NHS leadership and management

Leadership and Management are two different roles – what is your job, really?

Source: NHE Nov/Dec 19 

Dr Darren Leech, director at NHS Elect

‘Management’ remains a toxic word for the NHS. Managers have long been associated with a bureaucracy that impedes, rather than improves patient care and it is for that reason that many NHS organisations have focused on developing ‘future leaders’, rather than ‘future managers'. Telling everyone in the NHS that they are a leader is likely to cause problems. Not many people are able to clearly explain or differentiate between management and leadership roles, so there’s already plenty of scope for confusion and conflict.

So, what is leadership and what is management? Figure 1 below provides a clear summary, but concisely put, effective management ensures that systems are set up and working safely and efficiently. Management is focused on implementing, organising, measuring and ensuring everyone is clear on their role and contribution toward the task or goal. This is different to the role of leadership, which is more abstract - focused on developing and communicating a vision for the future that is different to the status quo. Leadership is about encouraging and empowering people to take risks and to innovate.

Figure 1. Leadership v Management





Take risk

Reduce risk







Coach / Delegate

Direct / Mentor

Long term

Short term


Structure / Control



Adapted from Handy (1993) and Kotter (2013)

A sizeable proportion of those with responsibility for managing people and services in the NHS were once (and may still be) proficient nurses, doctors, therapists or other clinically trained professionals. These folks were good at a role they originally aspired, studied and trained to do. They were recognised and rewarded (often via an unplanned period of “acting up”) with more senior “leadership” responsibilities.

Once promoted, they often learned how to undertake these new responsibilities through experience, mistakes and good fortune - rarely does the NHS provide such professional development pro-actively, prior to appointment. In addition, the NHS model of delivery remains one in which the patient expects to receive advice and direction from their clinician. The dominance of this ‘medical mindset’ along with a cultural reality that is heavy on regulation and hierarchy, means it’s no surprise that instruction, advice and mentorship are dominant. These management orientated styles remain the preferred professional approach of many senior people in the NHS - as opposed to leadership orientated traits such as coaching and delegating.

This situation poses several challenges and questions. Does the NHS really want senior people to coach and delegate more and if so, will there be some air-cover from regulators whilst ‘future leaders’ test out such skills? Do senior people in the NHS really understand the difference between leadership and management and if so, what is the dominant requirement of today’s day job? In reality, is visionary leadership really required given NHS objectives remain broadly the same - or do NHS organisations need more efficient and effective management?

Perhaps it’s time for the NHS to de-toxify and embrace the word ‘management’. Acknowledging that organisations need both effective management and leadership, the reality is that most senior people promoted from the ranks need to first consolidate their basic management skills and only then, can consider if they want to become a ‘future leader’.

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