Leadership and change in health and health services

Leadership is an ambiguous quality. Leaders can be strong and good, strong and bad, weak and good, weak and bad. Leadership is morally neutral but like electricity, it is the power in the wires that lead to the motor of change and development. Was Hitler an effective leader? Indeed. So, too, Martin Luther King. "I have a dream." It may be of heaven, but the path we walk behind our leader may instead lead to hell or most commonly, nowhere at all!

In the immensely complex social system that we refer to as 'health care,' leadership is the sap in the tree of reform. Its branches include organisational restructuring, changes to governance, new ways of funding health care through mixtures of private and public insurance, information system development and the fraught reallocation of resources away from the most expensive, often useless therapies to prevention. In all these activities, where change is needed, leadership is essential to achieve results.

Leadership in health research is often a lonely vigil. Faith in one's ideas drives experimentation in the face of the possibility of failure - in the laboratory, the operating theatre, on the ward or in developing a new administrative or managerial service model.

To lead a health research team requires resilience, a strong belief in the power of science, capacity for political trading with funders, empathy for anxious research subjects and sincere respect for the hope of those desperate for cure. Fail in one or more of those elements of leadership (and many do) and leadership can lose its grip and the research frequently fails to fulfil its promise.

The political efforts of research workers are at times Herculean – read the history of Nobel laureates to see how leadership skills in the political domain are critical alongside scientific prowess in advancing new ideas, research programs and institutes, and in succeeding.

The Harvard Business Review recently published a slim volume entitled HBR's 10 Must Reads on Change. Each essay is written by one or more experienced managers and manager/research academics. The cover blurb says that the book will inspire the reader to "lead change through eight critical stages:

• Establish a sense of urgency;   
• Overcome addiction to the status quo;   
• Mobilise commitment;   
• Silence naysayers;   
• Minimise the pain of change;   
• Concentrate resources; and   
• Motivate change when business is good."

Although not always explicit, each of the essays about change and how to manage it also concerns leadership. None assumes that change will occur without leadership. I suppose that assumption might be contested, but when it comes to deliberate innovative change, the assumption is probably sound. No leader, no go.

In 1991, I attended a seminar for international medical educators offered by the Harvard Medical School. The weeklong program provided insights into Harvard's new medical curriculum, which was built, as many innovative medical education programs are now, on small groups of students engaging in problem-based, multidisciplinary learning. This was a serious break with the traditional lectures and laboratory education of conservative universities. Harvard had imported educational methods from several 'radical' new medical schools including McMaster University in Canada. The international attendees in the seminar were amazed at Harvard's change.

Dan Federman, the charismatic dean of education and an eminent endocrinologist, was chair for the week. He had managed the change to the new curriculum under the deanship of Dan Tosteson. On Wednesday afternoon he ran a session about changing from conservative to innovative curricula. "Hands up all those who have a supportive dean back home," he challenged the group. About one-third sheepishly raised an arm. "Well, for the rest of you, the coffee shop is that way," he said, pointing. "I have nothing further to say to you."

I can't imagine any of the leaders I have known taking on a job without believing that change was important and that they were taking on the leadership mantle to change things. Hence the essay in the Harvard collection I referred to, "A survival guide for leaders," is especially important when thinking about leadership.

"To lead is to live dangerously," Heifetz and Linsky, the two authors of this essay, assert, pointing to the large number of executives who, starting brightly in a new job, soon crash and burn. There is, they say, a dark side to leadership: "The inevitable attempts to take you out of the game."