Leadership and leadership development in health care: The evidence base

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A key challenge facing all NHS organisations is to nurture cultures that ensure the delivery of continuously improving high-quality, safe and compassionate health care. Leadership is the most influential factor in shaping organisational culture and ensuring the necessary leadership behaviours, strategies and qualities are developed is fundamental. But what do we really know about leadership in health care services?

The Faculty of Medical Leadership and Management, The King’s Fund and the Center for Creative Leadership share a commitment to evidence-based approaches to developing leadership and collectively initiated a review of the evidence by a team including clinicians, managers, psychologists, practitioners and project managers. This report summarises the evidence emerging from that review.

Key messages

  • Leadership in NHS organisations needs to ensure direction, alignment and commitment to the core task of developing cultures that deliver continually improving, high-quality and compassionate patient care.
  • Leadership needs to: develop inspiring visions that are put into practice at every level by leaders; identify clear, aligned objectives for all teams, departments and individual staff; provide supportive and enabling people management; develop high levels of staff engagement; support learning, innovation and quality improvement in the practice of all staff; and promote effective team-working.
  • Leaders need to work together, spanning boundaries within and between organisations, prioritising overall patient care rather than the success of individual components, and to build a co-operative, integrative leadership culture – in effect collective leadership.
  • Developing collective leadership for an organisation depends crucially on local contexts and is likely to be done best ‘in house’ with expert support, integrating both organisational development and leadership development.
  • Experience in leadership is the most valuable factor in enabling leaders to develop their skills, especially when they have appropriate guidance and support. Focusing on how to enhance leaders’ learning from experience should be a priority.
  • Evidence-based approaches to leadership development in health care are needed to ensure a return on the huge investments made.


Eric Balki

Chief Executive,
TCG Medical Services
Comment date
22 March 2022

One of the most dramatic moments have arrived in developing nations, and that is a changing demographic. To cope effectively it is necessary to think outside the box and adapt. Business processes need re-engineering to cope with increasing demand on health care and we need strong leaders with business skills to to evolve healthcare that is equitable for all.

Joan OKK

Nursing unit supervisor,
Comment date
30 October 2018

want to learn and develop my leadership skills

Jude Walters

Comment date
31 March 2017
Leadership is an essential fact through which we are able to develop our skills. In all sector we need strong leadership attitude to lead and to get success, so we should follow different ingredients to develop our leadership skills. I would like to follow different sources and ingredients to develop my leadership attitude or else we should also take the help of different coaching programs.

david oliver

consultant physician,
kings fund visiting fellow
Comment date
27 February 2015
I haven't read your report, Suzanne, but as a jobbing doctor who works with patients and other frontline practitioners day in day out, I have a lot of sympathy with your argument. Of course some people are burnt out, treading water and just trying to survive the day/week. But in general, we come to work to try and make a difference to patients/clients and their families and also because there is tremendous camaraderie in clinical teams. I am about to do a 12 hour day on call for acute medical unit and I can guarantee this is what I will find when I get into work.
So.....clinical leaders are motivated by agendas around improving care for patients and driving high professional standards. They are constantly walking ethical/moral tight ropes - for instance the imperative to discharge as many patients as possible to keep pressurised beds clear versus a duty of care to individual patients and their families who may not always feel safe to go home; the desire to save lives whilst at the same time recognising when someone is dying and aiming to give them as peaceful and dignified a death as possible; the balance between risk/harm and benefit of treatment. The need to use scarce resources wisely while doing the best for individual patients.
I did a an ethics and law masters and also teach applied healthcare ethics to professionals because I came to realise that every second patient I see comes with ethical and legal dilemmas.

The tricky thing with doctors/clinicians as leaders is when their leadership role comes into conflict with their clinical values and their time as leaders is taken up with pleasing regulatory agencies hitting performance standard, dealing with finance and often implementing policies/imperatives that openly conflict with their professional role - in turn lowering their credibility with clinical colleagues

A clear example (now looking quite different since Francis 2 but leading to "overspends") has been state registered nurses, on the nursing register but no longer working at the coalface with patients, on boards of trusts and being responsible for reducing the spend on nurses, whilst knowing full well how much pressure nurses at ward level are under. This puts them in a clear conflict of interest. Although its true that clinicians make most of the decisions that affect spend and most NHS spend Is on workforce, there is an argument for saying that clinical staff/practitioners as leaders should advocate for quality, safety, training, skills, morale etc but not be be responsible for budgets or for hitting performance targets or top down regulatory frameworks. There is a bigger argument that all pracctitioners in leadership roles should continue (as I and many doctor-leaders do) to practice clinically at the coalface alongside their leadership role to ensure that they are fully grounded in reality and not divorced from the coalface. The Kings fund leadership survey showed a big disconnect in perceptions of organisational health and performance between people at board level and the staff interacting daily with the customers. If you haven't watched "undercover boss" it shows this need beautifully. I would love to see "undercover chief nurse" - and in some hospitals the chief nurse could go undercover on the ward without needing a disguise

David Oliver

Suzanne Shale

Healthcare ethics consultant,
Self employed
Comment date
25 February 2015
Perhaps it's a function of review articles on leadership that findings are reduced to highly generic principles, but having read the document it seems to offer little new insight into health leadership specifically. I tend to agree with the previous comment, although the review itself is more informative than the "key messages" summarised above. It may be that my own research - published as "Moral Leadership in Medicine: Building Ethical Healthcare Organisations" (Cambridge, 2012) did not measure up to the exacting standards required for inclusion in this evidence base. As a qualitative inquiry into the the moral experience of 24 NHS medical directors, it would not satisfy some of West et al's methodological requirements. It does, though, give readers a tangible sense of the moral tensions that healthcare leaders must contend with as an intrinsic part of their role. These arise because they are working - specifically - in healthcare. I would argue that to really understand what is involved in healthcare leadership we need to understand the moral and emotional demands made on healthcare leaders by the nature of the life and death, reassurance and anxiety business they are leading. My findings are not inconsistent with West's emphasis on 'vision' although I would put it in terms of needing to orchestrate organisational narratives that mobilise the commitment of fellow professionals. For the group of leaders I interviewed, patient safety and professional performance issues were at the forefront of their concerns, at the heart of their narrative activity, and the origin of the moral tensions they had to manage.


Public Health Wales
Comment date
25 February 2015
A noble attempt to shine a light on leadership and its development in the NHS. The research method paragraphs are the most telling, in that they specify the inadequacy of current research in to this field within Health. Whilst much can be learnt from other sectors, the context, means and substance of leading in Health are very different to other sectors. Critical amongst these are the political nature of the environment, the unique power of Drs and the high levels of complexity. I would have liked far more exploration of the effects of these factors on leadership rather than the traditional references to vision, culture, alignment, empowerment and competences etc. If organisational psycho dynamics and complexity theory are ignored then learning is inhibited. see Stracey, Snowden etc.

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