System leadership – part two

In part one of system leadership we previously covered what system leadership is within the context of the present NHS landscape and what qualities such a leader needs to embody and embolden across the health economies they lead.

Attain continues to partner with several health and care systems and economies across England, supporting leaders and their organisations to align, develop and implement new care models and accountability frameworks that better serve populations. There has been a lot of press on NHS leadership, mergers and failing organisations – Attain has coached and supported system leaders to surmount the obstacles, so how can a system leader navigate this environment to enable successful outcomes for the people they serve and what barriers need to be overcome to do so effectively?


Part two

With ongoing pressures on meeting targets and financial controls, it may feel like moving to the future NHS models of care is a series of sprinting events. Attain is working with leaders and executives across systems to achieve these goals in a step-by-step manner or phased approach, similar to the mindset of a marathon or steeplechase runner as opposed to a sprinter. System leaders need to take stock and ownership of their transformation timeline as best they can and how they can implement the right change for their region for the long haul. Demanding large transformative changes are required now, which will have considerable complexities and barriers – delay is not an option.

Barriers to change

It is a necessity in all industries for organisations and businesses to be able to change in response to market needs or pressures. There are four common barriers to implementing change effectively:

  1. Lack of consensus
  2. Lack of planning
  3. Inadequate communication
  4. People resistance – patients, public and staff

A system leader has a central part to play in overcoming these barriers across the whole system. In order to be successful, the leader will need to understand where the underlying reasons for the barriers lie within the following six categories (National Institute for Health and Clinical Excellence 2007):

  • Awareness and knowledge
  • Motivation
  • Acceptance and beliefs
  • Skills
  • Practicalities
  • External – beyond control

From our experience, the first three categories above are often where leaders need to prioritise their attention on in order to lead system change effectively and at both pace and scale. Attain has supported and enabled leaders to improve on these from the perspectives of both partnership and system understanding and development. We recommend that leaders follow our three steps below to help them overcome these barriers and develop the right working approach for the system:

How to overcome barriers in system working

  1. Leave the ego at the door
  2. Seek to bridge gaps in understanding between organisations
  3. Move towards a distributed leadership framework

Step 1 – Leave the ego at the door

Easier said than done. Many readers will know that such an approach is obvious in order to be a good leader and some will believe they do this too good effect. So first, let us better understand what is meant by the term ‘ego’. A quick online search reveals the definition of ego as “a person’s sense of self-esteem or self-importance” (Oxford English Dictionary). Read any management textbook or leadership course information and it will be stated that an individual’s focus on their self or own ideas can become detrimental to creating positive change or developing cohesive action across a wider group. In the context of system leadership, Step 1 not only refers to the individual leaving their ego behind (a must for any leader in system change) but also to the organisation leaving its sense of identity and relative importance.

Consider the ego from the other side of the coin: the opposite of the ego could be described as a ‘unified self’ (Lattimer, 2012).  The contrast between the characteristics of the unified self to that of the ego is that the unified self acknowledges and respects the sameness of ourselves and is more concerned for the collective ‘win/win’ outcome. This mindset is in alignment to how we at Attain guide leaders of organisations towards system change successfully. Achieving this is often difficult and contentious when leaders come to the table with varying organisational priorities and needs – a system leader must think and focus on the collective benefit that serves their population.

Similarly, when examining moving away from the ‘ego’-led approach, it is important to note the different leadership mentality types and which is more suited to the new environment of system leadership. Simon Western has identified the four different types of leaders (Leadership: A Critical Text, 2008) that have evolved over time:

discourses of leadership diagram

  1. Controller: This style of leadership focuses on improving efficiency and control to increase output. Staff are treated in a functional way as replaceable “cogs in the wheel” of the machine. Although an early 20th century form of established leadership, we have seen this style reappear in the  public sector, due to a focus on top-down and target-driven culture to achieve productivity measures.
  2. Therapist: These types of leaders are focused on increasing motivation and commitment in staff to achieve goals and the vision of the organisation. Usually, this approach is more concerned with individuals rather than groups or the collective.
  3. Messiah: Such leaders usually appear attractive when there is huge transformational need with the aim of creating strong and dynamic cultures. These prophetic leaders manage to create entrepreneurial and dynamic but rather conformist cultures. Longer-term results can create fundamentalist styles endemic to the organisational cultures that resist critical reflection and difference.
  4. Eco-leader: This leader is more concerned with the collective and holistic benefit to enable an interconnected whole system, where central control is out-dated. The aim is to create distributed leadership at local levels, inspiring leadership and building networks that are responsive and adaptive to change. Nurturing strong networks and building partnerships and collaborative relationships are vital to their success.

Evolving into an eco-leadership style will naturally require the leader and its organisation to shed its ego and branch out into a formation of leadership frameworks (see Step 3).

Step 2 – Bridge gaps in understanding between organisations

With eco-leaders at the helm of a system, there will undoubtedly need to be better comprehension of each organisations’ position, needs and priorities in the context of what the population needs are and will be in the future. However, compared to developing a partnership for transactional purposes alone, creating this foundation of a common understanding should go deeper and requires appreciation of cultures, working styles, ethics and opportunities to contribute to system development.

Many current partnerships are based on a formal collaborative arrangement with a defined level of integration as opposed to an informal arrangement of working together with embedded common goals and outcomes. This is due to the complexity and types of issues and problems across health and care sectors with central regulation that requires a well organised approach and structure around working arrangements. In acknowledging this focus, it’s important to note the following three points (Victorian Council of Social Services, Australia 2009):

  • Relationships are more important than structures;
  • Participation, representation and engagement are essential; and
  • Partnership development requires time.

As one would expect, leadership style is critical in influencing the effectiveness of all partnerships. To lead a successful system requires specific skills that although similar to the attributes for a leader in an organisation, require more nimbleness and fortitude. Therefore, it is essential that there is a clear path carved out to align system thinking and bridge any gaps in culture and performance to help weave an intertwined future that is sustainable, resilient and future fit. Attain is currently helping executive leaders to define this path in our experience working on STPs, Vanguards, system turnaround and in development of other integrated models of care.

Step 3 – Move towards a distributed leadership framework

Leadership formation across the system and within each organisation is imperative. As previously stated, this style of leadership is different than at an individual organisational level – it requires openness, flexibility in thought and adaptability in style. System leaders will need an understanding of what it takes to enable successful transformation at all levels of each organisation and strong communication and engagement skills.

distributed leadership framework diagram

From Attain’s strong track record in developing such frameworks, we recommend that underpinning this will need to be defined governance to support a distributed leadership framework and a shared vision with common outcomes and goals, the principles of which can be developed during Step 2 above. The framework of leadership should be co-designed with key leaders and stakeholders across the system that not only focuses on the interconnectedness between but also within each organisation. Getting in formation for system leadership will take time but must be set out as part of a comprehensive multi-year phased transformation programme.

Once these three steps have been taken to overcome barriers and forge the path to a ‘one system’ approach, a system leader will be in a stronger position to deliver the shared vision and achieve desired outcomes improvement and quality care to its population. Attain has and continues to work with and support leaders to shape their system-wide transformation programmes, help drive momentum for change and implement new models of care. We have assisted organisations and systems to do so by ensuring alignment with the shared vision and values of their system.  Having the right eco-leaders across the distributive leadership framework that support and feed into creating the right strategic foundations for the system, will not only empower the people you serve and employ, but also enhance the system’s sense of a ‘unified self’.

We shall conclude this series on system leadership in part three, where our discussion focuses on how Attain guides the development of a distributive leadership culture throughout the health and care system and not solely at the executive level.

System leadership – part one