System leadership

Since NHS England’s publication of the Five Year Forward View and development of Vanguards and subsequently the requirement to deliver Sustainability and Transformation Plans (STPs), system leadership has become a hot topic. Questions abound in the media, amongst staff and public groups: What makes a good system leader? What will these changes mean for patients and staff?

Attain is working in partnership with health and care organisations across the UK, supporting leadership and executive teams to broker consensus across organisational boundaries and realise the delivery of tangible changes in health and care services on a system wide basis. Working with providers and commissioners to develop STPs, deliver whole systems programmes and new models of care, we have learnt much about what is required of a strong system leader.

In a two-part series, Dr Shirani Rajapaksa breaks it down to its bare bones…

Part one

The old adage of “the phoenix rising from the ashes” comes to mind when discussing today’s NHS. However, in the current landscape it is not yet clear what might constitute the ashes or phoenix. What will be lost or let go? And what will our future selves or the next generation reflect on as the change agents of success?

The financial pressures of doing more with less, low staff morale, ageing and chronically sick populations, with proposed changes to A&E status and hospital designation; the merging of provider organisations; blurred (and possibly obsolete) boundaries between commissioners and providers; and a leaner workforce have set the challenge for us all and could represent the ‘ashes’.

Arguably, it is the role of our leaders to help identify the ‘phoenix’ and the reasons for us to be optimistic. The creation of new health and care environments or systems that are integrated and deliver seamless service user journeys between sectors and services, and the current wave of transformation provides system leaders with the opportunity to shape a new future, be an agent of true change – and enable our much loved system to ‘rise from the ashes’. Attain’s transformation experience, of designing and rolling out models of cross-continuum care, lends itself to the forefront of the work that will be required to build such systems and support leaders in brokering between various sectors.

To create an environment that is without silos and produces improvements in health and wellbeing to local populations, there will need to be more accountability, data transparency and decision-making powers given to leaders. Such accountability should align with autonomy and staff engagement that is robust and visible to the public: herein lies the role of a system leader.


What is a system?

In order to understand how to lead for the future and what leadership characteristics may be required, one must first understand the system. The Five Year Forward View (Department of Health, 2014) describes examples that incorporate all health sectors and some that include social care. Internationally there are examples of systems that provide housing, in line with the Marmot Review (Department of Health, 2010), where the social environment is seen as a key health determinant. A system does not necessarily have to cover all these areas. The World Health Organisation defines a good health system as one that has “a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; well-maintained facilities and logistics to deliver quality medicines and technologies” that could be of varying configurations.

Whatever the configuration or parties included in your system, future successful systems will all need, at their core, the ‘4 As’:

  • ACCOUNTABLE: the system is answerable for its actions at both collective and individual levels and that there is redress when duties and commitments are not met.
  • AUTONOMOUS:  the ability of the system to make its own decisions on purchasing and providing care.
  • ALLIANCE: there is a formal agreement between organisations in the system, usually motivated by improved service user experience, better population health outcomes and cost reduction. Such an agreement would involve equitable risk and opportunity share for all parties and be managed by an integrated project team.
  • ADAPTABLE: the system is flexible, altering itself or its responses to changed circumstances or environment. It has the agile ability to learn from experience.













Without all four traits, it will be difficult for a system to be resilient and sustainable or improve service user experience and outcomes.

What is a system leader?

A 2012 Kings Fund commission on leadership and management in the NHS acknowledged the need “to move beyond the outdated model of heroic leadership to recognise the value of leadership that is shared, distributed and adaptive. In the new model, leaders must focus on systems of care and not just institutions and on engaging staff in delivering results.” It remains to be seen whether this has been taken to heart across the country – those who have are in stronger positions to deliver sustainable change by 2020.

There has been plenty published on the need for Board development and organisational culture change in the NHS, and although neither rest solely on a system leader, they will require their steer and oversight. So what does it mean to lead a system? The Indo-European root of “to lead,” is leith, which literally means to step across a threshold and let go of whatever might limit moving forward (Stanford Social Innovation Review, 2014).

Can it be done? The HSJ Future of NHS Leadership Inquiry (June 2015) highlighted the problem of high executive turnover – median job span for a chief executive was 2.5 years, with 1 in 6 at the time having no substantive chief executive. Where care systems have been developed successfully, long-term leadership across the Board was a critical factor.

Outside of health, there has been multi-agency work in retail and sustainable agriculture programmes – of the latter, one leader noted that the programme’s success was due in part to acknowledging that all parties do see the world very differently, and that was their greatest strength as a collective.

Taking these insights together, there are a number of core capabilities that a system leader needs to have:

  • Able to ‘let go’ of old ways of working
  • Shares and distributes control, power and influence
  • Sees, understands and is committed to the whole complex system
  • Fosters reflection, builds long-term relationships and proactively seeks different points of view
  • Creates a culture of trust that rewards and incentivises good performance
  • Moves focus from reactive problem solving to co-creating the future.

Those recently chosen as system leaders for their STP footprints must ask themselves whether they, and the leadership teams around them, fully inhabit these qualities on a daily basis.

Why now?

The NHS is facing a host of systemic challenges beyond the reach of existing organisations and their hierarchical management structures. Previous opportunities to promote real transformation have not fully delivered; in part because they failed to foster collective leadership within and across collaborating organisations. In order to achieve desired real change, there is a growing sense that the dimensions inside and outside of an organisation must be connected. Empowering the workforce to better acknowledge and manage interfaces and interdependencies across various facets of the service user journey will enable this. Leaders who not only recognise this but seek to lead and engage on all fronts will be successful (Harvard Business Review, 2015).

The harsh reality is that external factors of financial constraints, rising prevalence of people with long-term conditions and a global shortage of health professionals to deal with the health burden result in no choice but to work more closely to innovate together. This inevitability, amidst uncertainty, must be viewed as an opportune moment. Entering into such unchartered territory with a true system leader at the helm is likely to yield the desired improvements in quality and financial sustainability and reductions in inappropriate service utilisation. Ultimately, together we may well achieve improved population health outcomes. What will be inevitable is building on the insights and experience of those who have already transformed and implemented change on a system level – our work on Vanguards and large-scale transformation and change management has had leadership support and system-wide negotiation at the centre. Our sustained emphasis on this in system transformation programmes is a key reason for their success.

There will need to be development and support to those individuals who have the raw talent and capabilities to become system leaders, not only from within their organisations and systems but also at a national level. Otherwise, one may have to refer to that other common phrase, “out of the frying pan and into the fire”.


Next month in part two, our discussion on the future system leader continues with thoughts on what this development might look like, how to navigate the system and overcome barriers to effective leadership.

System leadership – part two

For further information, contact Dr Shirani Rajapaksa.