Shaping the future challenges us to embrace a new style of leadership in the NHS – one that can deal with ambiguity and uncertainty; and harness the formidable power of the people working across the heath and care sector. 

So, what is the ‘right kind of leadership’ for the task now facing the NHS? Shaping the future sets out a credible argument for how we will deliver the future vision for the service. We need all elements of the proposed framework for change to be in place and the conditions for success to be clear. We will then just have the small matter of delivery.

I firmly believe that this means:

  1. Values based leadership, with explicitly stated values, will be essential to mobilise the people who work in the NHS. It will also support our decisions in an uncertain environment – when there is no right answer we must be guided by our values and the evidence.
  2. Recognising we are all system leaders – as well as running organisations we will need to be able to understand our leadership role in the system within which we operate.
  3. Leadership happens at all levels in the system and we must create the culture to support this in every organisation – 'leading from every seat' to deliver better care.
  4. Authority and leadership must be delegated to the level closest to the problem we are trying to solve or the role we are playing – each team and each part of the system must do what only it can do.

This will take a generational shift in approaches and attitudes. The good news is that we are already on our way there.

Extreme circumstances

One of the truisms of health care is that extreme circumstances lead to innovation.

There are many examples of the impact of battlefield medicine on surgical, anaesthetic and aseptic techniques. On my visits to our members, both commissioners and providers of NHS care, I see how a new kind of leadership has flourished in many parts of the service facing ‘extreme’ circumstances. This includes mental health and community providers with flat cash, trusts in special measures and some clinical commissioning groups. Where they are today, the rest of the service will follow.

'Stressed' organisations such as University Hospitals of Morecambe Bay NHS Foundation Trust and Barking, Havering and Redbridge University Hospitals NHS Trust are adopting a new approach to leadership under the auspices of chief executives Jackie Daniel and Matthew Hopkins. These are leaders who understand the heroic model of leadership will not work. When faced with extreme circumstances, they have chosen to unleash the power of their people by creating an ambitious vision of the future, founded on shared values. They then broker solutions with colleagues in the system, rather than attempting to 'grip' everything and create a fortress against the outside world.

They are not alone.

There are many other examples to cite, from the celebrated Frimley Park and Salford Royal to places like Wrightington, Wigan and Leigh NHS Foundation Trust. The latter rightly win scores of awards under chief executive Andrew Foster’s excellent leadership – underpinned by quality, values and engagement. Steven Michael, chief executive at South West Yorkshire Partnership NHS Foundation Trust runs an organisation defined by its values, constantly enriched by patient leadership and supported by an award winning quality academy.

We have some of the finest leaders in the country, operating at all levels of the NHS. Getting the most out of them, and delivering Shaping the future will mean changing the way we work, altering the behaviours learned by a generation of leaders where pacesetting and direction brought delivery. Those styles were designed for a stable environment and, as Shaping the future shows, uncertainty is the order of the day.

Building upon certainty

So we must bring certainty to play, building on what we know is important. The shared values that define most people that work in the NHS – described well in the NHS Constitution and locally owned variations in many organisations – are fixed. At a local level, we know that health needs will continue to be shaped by changing demography. In these turbulent times, shared values and the needs of patients and populations in a place become the new constants. This combination will guide our decisions on wicked issues.

The next few years will be about ensuring we tailor care to people’s local social, mental and physical health needs and their aspirations. In doing so, we will need to recognise the assets people bring. This means seeing ourselves as guests in people’s lives and reshaping care – and our organisations – appropriately.

A new kind of system leadership will be required to do this – one that engages everyone in the organisation and in wider partnerships too. This requires flexibility and a degree of humility. Local people, patients, clinicians and managers at all levels can bring to the table insight and new ideas on managing costs, improving quality and using innovation. Professor Michael West from Lancaster University Management School and others have shown how staff engagement leads to better quality and outcomes in the NHS. And the Centre for Patient Leadership has done much to demonstrate the positive impact patients can have when supported and engaged to use their knowledge in redesigning care.

It’s easy to say that leaders must work together, in the interests of patients, as leaders of their local systems and not just organisations. However it’s much harder to do – especially when senior leaders have for years been held personally responsible for their own organisation’s short term delivery against process targets and cost savings. It also means building and deepening partnerships with a range of other services and organisations, joining up care and developing sustainable solutions to challenges. I see this in all sorts of places – from Pennine Care NHS Foundation Trust’s work with local AgeUK and GPs to the Penwith Pioneer.  

Doing this whilst maintaining services requires all four of my leadership asks to be in place. Front line teams will work differently, fixing the problems in the system, guided by data and values, supported by organisations with the right leadership culture.

They can only do this, if the national system lets them.

A national framework locally delivered

Here too there are signs of change that reflect the consensus in the 2015 Challenge partnership of health and care organisations – we need a national framework that is locally delivered. The principles of subsidiarity need to guide us. Once we have the right power and authority delegated to the right levels, a new kind of relationship between national leaders and local leaders must emerge, based on trust and respect rather than hierarchy. Local leaders doing tough jobs need support, not censure, resources not just RAG ratings. All across the country, this appears to be emerging. In the wake of significant system pressure, the regulators know that the system, not its leadership, may be the issue.

To catch up with progress already being made in some areas, we need a reformed performance and regulatory culture. This needs to focus on populations and systems, not organisations as islands. Shaping the future is also right that a longer term approach to funding is really important for strategic change. It’s rare for a business investing in major service transformation to expect to break even in the first year and lessons from Europe and elsewhere suggest the payback in health care may be longer. Leaders need a longer timeframe to succeed.

Overall, we need ambitious transformation plans to be supported by a new, well judged, properly managed approach to risk. The final unanswered question will be that of the intermediate tier. Where is the axis between national and local and how clear will it be? Core cities like Manchester, Birmingham and Leeds may seek devolution to City Regions, but what of the rest of the country? Early resolution of this issue is long overdue.

Changing the health and care system needs political will and the personal backing by senior politicians of NHS leaders. This will benefit them, us and ultimately patients. I don’t underestimate the challenge.

Despite all of the challenges, there is reason for optimism. The NHS Confederation recently surveyed members – NHS leaders – about the current challenges. Eighty-one per cent told us being an NHS leader has become more difficult over the last 12 months. Despite this, more than half (53%) would still recommend a career as an NHS leader to family and friends. Why? Because our members are up for shaping the future for this generation and the next on an issue that defines them, their teams and the nation.


Rob Webster is Chief Executive of the NHS Confederation

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