The NHS is a huge, complex and heterogeneous organisation with the basic function of taking care of patients in primary, secondary or tertiary care, supported by a series of supportive functions which carry with them a number of managerial and leadership roles. Leadership therefore has different facets and aspects which vary according to the organisation or the team one works in. There remain key differences between managers and leaders (also see Chapter 11). To put it simply, managers manage and leaders lead. There is no doubt that in both roles there needs to be a degree of understanding and synergy so that both functions can be carried out. Sometimes these roles overlap and management skills may be embedded in leadership roles. There is a high level of validity to the view that the demands placed on managers in the NHS – be they clinical or non-clinical – are so great that traditional views of management and leadership need to be drastically overhauled if the service is to survive.

What is traditionally referred to as transactional management has been largely consigned to junior managers and administrators. By ‘transactional’, we mean the process-driven managerial activities, such as monitoring performance on a daily basis and the administration of people and their working lives in order to ensure effective performance. That is not to say that these skills are unimportant: they clearly are, but they are no longer the sole domain of today's leaders. The current agenda forces leaders to think in more transformational terms – how the service can be changed to meet the current demands of the population given an ever-decreasing level of resource. This requires individuals to be encouraged to think radically and to have the courage and opportunity to create original solutions, often requiring acknowledgement that they are part of a wider system, beyond the organisation they are working for. Unfortunately, many organisations within the NHS are transactional by nature and as such can be internally focused on short-term measures and fixes which simply delay the inevitable.

Organisational structures and leadership development

The result is ‘organisational compression’, which creates an environment of command and control, micro-management and the inevitable cultural background of stress, resentment and reluctant compliance (see Fig. 30. 1).