How the ‘biggest shift the NHS needs’ – more participative, architect-style leaders – can increase NHS performance by 10%

A top NHS improvement leader recently shared his view that ‘the biggest shift we need to see’ is away from the heroic problem-solving NHS leaders we see today towards problem-framing architect-style leaders, who create the right environment for others to solve NHS problems.
I investigate the impacts such a shift in leadership style could have – and suggest two proven (yet so far largely overlooked) ways we could choose to quickly help this crucial shift to happen.

Dr Amar Shah is a Consultant Forensic Psychiatrist and the National Clinical Director for improvement: the person with “the role of trying to help the whole NHS in England adopt improvement in a more systematic and rigorous way”, as he puts it.

Dr Amar Shah

It was a pleasant surprise when his closing keynote at a recent online NHS conference (#QIWeek) went beyond the kinds of NHS challenges you might expect to hear at an event this like this: falling productivity, funding constraints, staff burnout, backlogs, winter pressures, digital transformation, health inequalities and the coming NHS 10-year plan.

I think the mindset of how we solve problems in the NHS is the biggest thing we have to shift
– Dr. Amar Shah

Instead he strongly singled out the NHS’s urgent need to allow a new kind of leadership to emerge: “I think the mindset of how we solve problems in the NHS is the biggest thing we have to shift.”

Seeing a problem, finding a solution and implementing it is completely the wrong mindset for leading a continuous improvement organisation
– Dr. Amar Shah

“Ultimately people will rise up through the ranks because they’re extraordinarily good problem-solvers and they are very used to sort of seeing a problem, finding a solution and implementing it. And actually that is completely the wrong mindset for leading a continuous improvement organisation”, explains Dr Shah.

“You then need to see your role as problem-framing and creating the environment for others to solve problems. That's the shift: unlearning that you are the source of the solution and learning that you are the ultimate architect of the environment, in which others can solve problems. That, for me, that is the biggest shift we need to see.”

That's the shift: unlearning that you are the source of the solution and learning that you are the ultimate architect of the environment, in which others can solve problems
– Dr Amar Shah

Of course, Dr Shah isn’t alone in noticing this need for a more enabling and participative – less directive – form of leadership. For example, back in 2011 The King’s Fund published The Future of Leadership and Management in the NHS: No More Heroes – with a call to move from ‘heroic’ leadership to shared leadership.

And Prof Michael West and others have researched and written about how “dominant, hierarchical and top-down approaches to leadership are the the least effective ways of managing healthcare organisations”.

The 2021 book Systems Convening – a crucial form of leadership for the 21^st century (free pdf) similarly identifies the growing importance of a new type of humble and enabling leadership that works across traditional silos and boundaries to create novel spaces that enable learning and change. The book includes plenty of case studies of these NHS ‘Systems Conveners’. (I don’t seem to need too much of an excuse to gently drop in at this point that it was me who asked Bev and Etienne Wenger-Trayner to write the book).

In Education, it’s only the ‘Architect’ leaders who are successful in transforming their schools – yet they are the least recognised and least appointed. What lessons for the NHS?
Influential research – published in Harvard Business Review a few years ago – found that UK schools have in fact been appointing, rewarding and recognising precisely the wrong kind of leaders.
(NB I reach across to learn from Education, as the research I describe below seems spot-on about the architect-style leaders that Dr Shah argues the NHS so urgently needs to see more of).

This study of 411 school leaders, over seven years, uncovered that only one of the five types of leader they found – the ‘Architect’ – was ‘truly effective’. But these ‘Architects’ were the least well-known, the least rewarded and least recognised.

By contrast, the study found that it was the 38% of ultimately ineffective ‘Surgeon’ type leaders who were the ones who would get knighted by the Queen – and were typically paid 50% more than other leaders too!

Yet ‘Surgeons’ only actually excelled at short-term quick-fixes – focusing on how to drive improvement in that year’s exam results (through moves like shifting the best teachers to the final year, ignoring the younger students, cutting ‘non-essential’ activities, removing poor performing students etc).

Exam results do improve dramatically – at least at first. These leaders enjoy ‘winning’. But the positive results don’t last, and soon fall back to where they were, when the effects of lack of investment in all the other parts of the school come to fruition.

It seems to be strangely hard for everyone to see these ‘Surgeon’ leaders for what they really are: “expensive cutters (not transformational leaders) who reduce the school’s social impact and create long-term issues”.

‘Architects quietly redesign the school and transform the community it serves’
– Hill, Mellon, Laker and Goddard in Harvard Business Review

‘Architects’ – by contrast – “quietly redesign the school and transform the community it serves”, write the researchers.

“They take a holistic, 360-degree view of the school, its stakeholders, the community it serves, and its role in society”.

‘They are visionary, unsung heroes. Stewards, rather than leaders, who are more concerned with the legacy they leave than how things look whilst they’re there’
– Hill, Mellon, Laker and Goddard in Harvard Business Review

They are ‘insightful, humble and visionary’ leaders who take a long-term view of what they need to achieve.

“They are visionary, unsung heroes. Stewards, rather than leaders, who are more concerned with the legacy they leave than how things look whilst they’re there”.

As one ‘Architect’ leader put it: ‘No-one should notice when I leave the room’.

As one such ‘Architect’ leader put it: “No-one should notice when I leave the room”.

As mentioned, they are also paid far less than ‘Surgeons’ too: £86k on average, compared to £154k for ‘Surgeons’ (or £205k inflation-adjusted for 2024!).

Health Secretary Wes Streeting just announced his big NHS reforms will involve paying more to those NHS leaders who can ‘drive up performance’, complete with New Labour-style league tables to name and shame the struggling NHS trusts. Will this approach grow the number of ‘Architect’ leaders across the NHS?

James Titcombe

Though clearly steps that improve performance and increase patient safety are much needed, James Titcombe – who lost his nine-day-old son in the Morecambe Bay NHS scandal – adds (in a 13/11/24 Linkedin post) that “However, a clear lesson from history is that we need a healthcare system that incentivises senior NHS leaders to ‘problem sense’ and be open & transparent about issues affecting patient care. The danger with league tables and a top-down punitive approach to performance management is that it can create a culture where leaders only want to hear and report ‘good news’ and ultimately patient safety suffers as a consequence”.

“This was a major lesson from scandals such as Mid-Staffordshire [where between 400-1,200 patients died unnecessarily] – and we must avoid making the same mistake again”.

(Note: despite certain appearances, I’m pretty sure these leader types aren’t rigidly separate boxes. If the NHS reward system were changed, the behaviours of other leader types would be unblocked.)

And the long-term ‘Architects’ risk being fired
One particular peril – for ‘Architects’ – of taking their long-term (and ultimately successful!) approach is that 90% of them are almost fired at the end of their second year, as exam results aren’t improving fast enough. They are spending “most of their initial time and energy engaging with the local community and building the right environment within the school”.

School governors give them one year’s grace – and see exam results improving in the leader’s third year, and continuing to improve long after they’ve left.

“The problem is that [improved exam results] don’t happen for at least three years, if you’re making the right long-term improvements. This year’s exam results are actually an outcome of decisions three to five years ago – before the new head arrived”.

Ironically, it can then take schools up to four years to recover from the effects of the much-heralded ‘Surgeon’ Superheads, with up to just over £2m being paid to consultants ‘to help clear up the mess’ they’ve left behind.

‘Although they talk passionately about the importance of good teaching and get everyone excited, they don’t actually change anything and their schools either coast or decline
– Hill, Mellon, Laker and Goddard in Harvard Business Review

The research also goes into the other types of leaders commonly found leading schools: the ‘Philosophers’ are the most publicly recognised, with 43% being appointed as national leaders of Education, who then go on to establish best practice and guide other leaders. This despite them being the worst performing leaders in the whole study: “Although they talk passionately about the importance of good teaching and get everyone excited, they don’t actually change anything and their schools either coast or decline”.

It’s really for people working inside the NHS to judge whether there are parallels with what this research found in Education: showy leaders who make a short-term positive impact being rewarded rather than the humbler long-term-orientated ‘Architect’ leaders who slowly build up what’s needed, changing the organisational environment as well as engaging deeply with the community.

Are the ‘Surgeon’ tricks that boost a school’s exam results similar to the (initially) seemingly positive story around productivity during the decade of austerity? As the new IPPR report, From the Frontline, explains, NHS spending was diverted away from repairs, buildings and technology – with productivity at that point exceeding the other public services. The longer-term harm of this underinvestment would only become clear later: almost half of all English hospitals have closed wards or services due to maintenance issues since 2020, damaging productivity. (Do you think there are parallels in healthcare with the ‘Surgeon’ and ‘Architect’ leader behaviours seen in Education? Add a comment below.)

It certainly seems to me that Dr Shah’s call for a shift to more ‘Architect’-style leaders in the NHS is underlined by seeing how education ‘Architect’ leaders’ long-term approach transforms the community around them to enable a much deeper impact. Health Secretary Wes Streeting’s three calls – for a shift from hospital to community care, from sickness to prevention and for digital transformation – all feel like they invite (or even demand) the Architect’s more participatory, systemic, long-term approach.

How boosting the number of ‘Architect’ leaders would increase the sector’s performance by almost 10%
The impact on exam results of ‘Architect’ leaders is 15-23% higher than all the other types of leaders.

Making ‘Architects’ 50% of all school leaders would increase the UK’s schools performance by 9.68%

Interestingly, the research also estimates that if an effort was made to find and develop more ‘Architect’ leaders – making them 50% of all schools leaders – it “would increase the UK’s schools performance by 9.68%”.

Imagine what such an increase in performance of approaching 10% could mean if it took place across the NHS! (To give some rough idea, this figure might crudely translate into 36 million more GP appointments every year, and 1 million more operations).

Especially at a time when NHS performance seems to be going in the opposite direction: the hospital workforce increased by 17% between 2019 and 2023, yet productivity is at least 11.4% lower than it was in 2019. (Writing in IPPR’s new From the Frontline report, Annie Williamson and Parth Patel estimate that this fall-off in productivity amounts to a loss of £19 billion worth of additional care).

Let’s look now at how exactly we might achieve the goal of finding and developing far more ‘Architect’ leaders inside the NHS. To me this feels feasible, yet remains largely untried…

Proven ways the NHS can recruit and develop the ‘Architect’ type leaders it most needs
The development of these kinds of Architect-type leaders has been a focus of research and practice for some decades now.

Though the specific ‘Architect’, ‘Surgeon’, ‘Philosopher’, ‘Soldier’ and ‘Accountant’ leader labels are unique to this particular Education-focused research, long-established research into leadership growth/maturity has developed ways to recognise the humbler and more participative leaders who excel at successfully transforming their organisations (by listening to all stakeholders and questioning assumptions rather than driving their own solution). They have more recently been given the label ‘Transforming’ leaders (though an influential 2005 Harvard Business Review article about leadership maturity – ‘The Seven Transformations of Leadership’ – used an older label, the ’Strategist’).

One key study within this research, published in Leadership & Organization Development Journal, found a strong positive relationship with leadership effectiveness as leaders move towards being ‘Transforming/Architects’.
This includes in crucial capabilities like: leading change, thinking strategically about the future, creating a compelling vision, ability to challenge the status quo and emotional balance. It used 360-feedback – from superiors, peers and subordinates – to ensure a more comprehensive and grounded view of leader behaviour.

(NB I focus on Prof. Torbert et al’s leadership maturity approach as it shows a full range of seven-plus overarching lifetime shifts a leader can make, and what we might do to enable them. Other research – eg drawn from the Multifactor Leadership Questionnaire/Full Range Leadership theory – feels more limiting, as it just offers Transformational vs Transactional vs Laissez-faire. Though it still generally lends good support to what I discuss here, as it finds that Transformational leadership in healthcare is more effective than the other styles).

There has been a call – in Education – for the tracking of these leadership maturity shifts towards the ‘Transforming/Architect’ leader, as well as for seeking to understand what interventions best enable such shifts (see articles by Neil Gilbride and colleagues here and here).

The NHS is in fact already further ahead in trying to track these kinds of shifts in leaders.

One healthcare organisation that has strongly focused on how NHS leaders can shift towards being ‘Transforming’ leaders is the Faculty of Medical Leadership and Management (FMLM), the key UK organisation that trains and supports Clinical Leaders.

The developing leaders who join FMLM’s main Clinical Leadership programme, ‘Tomorrow’s Strategic Leader’ (developed in conjunction with the Royal College of Surgeons), are assessed before and after the programme to track their mindset shifts, from the ‘Surgeon’ type top-down mindset (eg ‘Experts/Technicians’ and ‘Achievers’) towards the enabling ‘Architect’ mindset – ‘Transforming’. Almost all participants showed significant progression. (And, yes, I have recently had to explain to a Surgeon that the ‘Surgeon’ type leader label isn’t aiming to describe actual surgeons!).

It can be argued that training and expectations of doctors and the target drive culture of healthcare systems favour the expert and the achiever
– Faculty of Medical Leadership and Management (FMLM)

A 2021 article in BMJ Leader – ‘Evaluating the impact of a national strategic leader development programme for UK doctors: myth-busting, mind-changing, mood-enhancing’ – shares some of what FMLM has learnt, and warns: “It can be argued that training and expectations of doctors and the target drive culture of healthcare systems favour the expert and the achiever” – which sounds like exactly the problem we saw that Education has, of mostly recruiting and rewarding leaders like the less effective, short-term-oriented ‘Surgeons’.

The NHS could – without too much difficulty or cost – copy what FMLM’s ‘Tomorrow’s Strategic Leader’ programme does: assess participants’ leadership maturity before and after on all its key leadership courses. Are these current programmes – and the many millions spent on them – actually helping NHS staff to grow into being effective longer-term ‘Architect’ style leaders, or not?

It’s not only leadership training programmes in their entirety that can be looked at: probing the Architect-inducing effects of the different constituent elements within a single leadership programme would be immensely valuable for helping us understand what practices and content have the strongest impact on catalysing moves from a ‘Surgeon’ to an ‘Architect’ mindset, for example.

Of course the kind of optional modules, control groups etc that would enable this more granular exploration are not always going to be available. But they are sometimes there: this 2021 US article – ‘The Impact of Graduate Education on the Mental Complexity of Mid-Career Military Officers’ – for example, tracks shifts over a leadership course for military leaders.

And it includes ‘control’ groups which did not undertake certain aspects of course. This makes it possible to identify which specific elements of the course are having an impact on enabling shifts to Architect-style leadership. (Interestingly, the programme used a tool called ‘Immunity to Change’ to help enable inner psychological shifts. This is the very same tool that was once added to the ‘Top Management Programme’ for UK public sector leaders (at the UK’s National School of Government) when it became clear that interest in systems thinking/systems change was almost ubiquitous, yet almost no-one was actually willing to take the risks to make such changes. The programme clearly needed to include some activity that could specifically catalyse an inner leadership maturity shift: ‘Immunity to Change’ was chosen. Prof Jake Chapman – author of System Failure – Why governments must learn to think differently – then (in a similar vein to FMLM) did before-and-after assessment of leadership maturity and saw that significant shifts towards Architect/Transforming leader mindsets were now taking place).

If we want to see that 10% increase in performance in the NHS – by boosting the proportion of ‘Architect’ leaders to 50% of leaders – the relatively simple step of bringing in a common before-and-after assessment of leadership mindset is an easy way to begin seeing our progress. Without it we’re essentially ‘flying blind’. Not that there aren’t plenty of leadership programme evaluations already taking place – just not ones that are common right across all major NHS leadership programmes and which specifically identify the shifts taking place towards Transforming/Architect leadership. My proposal here invites all these programme evaluations to include this single common yardstick, alongside whatever bespoke elements are relevant in each case.

But it must be admitted that relying solely on leadership development work to grow ‘Architect’ type leaders could prove to be quite a slog: many years of work. The respected leadership maturity expect, Prof Bill Torbert, estimates that it commonly takes around 10 years to go through the leadership transformations required to become a ‘Transforming/Architect’ type of leader. This is exacerbated by the fact that no widespread call has actually gone out from organisations stating that they are now seeking out such ‘Architect/Transforming’ leaders. (Bill also once told me – while being interviewed for the report Anti Hero – that no-one seems to progress to become a ‘Transforming/Architect’ leader without making real use of participative practices with their teams, day in day out. The 33 Liberating Structures feel like a good example of such practices, and the name was itself actually borrowed from Torbert’s own work, though I’m not sure if he knows this. But this proposed pre-requisite for becoming a ‘Transforming’ leader – that Torbert tantalisingly identifies – is a discussion for another day…).

The 33 Liberating Structures

Luckily, however, there is second – complementary – step that can be tried in parallel with developing leaders – and might well prove the quicker and easier of the two: simply find those ones that are already out there by recruiting the ‘Transforming/Architect’ leaders that appear in the candidate pool when vacancies come up.

Why wait? How to identify the ‘Architects’ when new NHS leaders are being recruited
When the then Kent County Council Chief Executive Sir Mike Pitt saw how powerful the widespread understanding of leadership maturity/mindset was proving to be at moving his council towards becoming an innovation-friendly ‘Learning Organisation’, he arranged for Kent’s top 120 leaders all to undertake such a leadership mindset assessment, and be offered transformative coaching support too. (He later received a knighthood in recognition of the transformation of the council he enabled in Kent).

When Mike moved on to become an interim Chief Executive – to try to turn around struggling Swindon Borough Council – he chose to make sure that a leadership maturity/mindset assessment was used to ensure they were – hopefully! –  able to spot a ‘Transforming/Architect’ Chief Executive as his successor. Sure enough, a single ‘Transforming/Architect’ did appear amongst the final few candidates, so was recruited.

Predictably, this new Swindon Borough Council Chief Executive, Gavin Jones, soon undertook many pioneering actions, including recruiting two visionary leaders to the Board and enabling the innovative experiment that would see Hilary Cottam invited in to help develop the inspiring ‘Troubled Families’ work (called ‘Life’, in Swindon). It was so effective that it would later be rolled out nationally. (It forms the first case study in Cottam’s influential book Radical Help – how we can remake the relationships between us and revolutionise the welfare state).

Ironically – and perhaps all too predictably? – this later national roll-out was not done using an Architect’s long-term mindset. Instead it was led by the usual political pressure for fast results (ie the kind of atmosphere that demands and appoints ‘Surgeons’). So the results were disappointing. Working effectively with families – as with schools – requires time.

Another timely use of such mindset assessment has emerged from research with Nurse leaders, done by Dr Bonnie Pierce, a US Associate Director for Patient Care/Nurse Executive. It turns out that mindsets also appear to have a major determining impact on whether leaders can effectively encourage speaking up (about poor patient care etc) within their organisations, or not. She found that one of the most common conventional healthcare mindsets would put the onus on the individual staff members to speak up, and only really want to hear about successes. If staff don’t speak up, the failure is theirs. But this can shift towards the ‘Transforming/Architect’ mindset and instead make strong efforts to create a pervasive culture and system for candidly speaking up, even if the Nurse is speaking up over the objections of their manager.

Dr Pierce concluded that the same kind of leadership maturity assessment as used in Swindon, Kent and by FMLM and the National School of Government needs to become a risk management strategy in Nursing in order to enable a widespread culture of speaking up, and not have it fatally undermined by leaders who largely lack the capacity for it.

And can the funders/commissioners/Ministers avoid the need for their own transformation?
Other research has found that philanthropic funders with the more commonplace leadership mindsets are caught up in a dominant narrative that focuses on changing others. They use self-reflection and feedback only to confirm their own existing viewpoints.

Yet, as philanthropists/funders grow towards the ‘Architect/Transforming’ mindset, they start to really want to challenge their own assumptions. They realise that the philanthropic leader, and the funding staff, can themselves also grow too – not only the recipients of funding outside the organisation.

In her article on this topic in Nonprofit Management and Leadership, Prof Jennifer Jones discusses how a truly generative Board – such as the NHS’s Board perhaps? – is likely to need at least one member with an ‘Architect/Transforming’ mindset, to enable this bigger vision to emerge.

Might ‘Architect’ leaders help bring in the relational, strengths-based ‘Liberated Public Services’ that could save £22bn (same as the UK’s budget ‘black hole’)?
It’s already pretty clear how current commissioning/funding and evaluation approaches far too often undermine a system-aware, long-term, approach – meaning that they stymie the very new services that enable the more preventative and community-led healthcare we’re trying to move towards. My 2023 Substack post ‘The possibility of autonomous Buurtzorg care teams across the UK: tantalising hope vs organisational rigidity’ showed how these pioneering services – including Neighbourhood Midwives and Wellbeing Teams – are curtailed by these current limiting cultures and funding structures.

Buurtzorg nurses team in Tower Hamlets

At least one leader with the ‘Architect/Transforming’ mindset might well be needed on the NHS Board, to really succeed in the work of removing such obstacles. (How many does it have now?)

It is not always necessary for the chief executive to be post-conventional but it is important that they develop or recruit this capacity or give more time and space for those who demonstrate post-conventional behaviour
– Flying High, Society of Local Authority Chief Executives and Senior Managers

Useful advice around this senior leadership topic appeared in a report called Flying High - a new look at local government leadership, transformation and the power of conversation from the Local Government leaders organisation SOLACE (Society of Local Authority Chief Executives and Senior Managers): “An important step for chief executives is to be aware of their own leadership ‘maturity’, especially if they want to transform their organisation… It is not always necessary for the chief executive to be post-conventional but it is important that they develop or recruit this capacity or give more time and space for those who demonstrate post-conventional behaviour. This is sometimes difficult, as quite often post-conventional individuals, by their very nature, will be challenging, disturbing of the status quo and more likely to be seen as ‘mavericks’.”

This is sometimes difficult, as quite often post-conventional individuals, by their very nature, will be challenging, disturbing of the status quo and more likely to be seen as ‘mavericks’
– Flying High, Society of Local Authority Chief Executives and Senior Managers

The report conveys well what a Chief Executive might begin to see – both in themselves and in their organisation – when a move towards the ‘Transforming/Architect’ zone is taking place: “Firstly, you might look at yourself and your own feelings. You might find yourself seeking less credit and recognition for what goes on and feeling less envious of the accolades showered on those around you. You will be less driven by ego, the limelight or the desire to be seen as a heroic leader. Everything you do will be designed to support and empower others; people leaving your office will feel trusted, able to take risks and responsibility, experiment with new ideas and do so without fear of failure. When things do go wrong you will relax and see them as opportunities for learning. You will not feel the need to know about everything that is going on.”

You might find yourself seeking less credit and recognition for what goes on and feeling less envious of the accolades showered on those around you
– Flying High, Society of Local Authority Chief Executives and Senior Managers

“Secondly, you might look to the behaviours of people throughout the organisation as a whole. They will think their jobs are exciting and your council is a great place to work. They will surprise and delight you, trying new ideas without seeking formal approval; even breaking the rules to speed up or increase the chances of achieving an important outcome. High priority will be given to customer care and front line services. Your council will also be easy to work with and will empower other organisations, giving them the credit for shared successes ... and so it goes on.”

Human Learning Systems homepage - impressive case studies.

Currently there is a Human Learning Systems movement that is doing sterling work in trying to both popularise – and make sense of – these emerging ‘Liberated Public Services’ – such as Wellbeing Teams and Buurtzorg Neighbourhood Care – that are doing this pioneering relational work (see their impressive collection of case studies). It also focuses on the convening/Steward type of leadership – seen in the ‘Transforming/Architects’. (It’s huge task they’ve set themselves – basically to help unravel our the now failing and costly era of ‘Markets, Managers and Measurement’, known as ‘New Public Management’, that was first championed under Thatcher and Blair). Funnelling everyone through transactional, step-by-step processes too often makes things worse, as Joseph Badman recently wrote about on Linkedin here).

Both NHS Chief Executive Amanda Pritchard and Health Secretary Wes Streeting have, though, praised one inspiring new community/relational/strengths-based approach – called ‘Community Appointment Days’. These days break down traditional barriers, guaranteeing everyone a 'what matters to you?' conversation with an musculo-skeletal therapist, but also bring in a wide range of other specialist community services to connect them to, if needed.

A Community Appointment Day

But – despite talk of the need for ‘reform’ – they don’t yet appear, to me, to take the next step of recognising that Community Appointment Days could in fact open the door to a truly new relational national model for services, that is sorely needed. A ‘Transforming/Architect’ leader, one hopes, would perceive this long-term shift, see the community-building and strengths-based aspects and the move away from the traditional top-down ‘Medical model’ etc. A ‘Surgeon’ will likely just latch onto the big cuts in waiting lists these Community Appointment Days also enable, and overlook the opportunity for a far deeper, long-term positive shift.

An internal NHS organisational design proposal – missed opportunity to legitimise ‘Architect’ leaders?
Before I finish, I’ll make a brief foray into an NHS internal structure discussion of the kind that few of us would usually hear about (it was certainly a first for me!). But there’s a good reason to mention it: the idea being proposed might just have led to the deliberate restructuring of the entire NHS in a way that would’ve optimised it not just for people with ‘Transforming/Architect’ mindsets, but for other mindsets too. I know you’re probably thinking that sounds rather unlikely, but let me explain…

It will surprise most people to learn that, for five or six decades at least, there’s actually been a model in use (around the globe) of how to structure our organisations which is grounded in an understanding of the kinds of mindsets we’ve been hearing about – in particular their increasingly long-term ‘time horizons’. It aims to enable each such mindset to do its best work.

The approach has been around so long that it’s been known by a number of different names. For example ‘Stratified Systems Theory’, ‘Levels of Work’ and ‘Requisite Organisation’. It was developed Dr Elliot Jaques (best known for coining the term ‘Midlife crisis’) with others.

The optimised organisation design it describes aims to remove the dysfunctions, misalignments and unnecessary layers that plague our organisations. ‘Non-Requisite’ organisations are beset with problems like unclear accountabilities, weak productivity etc – challenges that Lord Darzi highlighted in his recent critical survey of the state of the NHS. This leads to a huge amount of waste and unnecessary cost.

I was certainly surprised to learn that, in 2009, Clare Moriarty MBE, then a top Department of Health Civil Servant, had been asked to write an internal proposal for exactly such a ‘Requisite’ redesign of our NHS. Would this have transformed productivity in the NHS, as it has in other organisations? Freed up people’s potential and enabled work to thrive over longer ‘time horizons’ than usual? We’ll never know, as no such redesign ultimately took place. But the creation of an NHS structure that truly liberates all the different mindsets to fulfil their potential – not feel ‘in over their heads’ or that their best work is being held back – is surely the real foundation needed for enduring growth in productivity and effectiveness, rather than relying on things like the latest technological fixes.

So a ‘Requisite’ organisation design approach in the NHS would aim to remove misalignments, opaque accountabilities, bunched together organisational layers etc. For example, in non-Requisite organisations, an individual with more leadership maturity/a longer ‘time horizon’ may well find themselves misaligned to their manager, and will then sometimes be “seen as a threat, held back or disparaged” by their manager (to quote from the book It’s All About Work – Organizing Your Company to Get Work Done). Managers taking credit for what goes right and blaming subordinates for what goes wrong also often occurs when managers are ‘in over their heads’ due to the organisation not being Requisitely structured. This destroys creativity and innovation.

Of course it doesn’t matter if some future truly enabling, Architect-friendly NHS organisational structure is specifically a ‘Requisite’ hierarchy or not – and I’d certainly myself happily see a far wider spread of autonomous/self-managed teams in the NHS, and beyond, too. (So far I think I’m managing to keep my balance whilst simultaneously admiring both a hierarchical approach – Requsite – and a non-hierarchical one – self-managed teams – at the same time!).

Final thoughts
Participative ‘Architect’ leaders would be likely to transform the NHS, whether they specifically lead to that overall 10% increase in performance – calculated for Education – or not. As mentioned above, speaking up about poor patient care would likely be catalysed by such leaders, with a whole range of other improvements sure to follow. (For example, research by Dr. Julie Donnelly also found that the effectiveness of young physicians correlates with the maturation of their leadership mindsets towards ‘Transforming/Architect’; other research even found that it correlates with better preventative self-care amongst older adults).

The two enabling methods for new leadership I’ve proposed – ie prioritising leadership training approaches and programmes that are proven to successfully grow the participative ‘Architect’ style of leadership and simply recruiting many more of the ‘Architects’ who are already at large – are both simple(-ish) tweaks that could have huge positive knock-on impacts. Certainly they would be a misiscule fraction of the cost of an NHS technology failure like the National Programme for IT, abandoned at a cost of over £10 billion (see From the Frontline).

Research in the Journal of Organisational Behaviour has – perhaps unsurprisingly, given what we’ve been hearing – simiarly found that the leadership growth from ‘Expert’/‘Surgeon’ to ‘Architect’/’Transforming’ is correlated with the ability to successfully achieve a shift in one’s personal ‘paradigm’ (ie our personal system of controlling assumptions, expectations, feelings, beliefs, values etc). These ‘Architects’ “were able to more closely examine the personal philosophies, assumptions and beliefs that they had lived by and were beginning to alter and experiment with them.”

If that kind of deeper transformation is what we want to see, why wait any longer to start using methods that can realise this much-needed leadership?

Perhaps there’s somehow some semi-conscious hesitancy that novel types of responsive, relational, system-aware services that the ‘Architects’ might tend to catalyse could somehow be very costly to create, compared to today’s ‘efficient’ transactional step-by-step processes, fixed care packages etc?

Stick with the ‘expensive cutter’ Surgeon leaders, who will chop waiting lists down in double-quick time?

The Human Learning Systems intro video offers a visual explanation of why today’s transactional services end up being such an expensive way to help people

Yet such financial fears seem mistaken: a 2014 Locality/Vanguard research report – ‘Saving money by doing the right thing’ – that studied existing successful examples of relational services found that they would actually save £22bn (inflation adjusted for 2024) if enabled to spread nationally: a huge figure that is the same as the UK’s current budget ‘black hole’! [STOP PRESS: the day after I published this post, Prof Toby Lowe shared his newly-calculated figure that is significantly larger: £37bn that would be saved UK-wide if the Liberated Services/Human Learning Systems approach was used].

A 2014 Locality/Vanguard research report – ‘Saving money by doing the right thing’ found that relational services would actually save £22bn (inflation adjusted for 2024) if enabled to spread nationally: a huge figure that is the same as the UK’s current budget ‘black hole’!

How could such savings – in the billions – ever be possible, you might well ask?

It turns out that transactional, process-heavy, siloed services – that can’t flex to individual needs – end up hugely costly, as they so very often fail to solve people’s actual problems, fail to ‘get it right first time’ (especially when problems are complex and human rather than simpler and merely technical). This bloated ‘failure demand’ – unresolved problems that then have to return into the system as new demand – can run at 40%, 50%, 60%, 70% of the activity in many public services.

Gateshead’s ‘Liberated Services’ pioneer Mark Smith - in the recent video ‘Designing out hardship - Changing Futures Northumbria’.

Mark Smith’s ‘Changing Futures Northumbria’ team in Gateshead made the effort to track the ongoing cost of some ‘high intensity’ users of public services, who typically don’t get their underlying problems solved under the current system. They found in one example that it cost £2m+ over 14 years.

Brian has had over 3,000 interactions with services in 14 years and yet remained fundamentally misunderstood
– Changing Futures Northumbria

“Brian has had over 3,000 interactions with services in 14 years and yet remained fundamentally misunderstood,” the Gateshead team found. And Brian’s 14 years of being failed by multiple services is not an isolated example.

Yet when the team used their relational and strengths-based ‘Liberated Method’ – eg understanding, rather than assessing; asking ‘What matters to you?’ and much more along these lines – they were able to actually solve his underlying issues for just some tens of thousands of pounds. There are hundreds of thousands, even millions, of people with multiple complex needs in the UK (depending on how you choose to draw the line). What if many of them are, like Brian, currently mostly invisibly costing £2m+ due to siloed systems that cannot flex, cannot listen?

So it turns out that bespoke-by-default, relational services can rebuild lives and communities and remove billions in costly bureaucratic waste.

The age of “tightly defined and controlled brief transactions between strangers”, as the Fox brothers put it in their insightful new Demos report, may finally be starting to pass.

‘Liberated Services’, though, are still so novel that they – too often – lack the kind of top leadership support needed to make them permanent. It has struck me that perhaps they would greatly gain in credibility and influence by joining up with the ever-growing capabilities offered by Population Health Management (PHM) systems. These systems can offer easily visualised, and increasingly comprehensive, data for every person in an NHS Integrated Care System (ICS) area. Chief Execs and Chief Financial Officers are impressed by PHM dashboards’ ability to quickly predict costs, and savings, from proposed interventions, making strategic and resource-allocation decisions far easier to reach – and growing prevention too.

(Seeing Wes Streeting recently announce the topics, the people and the ‘I can/I am…’ statements – listed here – that together will help generate the new NHS 10-year plan, I can’t immediately discern where the impetus can come from to grow these ‘Liberated’ community/relational, strengths-based services, that work across the usual silos to ‘get it right first time’ for people. Does the NHS want to remove the ‘failure demand’ that clogs its systems? Do we want to start saving the £22bn currently wasted by supposedly ‘efficient’ services that struggle to respond to unique human needs? No sign of names like Human Learning Systems’ Prof Toby Lowe, Alex Fox, Hilary Cottam or Mark Smith (ex-Gateshead Council Director of Public Service Reform), who might help us achieve all this).

We have seen a revolution in thinking at a local level
– Ben Glover, Demos

A 2024 report on ‘Liberated Public Services’ by the think-tank Demos looked surveyed these novel services and concluded that “we have seen a revolution in thinking at a local level” – spearheaded by more effective services with a relational/community focus (that can surely greatly enable better prevention too). But this has yet to be taken up as a new national vision. Again, what are we waiting for?

As we saw with Swindon’s pioneering Life/Troubled Families project, once a ‘Transforming/Architect’ leader has been found and put in place, they are likely to open up the space to create exactly these types of ‘Liberated Services’. (But these services clearly need to be placed in the hands of ‘Architects’, rather than ‘Surgeons’, so they can thrive and spread successfully).

You’d hope that knowing that ‘Liberated Services’ might well save £22bn – and the Gateshead team now suspect the real figure is rather higher – would be a clincher in deciding to make a wholesale shift to more human and relationship-driven, strengths-based, community-focused services.

In truth, policymaking in England now reflects more a public service reform muddle than a model
– Harry Quilter-Pinner and Halima Khan, ‘Great Government – Public service reform in the 2020s’ (IPPR)

The think-tank IPPR’s report on public service reform in the 2020s concludes that today’s ‘New Public Management’ is no longer effective and crushes intrinsic motivation but hasn’t yet been replaced: “In truth, policymaking in England now reflects more a public service reform muddle than a model”.

It's time for us to write that next chapter in UK healthcare and other public services – and their leadership; to take the fork in the road that leads to an inspiring new vision, to reforms that many of us can already feel in our hearts are right.

A spot of further reading…

Allen, Jane, Gutenkunst, Heidi and Torbert, William R (2018), Street Smart Awareness and Inquiry-in-Action (Amara Collaboration).

Berger, Jennifer Garvey (2024), Changing on the Job: How Leaders Become Courageous, Wise, and Steady in an Anxious World (Stanford Business Books, 2nd ed.).

Binder, Thomas (2023), Ego Development for Effective Coaching and Consulting – Including a Comprehensive Overview of Ego Development Theory, its Validation, Critique and Empirical Foundations (Vandenhoeck & Ruprecht).

Boston, Richard and Ellis, Karen (2019), Upgrade – Building your capacity for complexity (LeaderSpace).

Bunting, Michael with Lemieux, Carl (2022), Vertical Growth – how self-awareness transforms leaders and organisations (Wiley).

Bushe, Gervase (2020), The Dynamics of Generative Change (BMI Series in Dialogic OD).

Bushe, Gervase and Marshak, Robert (2015), Dialogic Organization Development: The Theory and Practice of Transformational Change (EDS Publications).

Charlton, Ronald (2024), Rethinking Metrics: A Framework for Capturing Human Complexity in Public Services [blog].

Cheema, Kate (2024), Community Appointment Days Evidence Review & Evaluation – Interim report (Sussex MSK Partnership/Here/NHS Sussex Community Foundation Trust).

Clement, Stephen and Clement, Christopher (2013), It’s All About Work – Organizing your company to get work done (Organizational Design Inc.).

Capelle, Ronald (2014), Optimising Organization Design – a proven approach to enhance financial performance, customer satisfaction, and employee engagement (Jossey-Bass). 

Cavallaro, Liz and French, Brent (2021), ‘The Impact of Graduate Education on the Mental Complexity of Mid-Career Military Officers’, Journal of Adult Development.

Davidson, Sol, Kerslake, Bob, Pitt, Mike et al (2007), Flying High - a new look at local government leadership, transformation and the power of conversation (Society of Local Authority Chief Executives and Senior Managers).

Dorrell, Ed (2024), The Unnoticed Battle for the Future of Labour’s Public Sector Reform Agenda [blog].

Drago-Severson, Eleanor (2009), Leading Adult Learning: Supporting Adult Development in Our Schools (Corwin).

Drath, Wilfred H, (1993), Why Managers Have Trouble Empowering: A Theoretical Perspective Based on Concepts of Adult Development (Report no. 155, Centre for Creative Leadership).

Finucane, Laura and Lent, Adam (2024) Community Appointment Days: cutting waiting lists, building wellness [Zoom video].

Fox, Alex and Fox, Chris (2024), The Motivational State - A strengths-based approach to improving public sector productivity (Demos).

Gilbride, Neil, James, Chris and Carr, Sam (2020), ‘School principals at different stages of adult ego development: Their sense-making capabilities and how others experience them’, Educational Management Administration & Leadership.

Gilbride, Neil, James, Chris and Carr, Sam (2023), ‘The ways school headteachers/principals in England at different stages of adult ego development work with organisational complexity’, Educational Management Administration & Leadership.

Gittell, Jody Hoffer (2016), Transforming Relationships for High Performance – The Power of Relational Coordination (Stanford Business Books).

Glover, Ben (2024), Liberated Public Services: A new vision for citizens, professional and policy makers (Demos)

Hall, Donna (2024), Radical Place Leadership - how we can change public services for the better [blog]

Hamel, Gary and Zanini, Michele (2020), Humanocracy: Creating Organizations as Amazing as the People Inside Them (Harvard Business Review Press).

Harris, Lauren and Kuhnert, Karl (2008), ‘Looking through the lens of leadership: a constructive developmental approach’, Leadership & Organization Development Journal.

Hill, A., Mellon, L., Laker, B. and Goddard, J. (2016), ‘The One Type of Leader Who Can Turn Around a Failing School’, Harvard Business Review.

Hill, A., Mellon, L., Laker, B. and Goddard, J. (2016), ‘How to Turn Around a Failing School’, Harvard Business Review.

Hill, A., Mellon, L., Laker, B. and Goddard, J. (2017), ‘Research: How the Best School Leaders Create Enduring Change’, Harvard Business Review.

Hoare, Carol (ed.)(2011), The Oxford Handbook of Reciprocal Adult Development and Learning (Oxford University Press).

Hodgkiss, Daniel, Quinney, Suzanne, Slack, Tim, Barnett, Kayleigh and Howells, Brook (2024), Appreciating Health and Care – A practical Appreciative Inquiry resource for the Health and Social Care Sector (Appreciating People).

James CR, James JE and Potter I (2017), ‘An exploration of the validity and potential of adult ego development for enhancing understandings of school leadership’, School Leadership and Management.

Joiner, Bill and Josephs, Stephen (2007), Leadership Agility – Five Levels of Mastery for Anticipating and Initiating Change (Jossey-Bass).

Jones, Jennifer (2018), ‘An unseen lens: the relationship between philanthropists’ developmental meaning making and philanthropic activity’, Nonprofit Management and Leadership.

Kegan, Robert (2013), The Further Reaches of Adult Development (YouTube).
[Note: I invited Prof Kegan to give this RSA lecture in London, where he spoke about how the world needs more of the ‘Self-Transforming’ (‘Architect’) mind, as it is uniquely capable of fully listening to all the stakeholders involved in the world’s ‘wicked’ problems].

Kegan, Robert and Lahey, Lisa Laskow (2009), Immunity to Change: How to Overcome It and Unlock the Potential in Yourself and Your Organization (Harvard Business Press).

Kegan, Robert, Lahey, Lisa et al. (2016), An Everyone Culture – Becoming a Deliberately Developmental Organization (Harvard Business Review Press).

Laloux, Frederic (2014), Reinventing Organizations – a guide to creating organizations inspired by the next stage in human consciousness (Nelson Parker).

Laloux, Frederic (2016), Reinventing Organizations – an illustrated invitation to join the conversation on next stage organisations (Nelson Parker).

Lipmanowicz, Henri and McCandless Keith (2014), Liberating Structures - Simple Rules to Unleash a Culture of Innovation (Liberating Structures Press).

Lowe, Toby, Padmanabhan, Chandrima, McCart, Des, McNeill, Karen, Brogan, Andy and Smith, Mark (2022), Human Learning Systems - A practical guide for the curious (Healthcare Improvement Scotland, CPI, IRISS).

McKimm, Judy, Lees, Peter, Armit, Kirsten and Mills, Chloe (2021), ‘Evaluating the impact of a national strategic leader development programme for UK doctors: myth-busting, mind-changing, mood-enhancing’, BMJ Leader (NB the mindset shift measurement discussion is on page 5-6).

McGuire, John and Rhodes, Gary (2009), Transforming Your Leadership Culture (Centre for Creative Leadership).

Mentkowski, Marcia & Associates (2000), Learning that Lasts – Integrating Learning, Development, and Performance in College and Beyond (Jossey-Bass).

Mezey, Matthew Kalman (2015), ‘Planting the Seeds of New Possibilities: The Journey that led me to Reinventing Organization’ (interview with Frederic Laloux on Enlivening Edge website).

Mezey, Matthew Kalman (2015), ‘The Hot Management Trend of Self-organising Workplaces without Managers: will Left or Right be first to embrace it?’ (article on Enlivening Edge website).

Mortimer, John (2022) Creating an effective integrated care team - using a systems approach (video).

O'Connor, Dennis and Wolfe, Donald (1991), ‘From Crisis to Growth at Midlife: Changes in Personal Paradigm’, Journal of Organizational Behavior.

Pierce, Bonnie (2016), ‘Speaking Up: it requires leadership maturity’, Nurse Leader.

Pfaffenberger, Angela, Marko, Paul and Combs, Allan (2011), The Postconventional Personality – Assessing, Researching and Theorizing Higher Development (SUNY).

Quilter-Pinner, Harry and Khan, Halima (2023), Great Government – Public service reform in the 2020s (IPPR).

Reams, Jonathan (2020), Maturing Leadership – how Adult Development Impacts Leadership (Emerald Publishing Limited).

Rooke, David et al. (2015), The hidden talent: Ten ways to identify and retain transformational leaders (PwC/OSCA).

Rooke, David and Torbert, Bill (2005), ‘Seven Transformations of Leadership’, Harvard Business Review (PDF).

Rooke, David (2018), ’Transformational leadership capabilities for medical leaders’, BMJ Leader (PDF).

Rowson, Jonathan, Mezey, Matthew Kalman and Dellot, Ben (2012), Beyond the Big Society – Psychological Foundations of Active Citizenship (RSA).

Seddon, John et al (2014), Saving money by doing the right thing – why ‘local by default’ must replace ‘diseconomies of scale’ (Locality/Vanguard).

Seddon, John (2008), Systems Thinking in the Public Sector: The Failure of the Reform Regime... and a Manifesto for a Better Way (Triarchy Press).

Shepard, Ken et al (2007), Organization Design, Levels of Work & Human Capability Executive Guide (Global Organization Design Society).
[Note: my review of this book includes an overview of the ’Requisite organisation’ approach: http://integralleadershipreview.com/5282-book-review-organization-design-levels-of-work-human-capability-executive-guide/]

Sinnott, Jan D. (1998), The Development of Logic in Adulthood: Postformal Thought and Its Applications (Springer).

Smith, Mark (2023), The Liberated Method - Rethinking Public Service [blog].

Smith, Mark (2024), Liberating Public Services Conference: Reflections on Rebellion [blog].

Taylor, Paul (2023), Efficiency isn’t always Effective [blog].

Torbert, Bill and Associates. (2004). Action Inquiry – The Secret of Timely and Transforming Leadership (Berrett-Koehler).

Townshend, Vic, Bradshaw, Alexis et al (2024), Building system-wide population health management capabilities – A strategic partnership approach – Blueprint guide (Lincolnshire PHM/Optum).

Uhl-Bien, Mary (2019), How 'Adaptive Spaces' enable innovation in healthcare and beyond’ [video].

Uhl-Bien, Mary (2019), How to master the art of creating ‘Adaptive Spaces’ [video].

Voronov, Maxim and Yorks, Lyle (2015), ‘“Did You Notice That?” Theorizing Differences in the Capacity to Apprehend Institutional Contradictions’, Academy of Management Review.

West, Michael (2021), Compassionate Leadership: Sustaining Wisdom, Humanity and Presence in Health and Social Care (The Swirling Leaf Press).

West, Michael, Topakas, Anna and Dawson, Jeremy (2014), ‘Climate and Culture for Health Care Performance’ in The Oxford Handbook of Organizational Climate and Culture (OUP).

Williamson, Annie and Patel, Parth (2024), From the Frontline - empowering staff to drive the NHS reform agenda (IPPR).

Wilson, Richard, Mezey, Matthew Kalman and Nielsen, Nick (2013), Anti Hero – the Hidden Revolution in Leadership & Change (OSCA).

Woodhouse, Eleanor (2023), Literature Review: Approaches to Public Sector Delivery (IPPR, unpublished).