The leader as
an enabler

There is a comforting idea in leadership development that, if we read enough, reflect enough and understand the right models, we will eventually discover the type of leader we are meant to be.

Perhaps we are transformational leaders. Perhaps we are collaborative leaders. Perhaps we are decisive, strategic or compassionate. Once we have identified our style, the assumption goes, we simply need to apply it consistently.

Yet the more I reflect on leadership in healthcare, the less convinced I am that leadership can be reduced to a fixed identity or a preferred set of behaviours.

Healthcare does not stand still. Neither do the people working within it, the communities it serves or the pressures shaping its future. If our circumstances are continually changing, then the way we lead must also continue to evolve.

This does not mean abandoning our values. It means learning how to apply those values differently as situations, relationships and challenges develop.

It also means recognising that one of the most important things a leader can do is not to hold all the answers, but to enable other people to contribute theirs.

The only reliable thing is change

Harald Maikisch, an Austrian hospital administrator, offers a deceptively simple observation about his experience of leadership.

The only reliable thing was change.

After more than three decades working in healthcare, he describes a system repeatedly reshaped by rising costs, advances in medicine, changing workforce expectations and increasingly complex organisational demands.

Although his reflections arise from the Austrian healthcare system, the underlying challenges are immediately recognisable within the NHS.

Clinical innovation brings enormous possibilities, but frequently at considerable cost. Patients are living longer, often with multiple long-term conditions. Staff expectations are changing. The pressures on general practice, hospitals and community services continue to intensify. At the same time, organisations are being asked to work across traditional boundaries and develop more integrated approaches to care.

Against that background, it would be unrealistic to assume that the leadership approaches that served us yesterday will automatically meet the demands of tomorrow.

However, Maikisch also challenges the idea that every new problem requires an entirely new philosophy of leadership.

His argument is more nuanced. The essential tools may remain familiar, but leaders must learn how to use them wisely in changing circumstances.

That distinction matters.

Effective leadership is not about reinventing ourselves whenever a new policy appears. It is about developing the judgement to recognise when our established approaches need to be adapted.

Leadership style is not a permanent label

There is value in understanding leadership theories. They give us language for describing behaviour, identifying strengths and recognising potential weaknesses.

But there is also a danger in becoming too attached to a particular label.

A leader who sees themselves exclusively as decisive may fail to notice when a situation requires patient listening. A leader who prides themselves on collaboration may hesitate when clear direction is necessary. A leader who prefers consensus may avoid difficult conversations that ultimately need to take place.

In healthcare, different situations call for different responses.

When a patient is deteriorating, clarity and decisiveness are essential. When a multidisciplinary team is trying to understand a complex patient's needs, the leader may need to step back and create space for others to speak. When organisations are attempting to build trust after difficult discussions, progress may depend less on authority than on patience, consistency and a willingness to hear uncomfortable perspectives.

The challenge is not to choose one leadership style and defend it.

The challenge is to understand what the situation requires without losing sight of who we are.

For me, that distinction is becoming increasingly important.

My underlying principles remain consistent:

• Patients before organisations.
• Clinical purpose before structure.
• Relationships before pathways.
• Collaboration rather than organisational control.
• Distributed rather than concentrated clinical leadership.
• Delivery rather than endless structural discussion.

Those principles provide direction. But they do not dictate that I should behave in exactly the same way in every meeting, every clinical discussion or every organisational negotiation.

A leadership philosophy should be stable enough to guide us, but flexible enough to respond to reality.

The leader who brings people together

One of the strongest themes in Maikisch's reflections is the importance of teamwork.

He describes a hospital employing people from many different professions and national backgrounds. In such an environment, success depends not simply on the quality of individual departments, but on whether people can work together across professional and organisational boundaries.

That observation resonates strongly with the transformation taking place in East Staffordshire.

Neighbourhood health cannot be delivered by general practice alone. Nor can it be delivered by a hospital trust, a community provider or an integrated care board acting independently.

The people who need the greatest support often require contributions from many different parts of the system.

A patient living with heart failure, frailty and social isolation may need coordinated input from a GP, a practice pharmacist, a community nurse, a hospital specialist, a care coordinator and voluntary or community organisations.

Each professional may understand one part of the picture.

The patient experiences all of it.

Leadership, therefore, cannot simply be about deciding which organisation has authority over the others. It must involve creating the conditions in which those different contributions can be brought together around a shared clinical purpose.

This is where the idea of the leader as an enabler becomes particularly important.

An enabling leader does not ask only:

How do I make sure everyone follows my plan?

They also ask:

• What do these people need in order to work well together?
• Whose knowledge are we not yet hearing?
• What is preventing collaboration?
• How can we create the right conditions for better patient care?

That is not passive leadership.

It is a deliberate and demanding form of leadership focused on unlocking the contribution of others.

Enabling does not mean stepping away

There is sometimes a misunderstanding that collaborative or distributed leadership means avoiding responsibility.

It does not.

An enabling leader must still make decisions. They must still establish priorities, maintain accountability and address difficult issues when they arise.

What changes is the understanding that leadership effectiveness cannot be measured solely by how much control one person retains.

In complex healthcare systems, no single individual can possess all the relevant knowledge, relationships and practical experience.

Trying to centralise every decision may create the appearance of control, but it can also slow progress, discourage initiative and distance leadership from the realities of patient care.

The alternative is not a lack of structure.

It is a structure that allows expertise to emerge from the places where it already exists.

A pharmacist may understand the practical barriers to medicines optimisation more clearly than a senior manager. A care coordinator may recognise patterns in patient vulnerability that are invisible within formal reports. A community nurse may identify pressures in a household that no clinical dashboard can capture.

If those insights cannot influence decisions, the organisation becomes less intelligent than the people working within it.

The enabling leader helps connect that intelligence.

They ensure that responsibility is clear, but they do not confuse accountability with the need to dominate every conversation.

What our multidisciplinary teams are already teaching us

My experience at Carlton Group has increasingly reinforced this understanding.

Our multidisciplinary work has shown that meaningful progress often begins when the right people are brought together to discuss a real clinical problem.

The strength of these discussions does not come from everyone holding the same professional perspective. It comes from the fact that they do not.

General practitioners, pharmacists, care coordinators, nurses and community colleagues notice different things. They ask different questions. They bring different forms of knowledge.

When these contributions are properly connected, the resulting understanding of a patient can be far richer than any single professional assessment.

This is particularly relevant as we consider how integrated health teams might function within neighbourhoods.

An integrated health team cannot simply be announced into existence through an organisational chart.

It must grow from working relationships, shared clinical priorities, reliable coordination and an understanding of local population need.

There is a strong case for general practice to provide clinical leadership within such teams, particularly because of its continuity, understanding of patients and connection to the local community.

But primary care leadership should not mean primary care dominance.

A GP chairing a multidisciplinary discussion should not be the person who speaks most. The role should include drawing out the contributions of others, clarifying clinical priorities and ensuring that the patient's needs remain central.

The question is not whether the GP is in charge of every contribution.

The question is whether the team is being enabled to produce a better outcome for the patient.

Why adapting leadership requires self-awareness

Leaders cannot adapt effectively if they do not understand the impact they have on other people.

This is one of the reasons why self-awareness matters so much.

A leader may believe they are providing clarity, while colleagues experience their behaviour as overly controlling. Another may think they are encouraging open discussion, while others remain reluctant to challenge them.

The gap between intention and impact can be significant.

That gap becomes particularly important during periods of organisational change.

People do not experience change only as a new operating model or revised reporting structure. They experience it through uncertainty, workload, professional identity, trust and the behaviour of those around them.

If leaders fail to recognise those human responses, even sensible proposals can generate resistance.

Maikisch suggests that a good manager must combine an understanding of economics, psychology and law.

His description may not translate neatly into every NHS setting, but it identifies an important truth: leadership requires attention to resources, human behaviour and the formal responsibilities that shape organisational life.

Financial sustainability matters. Governance matters. Legal and contractual responsibilities matter.

But those things cannot be treated as substitutes for relationships.

Nor should they distract us from the fundamental question of whether our decisions improve the experience and outcomes of the people we serve.

Understanding the psychology of leadership means noticing when colleagues feel excluded, threatened or unheard. It means recognising when a team needs reassurance and when it needs challenge.

Most importantly, it means being prepared to ask:

Is the way I am leading helping these people contribute, or making it harder for them to do so?

Sometimes leadership means speaking less

As leaders develop, there can be a temptation to assume that influence must always be demonstrated visibly.

We contribute. We challenge. We offer ideas. We try to ensure that important concerns are heard.

There are times when that is necessary.

But there are also moments when the leader's most useful contribution is to create space.

If one person repeatedly dominates the discussion, even with good intentions, others may withdraw. The range of perspectives narrows. Debate becomes organised around the views of the most confident or persistent individual.

An enabling leader must recognise when their own voice is beginning to crowd out the voices they are trying to encourage.

Sometimes the most effective intervention is a carefully chosen question.

Sometimes it is an invitation for someone quieter to contribute.

Sometimes it is the willingness to remain silent long enough for another perspective to emerge.

This does not mean becoming disengaged.

It means recognising that leadership is not always demonstrated by being the most prominent person in the room.

At times, it is demonstrated by helping other people discover that their contribution matters.

Creating a shared purpose without erasing difference

Maikisch also describes the importance of developing a shared identity across teams and departments.

That idea has clear relevance for neighbourhood working, but it needs careful interpretation.

A shared purpose should not require every organisation to surrender its identity or every professional to think in the same way.

General practice, community services, hospitals and voluntary organisations each bring distinct expertise and responsibilities.

The aim is not to make those differences disappear.

It is to connect them around a common purpose.

In East Staffordshire, that purpose must include improving patient outcomes, addressing health inequalities and responding to the different needs of local communities.

The challenges facing more deprived urban populations may not be identical to those experienced in surrounding villages.

An effective neighbourhood model must be able to recognise those differences rather than forcing every community into the same organisational template.

The enabling leader helps bring people together around shared objectives while remaining attentive to local variation.

They understand that collaboration requires both common purpose and respect for difference.

Being willing to do things differently

Another striking element of Maikisch's reflections is his emphasis on not being afraid to take a different approach.

He argues that leaders should observe what others are doing, think carefully, make their own decisions and have the confidence to act differently when circumstances require it.

That does not mean rejecting established wisdom simply for the sake of being unconventional.

Nor does it justify ignoring colleagues or dismissing legitimate governance.

But it does mean recognising that imitation is not the same as leadership.

What works in one locality may not work in another. What appears persuasive in a policy document may be difficult to deliver in practice. What seems organisationally convenient may fail to reflect the needs of patients or clinicians.

Leadership requires the confidence to ask whether the accepted approach is actually the right one.

For me, that question increasingly returns to the relationship between structure and purpose.

Are we designing new arrangements because they will improve care?

Or are we becoming absorbed in organisational architecture while the practical work of collaboration remains underdeveloped?

Sometimes being different means insisting that conversations return to the patient.

Sometimes it means arguing that trusted relationships should come before elaborate pathways.

Sometimes it means demonstrating, through practical work within a practice or multidisciplinary team, that transformation can begin before every structural question has been resolved.

Evolving without losing direction

The longer I reflect on leadership, the less I believe the aim is to arrive at a final, settled style.

Leadership development is not the process of becoming a fixed type of person.

It is the process of becoming more aware of our values, more honest about our limitations and more capable of adapting to the needs of others.

There will be times when leadership requires decisiveness.

There will be times when it requires patience.

There will be times when it requires challenge, and times when it requires listening.

But across all those situations, one principle increasingly stands out.

The role of a leader is not simply to direct activity from above.

It is to help people work together in ways that make better outcomes possible.

Within healthcare, that means bringing professions, organisations and communities together without allowing structures, hierarchy or institutional interests to displace the patient.

It means understanding that the best ideas may emerge from unexpected places.

It means recognising that people closest to the work often understand most clearly what needs to change.

And it means accepting that leadership itself must remain open to change.

Perhaps the real test is not whether a leader can demonstrate that they are in control.

Perhaps it is whether the people around them are better able to contribute, collaborate and improve care because of the way they lead.