The practice of system leadership: Being comfortable with chaos

System leaders often do not see themselves as such, believing that any successes they achieve are due to working behind the scenes rather than leading from the front. But given the unprecedented challenges facing the NHS, the system needs leaders who can motivate staff and managers to work differently, across service and organisational boundaries. That is the only way to meet the needs of the growing number of people with complex and long-term conditions, many of whom rely on care and support from different services.

This report draws on the experiences of 10 senior leaders to look in depth at the skills needed to be a system leader. The 10 individuals are from different backgrounds and work in different contexts, and give some very candid reflections on their successes and failures. But they share a track record of having tried to bring about change (not always successfully) through using ‘soft’ power, enabling others to see and deliver the changes that are needed.

Key findings

Interviewees gave similar views on how to go about achieving system change and the barriers that need to be overcome. They emphasised the following strategies.

• Start with a coalition of the willing, build an evidence base, and build outwards; it is vital to engage clinicians in understanding the need for change and to lead efforts to achieve that change.
• Involve patients, service users and carers because they have an invaluable role to play in helping to identify which services need to be redesigned.
• Strike the right balance between constancy of purpose and flexibility by facilitating conversations about what needs to change and how; being flexible about how that might be achieved; and ensuring the momentum is there to deliver change despite the inevitable opposition.
• Pursue stability of leadership, something that has proved difficult in a context of frequent reorganisation of the provider and commissioning landscape.

Policy implications

There was consensus among those interviewed that much more needs to be done to develop system leaders. This could include ‘buddying’ younger, less experienced managers and clinical leaders with more experienced counterparts, and doing more to protect whistle-blowers. But there was some debate as to whether system leadership can be taught, or needs to be learnt the hard (and long) way.

There is now a strong and clear vision for system-wide change that is developing momentum, with the NHS five year forward view bringing together the multi-headed hydra that might be described as ‘the top of the NHS’ – NHS England, Monitor, the NHS Trust Development Authority, the Care Quality Commission, Public Health England and Health Education England.