This week we publish a HSMC newsletter on the theme of leadership. Over the last 25 years much has been written about leadership in the NHS and millions of pounds have been spent on developing leaders at local, regional and national levels, and yet the NHS has just emerged from yet another scandal that revealed an all too familiar tale of poor quality of care, patient neglect, and a lack of organisational leadership. What is clear from this continued legacy is that the approach to leadership development has not had the desired impact anticipated.

Deborah Davidson

Having an impact, cannot be achieved by developing individuals’ capabilities alone, as the contested and political context has a significant part to play in facilitating or hindering service improvement. Nor can impact be achieved by focussing on learning leadership theory through talk and chalk, because knowledge without action won’t lead to effective leadership practices on the ground.

At HSMC, we view leadership development as an organisational development intervention, not just the development of individuals because the purpose is ultimately about having a positive impact on care quality and service user experience. Because of this, our approach to leadership development is systemic (Knight, 2002[1]; James,1995[2]),focussing on impact in three domains: the individual, the team or service and the wider organisation and context.

On paper this seems logical and straight forward, in practice it is not, because it involves paying attention to what you do, why you do it, how you do it, how you articulate your thinking, being aware of the impact you have on others and how others respond to you; how you read and understand what is going on (being psychologically-minded) with your teams and colleagues, how you enable, empower and work developmentally with others; how you engage wider services, stakeholders and partners, service users, local culturally diverse communities; how you deliver policy related targets, reduce costs, drive much needed change….and so on.

How do you remain adaptive and work with this complexity? As Ron Heifetz said (1994)[3], there are no easy answers because this work is not about problems that have solutions, they are dilemmas to be worked with and through.

For us at HSMC, effective leadership is about working in that ‘dilemmatic space’ (Fransson and Grannäs, 2013) [4]with and between those three domains of experience. This is shown in Figure 1 below:

Figure 1: Domains of experience (Adapted from the © Grubb Institute, 2004)

Domains of experience diagram

It is also about having a self-awareness of how you behave, insight into the impact this has on others, and a degree of courage and humility to do things differently.  

Our leadership development programmes are designed to provide safe but challenging spaces in which to learn and experiment and rehearse doing things differently. We draw on a range of progressive development (Theodorson, 1953)[5]methods including residential programmes, experiential learning, scenarios, and action inquiry (Torbert, 1972)[6], because these approaches to learning, deepen the intensity of the learning experiences, and can accelerate individual behavioural changes, and shift mindsets. Because we focus on systemic impact, our educational design also involves the application of learning in the workplace, through focused activities with teams, colleagues and line managers. Together with theory about leadership, knowledge and innovation from other sectors, a focus on service users at the centre and the integration of equality and diversity in all of our learning activities, these approaches provide the potential for development and change both for individuals and for their organisations.  

However, we know from research (Bass, 1990)[7]that the return on investment is poor and these approaches are likely to fail without good organisational engagement and support before, during and after development, from line managers, from HR and from the Board. 

Too often people are ‘sent’ on external programmes as an intervention into the individual (you are the problem and so development of you is the answer), and support for applying learning back in the work place is not even thought about or embedded in organisational practices and procedures. Recent experience from working with participants on the Elizabeth Garret Anderson Programme, shows that despite the good efforts of the NHS Leadership Academy, and line managers signing a contract to sponsor, provide support and being liable for a substantial compensation fee if the person leaves due to lack of support, some line managers don’t provide days off to attend face-to-face days (forcing individuals to take annual leave), don’t cover travel expenses to national venues, don’t’ provide any study leave for assignments, and don’t make themselves available or don’t engage with learners.

We know these unproductive behaviours won’t just be affecting staff on development programmes, they will be impacting negatively in the organisation, its services and ultimately patient care; they are a good example of the very mindsets and behaviours in the NHS, our programmes seek to change.

A longer version of this blog appears in the HSMC newsletter.


[1]Knight, P. (2002) A systemic approach to professional development: learning as practice, Teaching and Teacher Education, Volume 18, Issue 3, Pages 229-241

[2] James, B. (1995) Designing Professional Development for Change. A Systemic Approach, Palatine, Illinoi: IRI/Skylight Publishing

[3] Heifetz, R. (1994) Leadership without easy answers, Cambridge, MA: Harvard University Press

[4] Fransson, G and Grannäs, J. (2013) Dilemmatic spaces in educational contexts: towards a conceptual framework for dilemmas in teachers work, Teachers and Teaching: theory and practice, 19:1, 4-17

[5] Theodorson, G.A. (1953) Elements in the Progressive Development of Small Groups , Social Forces(1953) 31 (4): 311-320.

[6] Torbert, W.R. (1975) Learning from Experience: Toward Consciousness,New York: Columbia University Press

[7] Bass, B., (1990) Handbook of leadership: theory, research and managerial applications, London: The Free Press