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Editor's blog 23 April 2009: Leading from the front, or from well behind the lines?

Leadership is one of those qualities that are hard to analyse. It is hard to define but very easy to feel.

Leadership is so often conceptualised in military terms. Put simply, you couldn’t run an army without severely hierarchical command-and-control structures, where deference to authority is beaten into trainees hard. People know and are well-trained in their jobs, and know who will be  making the decisions.

One of the best quotes about leadership in military terms may well be apocryphal, but we can only hope it isn’t. It is from a report on a trainee officer, and reads, “this officer’s men platoon will follow him anywhere, if only out of curiosity”.

Wonderfully wry. And the announcement of the new NHS Leadership Council by the Department of Health gives a fascinating ionsight into how leadership is seen by the Powers That Be.

Basically, if you are a front-line clinician, you are not in the ambit. Leadership is the purlieu of FT chief executives and SHA chief executives, it seems.

COI declaration (repeated) – I’m doing some press work for NHS Alliance, and have helped them put something together on this. But I like to think I would anyway have noticed that although there are 152 PCTs in England and around 23,000 GPs, the National Leadership Council has just two ‘core members’ from primary care: one PCT chief executive and one associate director. Its ‘fellows’ include one PCT chair. The token GP is Royal College of GPs chair Professor Steve Field. He is a good guy, but a primary care-led NHS this ain’t.

By contrast, the NHS’s 117 foundation trusts provide eight of the National Leadership Council: seven chief executives and one chair. The 10 intermediate strategic health authorities provide another three chief executives and one chair.

In financially straitened times, primary care’s role as the risk-sink of the NHS is more important than ever. If we are at all serious about world-class commissioning (and this is far from certain), then the leadership role in primary care, for both clinicians and managers, is enormous. The penny has failed to drop at the top level of the DH to a disturbing if not wholly surprising extent.

The NHS is not the army. Imagine an army with a lieutenant and sergeant class who are highly educated at enormous expense and who enjoyed very high levels of public trust. Conventional leadership would not manage such an army.

In the messy and uncertain world of primary care – which is where 90% of the NHS’s work is done, and which policy wants to do even more – distributed leadership is required throughout. What has been created is an old-school, ‘programme for top people’ project. If commissioning is ever to start to bite, even with milk teeth, signals like this suggest alarming top-level misunderstanding of what is needed.

Not just William Shakespeare’s birthday - Andrew Roth at 90
Some of you may know that from 2000-2008, I edited British Journal of Healthcare Management. I will today be going to the 90th birthday celebration lunch of the excellent Andrew Roth, whose Parliamentary Profiles and Westminster Confidential are among the best resources on politics. He was the parliamentary columnist for the magazine.

A columnist needs a few things: context, wit and the ability to make connections that give the reader a ‘yes, that’s right!’ moment. Andrew Roth was a joy to publish. Happy Birthday, Mr Roth.