Systems Leadership: how Chief Executives manage tension between organisation and system pressures

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ABSTRACT 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. It is not clear to what extent the current policy landscape supports leaders in managing misalignment between the needs of their organisation and the wider system, as many national structures still emphasise a focus on individual organisations. This study aims to understand how Chief Executives implement system leadership in practice when faced with decisions that benefit the system to the detriment of their own trust. Methodology Semi-structured interviews were conducted with ten Chief Executives from a range of 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 Themes raised by interviewees included both 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 the organisational incentives as currently structured support the implementation of system leadership in practice. 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.

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