The C Formula
for Leadership

Culture: the environment in which leadership happens

Culture is created through everyday behaviour. It is shaped by how colleagues speak to one another, whether questions are welcomed and what happens when someone raises a concern.

Within general practice, the quality of care depends upon more than individual clinical ability. It also depends upon whether reception teams, care coordinators, nurses, pharmacists, doctors and managers feel respected and able to contribute.

At Carlton Group Practice, developing multidisciplinary working has reinforced the importance of creating an environment in which different perspectives are taken seriously. The person coordinating a patient’s care may understand practical barriers that are not visible in a clinical record. A pharmacist may recognise a medicines-related problem that changes the direction of a discussion. A community colleague may identify social difficulties that explain repeated contact with health services.

A healthy culture makes those contributions possible.

It also makes challenge possible. If people feel unable to question decisions, leadership can appear orderly while important problems remain unspoken.

Culture becomes particularly significant when different organisations begin working together. General practice, community services and hospital teams each bring their own history, professional assumptions and ways of making decisions. Bringing them together does not automatically create a shared culture.

That culture has to be developed deliberately through trust, respectful dialogue and a willingness to understand one another.

For me, culture is not a background consideration. It is the foundation upon which the remaining elements of leadership depend.

Compassion: remembering the human experience

Healthcare leadership must remain attentive to the people affected by its decisions.

That includes patients, particularly those living with multiple conditions, deprivation, social isolation or difficulties accessing care. It also includes the professionals attempting to support them while managing increasing workloads and uncertainty.

Compassionate leadership begins with listening. It asks what colleagues are experiencing, what pressures they are carrying and how decisions are likely to affect them in practice.

Compassion does not mean avoiding difficult conversations or accepting poor standards. It means approaching challenge with fairness, dignity and an awareness that professional disagreement can carry an emotional cost.

Across East Staffordshire, discussions about neighbourhood working and organisational change can easily become dominated by structures, responsibilities and competing institutional priorities. Compassion brings the conversation back to a more grounded question:

What will this mean for the patient, and what will it mean for the people expected to deliver their care?

There is another dimension that leaders can overlook. Compassion must also extend towards ourselves.

Leadership often involves absorbing uncertainty, managing disagreement and carrying responsibility that others may not see. When that responsibility becomes relentless, it can affect judgement, relationships and personal wellbeing.

Recognising the need to pause, reflect and recover is not a failure of leadership. It is part of sustaining the capacity to lead responsibly.

Coherence: connecting purpose with action

Coherence means that what we say, what we do and what we ask others to do make sense together.

If we describe neighbourhood care as patient-centred, patients’ needs should shape its design. If we claim to value clinical leadership, practising clinicians must have a meaningful voice in decisions affecting their work. If we speak about collaboration, organisational behaviour must support shared responsibility rather than concentrated control.

When these elements do not align, colleagues notice. Trust can weaken when the language of transformation becomes disconnected from the experience of those expected to deliver it.

Coherence also requires a clear understanding of purpose.

At Carlton Group Practice, that purpose can be expressed simply: improving care for patients through better clinical coordination, stronger multidisciplinary relationships and closer working with community and specialist colleagues.

When considering frailty, complex care or a potential community heart failure service, the starting point should not be which organisation owns the pathway. It should be the needs of the patient and the contribution each professional can make.

Clinical purpose must come before organisational architecture.

Coherence does not require every organisation to have identical priorities. It requires those priorities to connect around a shared understanding of why the work matters.

Without that connection, activity can multiply while meaningful progress remains limited.

Confidence: providing direction without claiming certainty

Leadership requires confidence, particularly when change feels uncomfortable or the route forward is not immediately clear.

However, confidence should not be confused with dominance. A confident leader does not need to have every answer, occupy every position or control every conversation.

The kind of confidence that matters is rooted in clarity of purpose and a willingness to act. It enables a leader to advocate for patients, raise legitimate concerns and support colleagues through uncertainty.

It also creates space for others.

A leader who is secure in their purpose can listen carefully, acknowledge when they are wrong and invite contributions that challenge their original thinking. They understand that another person’s expertise strengthens collective decision-making rather than diminishing their authority.

Confidence is particularly important when leadership emerges from the front line rather than from a formal appointment.

My experience of working across organisational boundaries has reinforced that professional credibility, constructive relationships and a clear clinical purpose can help initiate change even when a formal leadership role is absent.

Nevertheless, confidence must remain connected to legitimate authority, accountability and recognised responsibility.

Informal influence can begin a conversation, but sustainable transformation requires transparent arrangements that enable people to contribute without carrying unrecognised or unsupported responsibility.

Confidence should give a team direction. It should never become a reason to silence the very people whose insight is needed to move forward.

Consistency: building trust over time

Trust is rarely created by a single conversation. It develops when people experience leadership as fair, reliable and predictable over time.

Consistency means returning to the same principles when circumstances become challenging. If we believe in collaboration, that commitment must remain visible when opinions differ. If we value transparency, it cannot disappear when decisions become uncomfortable.

In a changing healthcare system, colleagues need to know that leadership will not shift according to personalities, organisational pressure or immediate convenience.

Consistency also strengthens relationships between organisations.

General practice, community providers, hospitals and commissioners may bring different histories, pressures and priorities. Working together requires repeated evidence that commitments will be honoured, concerns will be heard and shared objectives will remain in view.

However, consistency should not be mistaken for rigidity.

Healthcare transformation is an iterative process. Plans may need to change as evidence develops, feedback emerges or circumstances shift. The ability to adapt is essential.

What should remain stable are the underlying values: fairness, honesty, shared clinical purpose and an unwavering focus on the people receiving care.

Consistent leadership allows others to understand not only what a leader believes, but whether those beliefs remain dependable when tested.

Collaboration: turning shared purpose into shared action

No single organisation can meet the full range of needs experienced by patients and communities.

General practice understands continuity, clinical complexity and the circumstances of registered populations. Community teams bring experience of supporting people outside hospital. Specialist colleagues contribute expertise in particular conditions. Care coordinators help connect services. Voluntary and community organisations often understand the practical and social barriers shaping people’s lives.

Effective leadership recognises that these contributions are complementary.

At Carlton Group Practice, multidisciplinary discussions have shown how much can be achieved when different professionals come together around a shared clinical concern. Developing those foundations into integrated neighbourhood working requires the same principles at a broader scale.

Consider a patient living with heart failure who also experiences frailty, financial difficulty and limited social support.

Their needs cannot be addressed fully through a single consultation or referral. Effective support may require coordinated input from a GP, a community heart failure specialist, a hospital consultant, a pharmacist, a care coordinator and voluntary-sector organisations.

The quality of care depends not only upon the expertise of each professional, but upon how effectively those professionals work together.

However, collaboration is more demanding than simply bringing people into the same room.

It requires trust, clarity about responsibilities and genuine respect for different professional perspectives. It requires an openness to challenge and an understanding that shared leadership does not mean unclear accountability.

It also requires recognition that patients do not experience healthcare in organisational compartments.

Collaboration becomes meaningful when those involved stop asking only what their organisation provides and begin asking what the patient actually needs.

Challenge: creating the courage to question

Leadership cannot improve if it is never questioned.

Challenge is sometimes misunderstood as opposition, disloyalty or unnecessary difficulty. Yet in healthcare, the willingness to ask searching questions is essential to patient safety, sound governance and meaningful change.

The issue is not whether challenge should exist. It is whether organisations know how to handle it constructively.

A team that feels unable to question an assumption, raise a concern or suggest an alternative may appear harmonious. Beneath that appearance, however, there may be uncertainty, frustration and risks that remain unaddressed.

Constructive challenge allows those concerns to enter the conversation before they become larger problems.

For leaders, that means being willing to ask difficult questions:

Are we hearing the people expected to deliver this work? Does the proposed structure reflect the needs of our patients and communities? Are responsibilities clear, and are decisions being made transparently? Have we confused agreement with genuine engagement?

In neighbourhood working, such questions can be uncomfortable. They may expose differences in organisational priorities, unequal influence or assumptions that have gone untested.

However, avoiding those questions rarely strengthens relationships. More often, it allows uncertainty to deepen and trust to weaken.

My experience across East Staffordshire has reinforced that challenge is most valuable when it remains focused on purpose rather than personality.

The intention should not be to embarrass colleagues, win an argument or resist change for its own sake. It should be to improve decisions, widen participation and ensure that patient care remains visible.

Challenge also places responsibilities on the person offering it.

It must be grounded in fairness, professional curiosity and a willingness to listen to the response. A leader who challenges others must also be prepared to have their own assumptions questioned.

That reciprocity matters. Without it, challenge can become criticism delivered in only one direction.

Handled well, constructive challenge is an expression of commitment. It shows that people care enough about the work, the team and the patients involved to ask whether something could be done better.

The strongest leadership cultures do not merely tolerate challenge. They make it safe, purposeful and useful.

The relationship between the seven Cs

These qualities are most useful when considered together.

A positive culture is difficult to sustain without compassion. Compassion becomes less effective when there is no coherent direction. Confidence without collaboration can become dominance. Collaboration without consistency can weaken trust. Consistency without reflection can become inflexibility. Challenge without compassion can become confrontation, while compassion without challenge can allow important problems to remain unaddressed.

Each quality strengthens the others.

A team that feels respected is more willing to contribute. Contributions improve the quality of collective decisions. Constructive challenge tests assumptions and exposes weaknesses before they become embedded. Better decisions strengthen confidence. Consistent follow-through builds trust. Trust makes deeper collaboration possible.

The same relationship works in reverse.

When culture becomes defensive, people may stop raising concerns. Without open discussion, coherence suffers. Confidence becomes concentrated in a small number of voices. Collaboration becomes performative, challenge becomes unwelcome and trust begins to weaken.

The formula matters because it helps us recognise how leadership behaviours interact.

It also offers a practical question when progress appears to stall:

Which of these seven qualities is missing, and what would change if we addressed it?