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Systems leadership: how chief executives manage tension between organisation and system pressures
  1. Ben Gordon1,
  2. Matthew Gwynfryn Thomas2,
  3. Ara Darzi3,
  4. Lisa Aufegger4,
  5. Colin Bicknell3
  1. 1 Central Team, Health Data Research, London, UK
  2. 2 Insight and Improvement, British Red Cross, London, UK
  3. 3 Department of Surgery and Cancer, Imperial College London, London, UK
  4. 4 Faculty of Medicine, Institute of Global Health Innovation, Imperial College London, London, UK
  1. Correspondence to Ben Gordon, Health Data Research UK, London NW1 2BE, UK; ben.gordon{at}


Aim System leadership is the requirement for a leader of a single organisation to operate on behalf of a wider system, rather than their individual organisation. The current policy landscape does not incentivise system leadership, as many national structures emphasise a focus on individual organisations. This study aims to understand how chief executives in the National Health Service (NHS) in England implement system leadership in practice when faced with decisions that benefit the system to the detriment of their own trust.

Methodology Semistructured interviews were conducted with ten chief executives from various NHS trust types to understand their perceptions and decision-making process in practice. Semantic thematic analysis was used to draw out themes in relation to how chief executives approach decisions which weigh up the system and organisation.

Results Interviewees expressed advantages (such as support in managing demand) and disadvantages (such as increased bureaucracy) of system leadership and practical considerations in operationalisation (such as the importance of interpersonal relationships). Interviewees endorsed system leadership in principle, but did not feel that current organisational incentives support the implementation of system leadership in practice. However, this was not seen as a major challenge or impediment to effective leadership.

Conclusion As a specific policy area, a direct focus on systems leadership is not necessarily helpful. Chief executives should be supported to make decisions in a complex environment, without a specific focus on healthcare systems as a unit of operation.

  • health policy
  • health system
  • incentive
  • management
  • regulation

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  • Contributors BG planned the study, conducted the interviews and analysed the findings. MGT undertook a secondary, comparative analysis of the themes. LA supported the development of the findings and the drafting of the paper. CB and AD helped develop the questions and interview approach and overall methodology. The guarantor of the findings is CB.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.