as prompts for blame. This encourages collective openness to and learning from errors, near misses and incidents.


Frank Roe

Former NHS finance manager. Now business mentor & coach,
Gain Success
Comment date
22 May 2014
Might the difference between executive and clinical responses indicate the former's willingness to "say the right things" while the latter's is a truer reflection of the state of care?
Might it also indicate that many at executive level do not yet possess the vision and skills to start creating the cultural and learning changes required?

Nigel Rose

Strategic Lead (Commissioning),
Comment date
23 May 2014
I work in the VCS but also spend some of my time working with senior NHS managers particularly around integration. I very much welcome the focus of the King's Fund on collective leadership. It seems to me that now, more than ever, NHS managers need to encourage and enable collective responsibility for services and change throughout their organisations.

However, I think that there needs to be more emphasis in collective leadership models and especially the key messages on how leadership also involved relationships with external organisations. NHS managers are publicly funded democratic agents, their relationship to civil society is fundamental to their roles not an added extra. As the balance in the social contract shifts back towards informal and voluntary sector support then this becomes even more critical.

David Oliver

visiting fellow,
kings fund
Comment date
24 May 2014
The survey is fascinating reading and I commend the authors for a great piece of work. I have reposted it on the BGS website for out members. I am very interested in the mismatch between exec level leaders and coalface doctors and nurses - especially as a hands on jobbing doctor myself who also goes into other hospitals and health economies to give constructive sense checks and external advice. My guess is that for those who spend hours working in busy acute medical units or emergency departments or on wards struggling to recruit and retain nursing staff and who are dealing with (sometimes justifiably unhappy) patients daily, their perception of any care gaps is grounded in palpable operational reality. And if these same staff are the ones reporting problems up the line, they are also best placed to know how much they feel listened to and whether their concerns are taken seriously. The "don't bring me problems bring me solutions" and "I only want to hear good news" attitude of some senior leaders in some organisations doesn't help; in its worst form this leads to staff who raise concerns being slapped down or marginalised; nor do leaders who are focussed far more on strategy than on operational issues. Also, organisational leaders are still held to account far more for issues like financial performance or centrally measured KPIs than some of the softer issues like staff morale and engagement or patient experience. I do find it interesting that in effect, front line doctors and nurses, despite having a professional pride in their job and a desire to do it well are still telling the survey team that they often know the care they are able to deliver within the resource they have is short of what they would like to offer. Perhaps the survey reflects that for those at the top of organisation, its simply to much of a threat to their self esteem to own up to not in the garden being rosy. Anyway, if I could offer one solution to the disparity, I would suggest that all senior leaders with clinical backgrounds and qualifications continue to practice clinically within their organisations. A chief nurse/divisional nurse doing a full shift on a ward each week alongside their exec role. And non clinical managers getting out of trust HQ and doing some shifts as porters/HCAs/spending nights on call with the ward cover junior doctors. You would get a better insight than any amount of staff engagement events or walking the wards being a "visible presence". For those who haven's try watching "undercover boss" and you will see what I mean. Sadly, in some organisations I have visited, the staff on the shop floor wouldn't recognise some of the exec team - who in such places tend to hunker down in "trust HQ". Lessons of Mid Staffs anyone?

David Oliver

Ian Holder

Director and Chair,
Comment date
11 November 2015
This makes sense and curious how social care and co-creation integrate with these ideas

Rick Mclean

Comment date
08 April 2017
Leaders are playing a vital role in the development of their organization. They are able to bring good positive changes for their organization, here this article also describes the contribution of leaders and how they are effective for health care sections. Thanks for highlighting such important topics.

Collins Yaw Amoah

Comment date
22 November 2020

Very effective course

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