If Florence Nightingale worked for the NHS of today, she would be looking outwards to find people to make her wards work better. These people would be system leaders, not just strong leaders of single organisations, says Nick Timmins

Sir Roy Griffiths in his seminal report on NHS management some 30 odd years ago observed that if Florence Nightingale had been carrying her lamp through the corridors of the NHS then, “she would almost certainly have been searching for the people in charge”.

‘If she saw the NHS today, Nightingale would be looking for system leaders to work with her’

Thirty years on, she would be looking outwards – into general practice and social care, and into the private and voluntary sectors, in order to find the people who would make her wards work better.

She would, in other words, be looking for system leaders to work with her. For it is a truth now universally acknowledged that it is system leadership that the NHS and social care requires, not just strong leaders of great but single organisations.

A leading catalyst

But what does system leadership entail?

That was the question the King’s Fund sought to at least partially answer by interviewing 10 “system leaders” on their views and experience.

Nick Timmins

The interviewees ranged from the chief executive of a large county council, to people who work with clinical networks, clinical senates and academic health science networks.

They included the head of a large voluntary organisation, the chief executive of a large teaching hospital and individuals who have led, or who still lead, elements of the NHS at regional and national levels.

So what were their views?

Well, intriguingly, while all of them recognised the need for system leadership, a significant proportion had no wish to claim the title of system leader. 

‘A significant proportion of system leaders had no wish to claim the title’

To do so “is to put yourself 40-love down before you start”, says Sir David Fish, managing director of UCLPartners, says.

“It can have really negative connotations. It sounds as though I am telling you what to do. And we don’t do that. We are, instead, a catalyst, an enabler. We are trying to help good things go faster.”

The act of persuasion

A second and related theme was “that you can achieve almost anything if you don’t wish to claim the credit for it”.

So being a system leader was definitely not a heroic, Henry V, type role.

What it essentially involved was an act of persuasion - across the primary, hospital, social care and other divides - to convince individuals and organisations to act in the best interests of the patients, even when that was not necessarily in the best interest of individual organisations or, indeed, of the individuals involved.

It required different skills to line management, and to those needed only to lead a single organisation.

‘It starts with a coalition of the willing, from which one can build outwards’

It is not a task that will suit every personality.

It requires, perhaps obviously but also ideally, a strong evidence base – not least to help convert the unwilling. And it starts with a coalition of the willing, from which one can build outwards.

“You need the best, most diverse group of clinical leaders that you can possibly muster. One of the biggest sources of influence was your ability to get powerful clinical leaders on side and then to take responsibility for leading it on your behalf,” says Ruth Carnall, chief executive of the former London Strategic Health Authority.

Time and again, these system leaders said it was crucial to involve patients, service users and carers in designing the new. They, after all, often have strong views on what is wrong with the present. When they line up behind a system change “it is very hard to say to a patient you are not going to do something because your trust will lose out”, director of Cheshire and Merseyside Strategic Clinical Networks Jan Vaughan says.

Barriers to system leadership

There are plenty of paradoxes in system leadership – for example, it requires both constancy of purpose, but also a degree of flexibility in precisely how the goal is to be achieved. And it clearly works best when there is stability of leadership.

So what are the barriers?

Unfortunately they turn out to be legion.

The churn of chief executives – the lack of stability - is one.

‘The job would be a lot easier if it was made easier to do’

The sheer complexity of the current architecture is another. This leads to difficulty over coordination of goals, targets and requirements, while the consultation process for change, and the myriad impact assessments and business cases involved, came repeatedly under fire.

No one advocated another reorganisation. But it is clear that some at least miss the former strategic health authorities with there now being no one place where people can come together to resolve crucial issues.

The picture that emerged was far from entirely gloomy.

After all, those interviewed had all achieved at least a degree of system change, and the collected interviews amount almost to a handbook on how to think about and go about the task.

The King’s Fund’s publication contains no formal recommendations. But the clear message from the interviewees is that the job would be a lot easier if it was made easier to do.

Nicholas Timmins is a senior fellow at the King’s Fund. He conducted the interviews for The Practice of System Leadership: Being Comfortable with Chaos.