Followership: what sort of a word is that? Whatever it is, it has been troubling me for some time.

Everyone seems to acknowledge its importance; it trips off the tongue as a challenging issue for consortia; it is often intermingled with the words “distributed leadership”. But before we slide into management speak what is followership and how do we achieve it?

It seems to me that there are two main types of challenges we face daily in the NHS. There are those that I call type 1, or linear: there is a problem, a solution is found that directly effects the outcomes we need and it is then implemented – job done. The problem may be relatively simple or highly complicated, but there is a clear direct response between action and result.

Then there is type 2, or the wicked problems. These are non-linear and inhabit that strange realm of the complex adaptive system with positive and negative feedback loops lurking in the shadows to catch you out. They are difficult to define and merely by observing and being part of the issues and the challenge we change them.

Many of the actions that rely on behavioural change will fall into this category. But all too frequently we approach it head on with a linear solution.

In the past, heroes have served us well: coming in, taking strong, decisive actions and driving through solutions, often very good solutions to linear problems; but will this work in the world of commissioning consortia?

I am not sure direct action from the top will work well in consortia as I suspect these models will be very clear examples of complex organisations tackling complex problems. It will work for a short time but soon the system will adapt around it, leaving even more complex issues to resolve.

Sustainable performance (SP), can be defined by what I have named Zollinger-Read’s first law:  SP=(C*I)CR where C = capabilities, I = incentives and CR = constructive relationships.

In short, to deliver sustainable performance you need the right capabilities and incentives. These will be correlated directly with the outcomes you seek, but putting the right constructive relationships in place will have a much greater effect, as it has a power relationship to performance.

So what are the messages for consortia? To start with, let’s look at things that work well already, for example the many successful clinical networks that have developed around the country.

They have the right clinical relationships, the skills, capabilities and incentives. Here incentives are far wider than financial – it is about improving “my patients’ lot”, the quality of care, working life, and so on.

The challenges consortia will face will require collective wisdom, not heroic action and this cannot be simply placed with single individuals.

So if we accept that we need different types of leadership approaches in consortia how do we get there? Skilled leaders will know their different leadership styles, such as directive, visionary or pace-setting.

However, the challenge of consortia requires more than this; it is a pluralistic type of leadership invested in others and through others. It is a network – collectivism.

Rather than diving in and effecting solutions this approach considers the needs of the differing relationships in and outside the group; hence this system co-designs and co-creates its direction.

Developing this is (surprise, surprise) not linear. But a good place to start is with the building blocks of organisational health to help this type of leadership emerge. Emerge it must, or rejection of any transplant will undoubtedly happen.

If we need a new style of leadership perhaps we need a different way of approaching challenges; our modus operandi. We are all too often perplexed as to why good practice does not spread. Perhaps we need to focus on the underlying enablers such as the cohesion of primary care; the necessity of integrated care and the blinding logic of population healthcare. Maybe it is time to refocus.

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