The practice of system leadership: Being comfortable with chaos

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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.

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More on system leadership


Anthony Consta…

Comment date
31 January 2022

"I think collaboration is the most important innovation for the NHS today". It is not the fancy technology that is holding us back but largely:


Comment date
19 July 2018

Nice article thank you


Gareth Evans

Organisational Development Manager,
Comment date
22 May 2018

Some really true and useful responses and comments here to the report; for me systems leadership is both simple and complex in its application - it's simple because its a practice rooted in some very basic human things - a willingness to privilege relationships, connection, open and honest conversation and a view always to the greater context of which you are an interconnected and interdependent part.

Its complex for all the same reasons; as the invitation often coming from our own organisations is to make the idea of 'thinking locally' equivalent to 'just think within our organisational bounds'. This pressure to look after our own whilst playing the game of 'being involved for the greater good' can be felt with real urgency and the need to have (enough) time to foster meaningful relationships (from multiple perspectives) with people from all places within our communities means that those leaders attempting to reach across their own systemic boundaries can all too often be pulled sharply back in...

Space to think, relate, learn and pause (so as to understand) before taking (what you hope is wise) action is crucial - what presses against this is the tendency toward a type of short-term thinking driven by anxiety and a need to constrain uncertainty (impossible to do!) so as to do things that simply recycle 'more of the same' types of solutions that too often only compound wider issues - this is the antithesis of the space systems leaders have to be able to sit in - managing uncertainty so as to still act - in local ways that over time influence wider systemic patterns.

This is a key skill and capability and systems leaders need time, space, support and encouragement to step into this space. Let's hope more of them do...


Nick Sharpe

Comment date
22 February 2017
The quality of a leader can influence others to follow and to learn to develop their leadership skills. Leaders have unique personality and their attitude is also different from other while following their footsteps, we are able to improve our personality and skills. I would like to follow the instructions present here to develop my personal leadership skills and apart from we should also follow guidelines from here.

Peter A Barnard

Writer / reseracher / reader / annoyer,
Comment date
06 December 2015
1. There is no shortage of leaderhip
2. There is no leadership training
3. But I believe systems leadership can be taught and I am happy to share how although health is not my field...

Pearl Baker

Carer/Independent Mental Health Advocate and ADvisor,
Comment date
22 May 2015
It goes without saying you cannot be a systems leader unless you know the system, which is changing all the time. Lets take 'integration' LTC
such as Mental Health, first question are you subject to section 117, Guardianship or COP, second what are their problems? assess, including 'safeguarding', identify needs, then implement. What agencies could be involved in this exercise. DWP,COP, Appointees, Housing, Guardianship, CCG, LA, Carers, Banks, Building Societies, Personal Budget, Support Workers.

To be a Systems Leader you must have knowledge, and that takes time.

There needs to be various System Leaders specializing in different subject matters, with some 'crossover' between agencies, i.e Housing Benefit regulations is the same for all groups.

It comes down to one question, you cannot be a System Leader if you don't know the system.

george coxon

various inc system leader I believe!,
care homes and various other groups and bodies
Comment date
22 May 2015
I've devoted a good amount of time this morning to reading this report with an open mind and receptive heart before I meet the Regional Skills for Health Director in the southwest and the Skills for Care lead too later this morning and have printed extracts for onward use and application so thanks to all for this - written by great people I recognise
I feel 80 page investment of time reading is as critical as time compiling so the value of the impact and contribution it will make is dependent on the likes of me - a modest front line leader dealing with enabling, empowering, reflecting, shaping culture, instilling pride, humour and reputation for our services in my 50 odd staff. The bit that I would want to add re leadership citing Derek Sivers and his irresistible 3 minute youtube clip on leadership is to say it is about credibility - ie leading by example - if you are no longer doing the thing you are leading about be very careful how you pronounce and expect others to follow - see the dancing guy in the Sivers clip - He started dancing and is still dancing when all the crowds joined him !!


Member of the public,
Comment date
22 May 2015
Oh how I wish I could be reading something new here. So many of the same old words and wish lists while even the most basic of services to the patient continue to suffer. Integration of heath and social care seems as far away as ever.
Does it really mean that the service is no longer properly selecting, training and developing present and future leaders?....I think so. Individuals seem to be simply looking for their next promotion rather than the giving of a service. How dare whistle blowers tell the public the true facts!!... Lets have more meetings more reports and maybe the problems will simply disappear!
There are centres of real excellence but they are being overshadowed by a growing number of inflexible, incompetent managers and leaders who still find ways of staying in post and unfortunately promoting those in their own image.

Prof. Minesh Khashu

Consultant & Prof. of Perinatal Health,
Poole Hospital NHS FT
Comment date
21 May 2015
Thanks Nick. Useful insights.

"I think collaboration is the most important innovation for the NHS today". It is not the fancy technology that is holding us back but largely:

1. Poorly set up and functioning structures. The system is set up to work in a 'them and us' way. Evaluation is based on organisation not system performance e.g. CQC

2. Lack of right skill set for the job at hand. Too much EGO and organisation centric agenda. Behaviours need to demonstrate efficient working beyond boundaries.

3. How do you expect laprosccopic surgery to flourish if the leader has been practising open surgery for 35 years and is too 'rigid' to accept that he/she needs to pick up a new skill or focus on a different set of behaviours. Quite a few 'senior leaders' happy in their old ways which brought them success in the past but are outdated for what the NHS requires today.

4. Their is urgency mentioned umpteen times in the 'talking' but very little urgency shown in action.

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