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Training

Leadership Case Studies

Here is a sample of three case studies from the book, Leadership Case Studies, that are most instructive and impactful to developing leadership skills.

Leadership Case Studies

For the past 30 years, I have conducted seminars and workshops and taught college classes on leadership.

I used a variety of teaching aids including books, articles, case studies, role-plays, and videos.

I recently created a book, Leadership Case Studies that includes some of the case studies and role-plays that I found to be most instructive and impactful.

Here is a sample of three case studies.

Peter Weaver Case Study

Peter Weaver doesn’t like to follow the crowd. He thinks groupthink is a common problem in many organizations. This former director of marketing for a consumer products company believes differences of opinion should be heard and appreciated. As Weaver states, “I have always believed I should speak for what I believe to be true.”

He demonstrated his belief in being direct and candid throughout his career. On one occasion, he was assigned to market Paul’s spaghetti-sauce products. During the brand review, the company president said, “Our spaghetti sauce is losing out to price-cutting competitors. We need to cut our prices!”

Peter found the courage to say he disagreed with the president. He then explained the product line needed more variety and a larger advertising budget. Prices should not be cut. The president accepted Weaver’s reasoning. Later, his supervisor approached him and said, “I wanted to say that, but I just didn’t have the courage to challenge the president.”

On another occasion, the president sent Weaver and 16 other executives to a weeklong seminar on strategic planning. Weaver soon concluded the consultants were off base and going down the wrong path. Between sessions, most of the other executives indicated they didn’t think the consultants were on the right path. The consultants heard about the dissent and dramatically asked participants whether they were in or out. Those who said “Out” had to leave immediately.

As the consultants went around the room, every executive who privately grumbled about the session said “In.” Weaver was fourth from last. When it was his turn, he said “Out” and left the room.

All leaders spend time in reflection and self-examination to identify what they truly believe and value. Their beliefs are tested and fine-tuned over time. True leaders can tell you, without hesitation, what they believe and why. They don’t need a teleprompter to remind them of their core beliefs. And, they find the courage to speak up even when they know others will disagree.

  • What leadership traits did Weaver exhibit?
  • If you were in Weaver’s shoes, what would you have done?
  • Where does courage come from?
  • List your three most important values.

Dealing with a Crisis Case Study

Assume you are the VP of Sales and Marketing for a large insurance company. Once a year your company rewards and recognizes the top 100 sales agents by taking them to a luxury resort for a four-day conference. Business presentation meetings are held during the morning. Afternoons are free time. Agents and spouses can choose from an assortment of activities including golf, tennis, boating, fishing, shopping, swimming, etc.

On day 2 at 3:00 p.m., you are at the gym working out on the treadmill, when you see Sue your administrative assistant rushing towards you. She says, “I need to talk to you immediately.”

You get off the treadmill and say, “What’s up?” Sue states, “We’ve had a tragedy. Several agents went boating and swimming at the lake. Randy, our agent from California died while swimming.”

(Background information – Randy is 28 years old. His wife did not come on the trip. She is home in California with their three children).

  • Explain what you would communicate to the following people.
  • Your Human Resources Department
  • The local police
  • The attendees at the conference (Would you continue the conference?)
  • How will you notify Randy’s wife?
  • If Randy’s wife and a few family members want to visit the location of Randy’s death, what would you do?
  • What are some “guiding principles” that leaders need to follow in a crisis situation?

 Arsenic and Old Lace Case Study

Review the YouTube video, “ I’ll show them who is boss Arsenic and Old Lace.”   

Background Information

The Vernon Road Bleaching and Dyeing Company is a British lace dyeing business. It was purchased in bankruptcy by the father/son team of Henry and Richard Chaplin. Richard has been acting as “Managing Director” which is the same as a general manager or president of a company.

The company has had 50-to-150 employees with 35-to-100 being shop floor, production employees. The company produces and sells various dyed fabrics to the garment industry.

Gerry Robinson is a consultant who was asked to help transform methods of conducting business to save the company.

Jeff is the factory manager.

  • What are Richard’s strengths and weaknesses as a leader?
  • What could Richard have done to make the problems of quality and unhappy customers more visible to the workforce?
  • What do you think Richard’s top three priorities should be for the next 12 months?
  • What could Richard have done to motivate the workforce?
  • Evaluate Jeff’s approach and effectiveness as a leader.

The book contains 16 case studies, four role-plays, and six articles. I hope you find some of the content useful and helpful in your efforts to teach leadership.

Click for additional leadership case studies and resources .

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How to Make Different Business Leadership Styles Work (With Case Studies)

Several thought leaders have referred to 2020 as the year of great reset. But if you want to be really strict about it, most of the biggest business shifts started way back at the onset of the 21st century. 

Traditional business leaders who are banking on traditional business leadership styles in this new century needlessly risk losing their businesses to unhealthy age-old leadership practices.

The pandemic just helped reiterate the need for business leaders to change the way they approach business problems primarily due to the following reasons:

  • New technologies
  • Pace of change
  • Changing demographics and employee expectations
  • Changing customer expectations

The chart below gives you a better glimpse of the reasons why there is a difference in the requirements for the kind of leaders we need to have in this era. The data depicted is from Deloitte’s Human Capital Trends Survey .

What are these particular requirements? According to the same study by Deloitte, business leaders need to have the following abilities:

  • lead through more complexity and ambiguity
  • lead through influence
  • manage on a remote basis
  • manage a workforce with a combination of humans and machines
  • lead more quickly

See this second figure below.

According to Forbes , there are three notable leadership skill shifts for 2021 and these are the following:

  • Communication to Empathy 
  • Emotional Intelligence to Emotional Agility 
  • Time Management to Context Management

Leaders are expected to be effective communicators, but the shift is now focused on empathy as a priority for business leaders this year. The Management Research Group found empathy to be the leading positive leadership competency and one of the biggest predictors of senior executive effectiveness . This makes a lot of sense especially now that the recent challenges brought about by the pandemic have highlighted the value of caring while communicating.

Emotional intelligence to emotional agility is another important shift. Susan David , a psychologist and the author of the book “Emotional Agility: Get Unstuck, Embrace Change, and Thrive in Work and Life” describes emotionally agile people be the type of people who are not only aware of their feelings but also know how to navigate through them.

Now the shift from time management to context management gives emphasis on how the change in the context of how and where we work requires realignment in managing our time and designing our days around how we work. 

While there are several leadership styles and the specific strategies vary depending on the field or industry, the concepts are basically the same. Let’s take note of these leadership skill shifts mentioned earlier in studying how we can better tailor the different leadership styles to suit the changing times. 

The following are six of the different leadership styles we will tackle further:

  • Autocratic Leadership Style
  • Democratic Leadership Style
  • Laissez-Faire Leadership Style
  • Situational leadership style
  • Transactional Leadership Style
  • Transformational Leadership Style

First off, let’s start with the traditional business leadership styles.

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1. autocratic leadership style.

Case Study: Howell Raines of The New York Times

The New York Times under Howell Raines as the Executive Editor decided at one point to only put resources on the stories that he deemed as worth covering. While this led to The New York Times winning a record-breaking seven Pulitzer awards in a single year, several staff members got demoralized.

There is no known theorist behind autocratic leadership so it is considered as an organic leadership style that has developed over the course of time that it has been used. 

Basically, an autocratic leader is the type of leader who would make decisions without proper consultation. You may think that this leadership style is unacceptable for who decides on his own especially if the decision concerns an entire organization, right? 

But, Cleverism articulates three situations where the autocratic leadership style can be used and these are the following:

  • The situation requires fast and immediate decision-making
  • There is no clarity in the process of the procedure and pushing ahead might only lead people to danger
  • There are more inexperienced people in the group and most of them are demotivated

The tendency of most businesses with an autocratic leader is that the subordinates will become passive and mediocre, or conflicts may arise.

In these situations where a business leader must step up and use the autocratic leadership style, it is important to take note of communicating openly and regarding others with respect the entire time.

2. Democratic Leadership Style

Case Study: Sergey Brin and Larry Page of Google

Founders Sergey Brin and Larry Page hired Eric Schmidt to jump-start the Internet search engine. Blending autocratic, laissez-faire and democratic leadership styles, they allowed someone knowledgeable and experienced into Google which would then lead to more democratic teams composed of experienced talent. 

Also known as the participative leadership style, the democratic leadership style in business management is often characterized as the style that encourages collaboration with fellow leaders and team members. In other words, everyone is allowed to participate in the decision-making process. 

While this style of leadership is very motivating for most people as compared to the autocratic leadership style, it works best for businesses that employ experts in their departments so little supervision is required. 

According to St. Thomas University , the following organizations can take advantage of this:

  • Biotech R&D divisions
  • Housing construction sites
  • Universities
  • Information technology companies

Furthermore, the university lists the following as the disadvantages of this leadership style:

  • Business leaders may become too dependent on their subordinates
  • Getting everyone’s input may take a lot of time 
  • Missed deadlines are possible 
  • Consulting with people who lack accurate data or sufficient knowledge
  • Too much burden for business leaders to oversee collaboration

The democratic leadership style can bring forth massive business growth if business leaders are willing to take responsibility for the decisions made and provide support and expertise during collaborations.

Such requires highly productive leaders who know what they do and will take action.

3. Laissez-Faire Leadership Style

Case Study: Warren Buffett of Berkshire Hathaway

Warren Buffett is known for exemplifying the laissez-faire leadership style as he allows people he works with to do their jobs without his supervision or intervention. His great success over several years has been attributed to his style of leadership which allows a culture of motivation and confidence. He, however, sees to it that he only hires people he can trust to do their jobs.

The laissez-faire leadership style emerged from the French word laissez-faire which means “leave alone”. Also called the hands-off approach, this style is based on the concept that leaders can leave their employees or teams alone in coming up with ideas or decisions for the business departments they are part of. 

This used to be a very popular style before the 19th century, but as modernization started, more and more business leaders find the disadvantages of leading teams with no supervision to be detrimental. This is particularly possible for companies that lack expert talent.

What business leaders who employ this leadership style should note is that assuming that subordinates must be free from accountability. This only encourages the company’s people to be complacent.

The business leader must ensure that teams are composed of highly-skilled individuals who can be reliable in achieving business goals under their responsibility.

At this point, we’ve already discussed the three leadership styles that can be highly traditional unless approached with a fresh perspective that takes into account the new leadership needs and skill shifts.

How these three business leadership styles work is illustrated below.

Which leadership style can you resonate with the most?

We now have what we call modern leadership styles or approaches. These styles have emerged as a response to the traditional styles that do not allow much room for innovation. 

Although most of these new approaches are modified versions of the traditional leadership styles, they are identified mainly based on the following types of categories:

  • Situational leadership
  • Transactional leadership
  • Transformational leadership
  • Innovative leadership

4. Situational Leadership Style 

This leadership style follows the contingency-based leadership model when responding to situations or making decisions. Business leaders who employ this style are flexible and would normally use varying leadership strategies depending on the situation.

Goleman believes that a situational leader must be able to incorporate the six specific leadership styles given the right circumstances.

5. Transactional Leadership Style

Also known as managerial leadership, transactional leadership is a style that focuses on supervision, organization, and group performance.

Business leaders under this style use rewards and punishments to motivate subordinates in a given task.

According to Verywell Mind , the basic assumptions of transactional leadership are the following:

  • When the chain of command is clear, your workforce performs their best
  • Rewards and punishments are effective agents of motivation
  • Obeying the leader is the most important goal of the subordinates
  • Careful monitoring is a must

When giving assignments, the business leader must be clear when it comes to the instructions, rewards and consequences, as well as giving feedback. 

6. Transformational Leadership Style

Business leaders who subscribe to the transformational leadership style serve as inspirations to their subordinates.

They inspire as they lead by example and as they cultivate an environment that welcomes creativity and innovation. This suits employees who have entrepreneurial minds as transformational business leaders seek to inspire just the right amount of intellectual independence in the workplace.

In a roundup article, Harvard Business Review lists the following as the best examples of transformational leadership:

  • Jeff Bezos , Amazon
  • Reed Hastings , Netflix
  • Jeff Boyd and Glenn Fogel , Priceline
  • Steve Jobs and Tim Cook , Apple
  • Mark Bertolini , Aetna
  • Kent Thiry , DaVita
  • Satya Nadella , Microsoft
  • Emmanuel Faber , Danone
  • Heinrich Hiesinger , ThyssenKrupp

The Harvard Business Review refers to this group as the Transformation 10 for exemplifying transformational leadership.

Strengthening Your Leadership Mindset

About 60% of the executives who participated in the 2021 Deloitte Global Human Capital Trends said that what prepared them for the unknown is leadership . This is the kind of leadership that takes into account the unpredictable and incorporates strategies surrounding that through coaching, teaming, and fostering.

But did you know that based on the research of the Corporate Executive Board , about 50%-70% of the new business executives or leaders fail within the first 18 months? Unless you have the right leadership mindset and you solidify that mindset, you will become part of this figure. 

Whenever a major business problem happens, you can either succumb to the pressure and give up, or find a solution to the problem . The most successful business leaders try their hardest to never give up.

Most business leaders would rather grind than get back to their regular jobs of 9-to-5.

In 1519, a Spanish explorer and conquistador Hernán Cortés pursued the treasures of the Aztecs with 11 ships and a crew of 100 sailors and 500 soldiers. His army was vastly outnumbered and some soldiers tried to escape. Cortés gave the order to burn the ships and left no choice but to fight until their last breath.

That wasn’t the end for everyone. Part of the army survived and they got a hold of the treasure.

At first, calmness is a myth. People are emotional by nature and react to any deviations from their plans. With time, those who choose to be in the captain’s spot until the end see problems that have to be solved and suppress the emotional part that is dragging them down.

The role of a business leader isn’t easy in the first place. Constant changes and surprises are not abnormal and at some point, they become a daily routine.

Plenty of problems appear to be critical, but in the end, they should be solved. You don’t run away from them. You step up as a business leader and inspire your teams to follow through.

The most effective leadership style for business is the leadership that inspires.

If being a business leader of a successful company is among your highest priorities, work on your leadership know-how, develop your management soft skills , and make it work for your people.

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leadership style case study examples

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Leadership →

leadership style case study examples

  • 24 Jan 2024

Why Boeing’s Problems with the 737 MAX Began More Than 25 Years Ago

Aggressive cost cutting and rocky leadership changes have eroded the culture at Boeing, a company once admired for its engineering rigor, says Bill George. What will it take to repair the reputational damage wrought by years of crises involving its 737 MAX?

leadership style case study examples

  • 02 Jan 2024
  • What Do You Think?

Do Boomerang CEOs Get a Bad Rap?

Several companies have brought back formerly successful CEOs in hopes of breathing new life into their organizations—with mixed results. But are we even measuring the boomerang CEOs' performance properly? asks James Heskett. Open for comment; 0 Comments.

leadership style case study examples

  • Research & Ideas

10 Trends to Watch in 2024

Employees may seek new approaches to balance, even as leaders consider whether to bring more teams back to offices or make hybrid work even more flexible. These are just a few trends that Harvard Business School faculty members will be following during a year when staffing, climate, and inclusion will likely remain top of mind.

leadership style case study examples

  • 12 Dec 2023
  • Cold Call Podcast

Can Sustainability Drive Innovation at Ferrari?

When Ferrari, the Italian luxury sports car manufacturer, committed to achieving carbon neutrality and to electrifying a large part of its car fleet, investors and employees applauded the new strategy. But among the company’s suppliers, the reaction was mixed. Many were nervous about how this shift would affect their bottom lines. Professor Raffaella Sadun and Ferrari CEO Benedetto Vigna discuss how Ferrari collaborated with suppliers to work toward achieving the company’s goal. They also explore how sustainability can be a catalyst for innovation in the case, “Ferrari: Shifting to Carbon Neutrality.” This episode was recorded live December 4, 2023 in front of a remote studio audience in the Live Online Classroom at Harvard Business School.

leadership style case study examples

  • 05 Dec 2023

Lessons in Decision-Making: Confident People Aren't Always Correct (Except When They Are)

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  • 21 Nov 2023

The Beauty Industry: Products for a Healthy Glow or a Compact for Harm?

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  • 14 Nov 2023

Do We Underestimate the Importance of Generosity in Leadership?

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  • 24 Oct 2023

From P.T. Barnum to Mary Kay: Lessons From 5 Leaders Who Changed the World

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  • 06 Oct 2023

Yes, You Can Radically Change Your Organization in One Week

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  • 26 Sep 2023

The PGA Tour and LIV Golf Merger: Competition vs. Cooperation

On June 9, 2022, the first LIV Golf event teed off outside of London. The new tour offered players larger prizes, more flexibility, and ambitions to attract new fans to the sport. Immediately following the official start of that tournament, the PGA Tour announced that all 17 PGA Tour players participating in the LIV Golf event were suspended and ineligible to compete in PGA Tour events. Tensions between the two golf entities continued to rise, as more players “defected” to LIV. Eventually LIV Golf filed an antitrust lawsuit accusing the PGA Tour of anticompetitive practices, and the Department of Justice launched an investigation. Then, in a dramatic turn of events, LIV Golf and the PGA Tour announced that they were merging. Harvard Business School assistant professor Alexander MacKay discusses the competitive, antitrust, and regulatory issues at stake and whether or not the PGA Tour took the right actions in response to LIV Golf’s entry in his case, “LIV Golf.”

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  • 01 Aug 2023

As Leaders, Why Do We Continue to Reward A, While Hoping for B?

Companies often encourage the bad behavior that executives publicly rebuke—usually in pursuit of short-term performance. What keeps leaders from truly aligning incentives and goals? asks James Heskett. Open for comment; 0 Comments.

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  • 05 Jul 2023

What Kind of Leader Are You? How Three Action Orientations Can Help You Meet the Moment

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How Are Middle Managers Falling Down Most Often on Employee Inclusion?

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  • 14 Jun 2023

Every Company Should Have These Leaders—or Develop Them if They Don't

Companies need T-shaped leaders, those who can share knowledge across the organization while focusing on their business units, but they should be a mix of visionaries and tacticians. Hise Gibson breaks down the nuances of each leader and how companies can cultivate this talent among their ranks.

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Four Steps to Building the Psychological Safety That High-Performing Teams Need

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  • 31 May 2023

From Prison Cell to Nike’s C-Suite: The Journey of Larry Miller

VIDEO: Before leading one of the world’s largest brands, Nike executive Larry Miller served time in prison for murder. In this interview, Miller shares how education helped him escape a life of crime and why employers should give the formerly incarcerated a second chance. Inspired by a Harvard Business School case study.

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  • 23 May 2023

The Entrepreneurial Journey of China’s First Private Mental Health Hospital

The city of Wenzhou in southeastern China is home to the country’s largest privately owned mental health hospital group, the Wenzhou Kangning Hospital Co, Ltd. It’s an example of the extraordinary entrepreneurship happening in China’s healthcare space. But after its successful initial public offering (IPO), how will the hospital grow in the future? Harvard Professor of China Studies William C. Kirby highlights the challenges of China’s mental health sector and the means company founder Guan Weili employed to address them in his case, Wenzhou Kangning Hospital: Changing Mental Healthcare in China.

leadership style case study examples

  • 09 May 2023

Can Robin Williams’ Son Help Other Families Heal Addiction and Depression?

Zak Pym Williams, son of comedian and actor Robin Williams, had seen how mental health challenges, such as addiction and depression, had affected past generations of his family. Williams was diagnosed with generalized anxiety disorder, depression, and post-traumatic stress disorder (PTSD) as a young adult and he wanted to break the cycle for his children. Although his children were still quite young, he began considering proactive strategies that could help his family’s mental health, and he wanted to share that knowledge with other families. But how can Williams help people actually take advantage of those mental health strategies and services? Professor Lauren Cohen discusses his case, “Weapons of Self Destruction: Zak Pym Williams and the Cultivation of Mental Wellness.”

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  • 11 Apr 2023

The First 90 Hours: What New CEOs Should—and Shouldn't—Do to Set the Right Tone

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  • 01 Mar 2023

How Much Does 'Deep Purpose' Matter to the Bottom Line?

More leaders want their employees to aspire to loftier goals at work. But is deep purpose more about feel-good ideas or delivering business value? wonders James Heskett. Open for comment; 0 Comments.

The Ethical Leadership Case Study Collection

The Ted Rogers Leadership Centre’s Case Collection, developed in collaboration with experienced teaching faculty, seasoned executives, and alumni, provides instructors with real-life decision-making scenarios to help hone students’ critical-thinking skills and their understanding of what good leaders do. They will be able to leverage the theories, models, and processes being advanced. Students come to understand that workplace dilemmas are rarely black and white, but require them to think through and address competing claims and circumstances. Crucially, they also appreciate how they can, as new leaders and middle managers, improve decisions by creating realistic action plans based on sound stakeholder analysis and communication principles. These case studies are offered free of charge to all instructors.

group of students at a round table during the Top 200 Program summit

Cases come in both long and short forms. The long cases provide instructors with tools for delving deeply into subjects related to a variety of decision making and organizational development issues. The short cases, or “minis,” are quick in-class exercises in leadership.

For both the long cases and the minis, teaching-method notes are provided, which include not only recommended in-class facilitation methods, but also grading rubrics, references, and student feedback.

Testimonials

“I have been invited to judge the Leadership Centre’s Annual Ethical Leadership National Case Competition since its inception. Each year, competitors are given a Centre’s case to analyze and present. These cases are like nothing else. They bring the student into the heart of the situation. To excel, students must not only be able to cogently argue the options, but also demonstrate how to implement a decision based on a clear-eyed stakeholder analysis and an understanding of the dynamics of change.” Anne Fawcett, Special Advisor, Caldwell Partners
“I have worked with the Ted Rogers Leadership Centre to both develop and pilot test case materials. Feedback consistently shows that the Centre’s cases resonate with students, providing them with valuable learning experiences.” Chris Gibbs, BComm, MBA, PhD, Associate Professor
"As a judge in the recent national Ted Rogers Ethical Leadership Case Competition, I was very impressed with the quality of the case study prepared by the Leadership Centre. It was brief but well-composed. It exposed the students to ethical quandaries, of the sort they may well face in their business careers. It not only tested their reasoning, but it challenged them to develop a plan of action when faced with incomplete information and imminent deadlines.” Lorne Salzman, Lawyer

We value your feedback

Please inform us of your experience by contacting Dr. Gail Cook Johnson, our mentor-in-residence, at [email protected] .

What Is the Authentic Leadership Style? 3 Real-Life Examples

Authentic leadership

Talented leaders must balance the input and needs of their followers while still ensuring the collective meets its goals.

They must carefully regulate their own behavior and emotions, recognizing these are contagious and can reflect on the image of their team.

Most importantly, skilled leaders ensure consistency between what they say and what they do, and take care to make decisions that allow them to sleep soundly at night.

The few of us who’ve mastered this balancing act can be said to have mastered the art of authentic leadership . And although it may seem challenging, this empowering and open style of command is within reach for even rookie leaders.

Before you continue, we thought you might like to download our three Positive Leadership Exercises for free . These detailed, science-based exercises will help you or others adopt positive leadership practices and help organizations thrive.

This Article Contains:

What is the authentic leadership style, the theory and model explained, 10 characteristics and traits of authentic leaders, 3 examples of authentic leadership in action, pros and cons of the leadership approach, training authentic leadership skills in coaching, 7 best exercises and activities, 2 questionnaires and inventories, 8 questions to ask your coaching clients, fascinating books on the topic, a take-home message.

Authentic leadership is

“a pattern of leader behavior that draws upon and promotes both positive psychological capacities and a positive ethical climate, to foster greater self-awareness, an internalized moral perspective, balanced processing of information, and relational transparency on the part of leaders working with followers, fostering positive self-development.”

Walumbwa, Avolio, Gardner, Wernsing, and Peterson, 2008, p. 94

This definition combines many key aspects of authentic leadership identified by researchers, including:

  • The promotion of followers’ psychological capacities, such as resilience (Luthans & Avolio, 2003)
  • High self-awareness, self-esteem , and self-acceptance that facilitates openness and non-defensiveness with others (Gardner, Avolio, Luthans, May, & Walumbwa, 2005; Kernis, 2003)
  • Consistency between our values, beliefs, and actions (Walumbwa et al., 2008)
  • The use of high ethical standards to guide decision-making and behavior (May, Chan, Hodges, & Avolio, 2003)

Authentic leadership and emotional intelligence

The facets of an authentic leadership style overlap substantially with conceptualizations of emotional intelligence (EI). For instance, Goleman’s four-dimensional model of EI includes the component of self-awareness .

Further, this model includes various competencies that overlap with authentic leadership, such as confidence and transparency, which are similar to self-esteem and openness and aimed at facilitating positive interactions with others (Goleman, 1995; Miao, Humphrey, & Qian, 2018).

Indeed, meta-analytic research has confirmed that the authentic leadership style is significantly and positively related to EI and that high-EI leaders can better discern when it is most appropriate to employ the authentic leadership style (Miao et al., 2018).

Leadership self-awareness

  • Self-awareness Understanding how you make meaning of the world and how that meaning-making process affects self-image over time; awareness of strengths, weaknesses, your multifaceted nature, and your impact on others.
  • Relational transparency Presenting your authentic self to others; promoting trust through disclosure, information sharing, and expression of true thoughts and feelings.
  • Balanced processing Objective analysis of all relevant data before making decisions; a willingness to solicit and consider views that challenge your own.
  • Internalized moral perspective Self-regulation guided by internal moral standards and values rather than external standards; behaving and making decisions consistent with these internalized values.

leadership style case study examples

Download 3 Free Positive Leadership Exercises (PDF)

These detailed, science-based exercises will help you or others to adopt positive leadership practices to help individuals, teams and organizations to thrive.

Download 3 Free Positive Leadership Exercises Pack (PDF)

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So what makes good, authentic leaders?

If a person possesses some of the following traits, they are likely to use the authentic leadership style effectively (Kotzé & Nel, 2017).

  • Consensus orientation
  • Skill at critical evaluation
  • Persuasiveness
  • Social skills/confidence
  • Innovation/forward thinking
  • Open expression and display of emotions
  • Behavioral consistency across people and situations
  • Ability to self-regulate
  • Empathy and caring

Unsurprisingly, these characteristics overlap significantly with the various components of authentic leadership’s four-dimensional conceptualization. For instance, critical evaluation skills can aid with balanced processing when making decisions, while empathy can aid with relational transparency.

Authentic Leadership in Action

Authentic leadership in the workplace

One interview-based study exploring the intersection between work managers’ identities and authentic leadership highlights the challenges involved in balancing the authentic leadership style with your preferred leadership style (Nyberg & Sveningsson, 2014).

The managers in this study explained that they constituted a natural hub around which their workgroups and departments revolved. This meant they had a high level of impact on operational procedures and outcomes.

Consequently, the managers of this leader-centric organization found the principles of authentic leadership, which center around inclusion and worker involvement, to contrast with their natural approaches to leadership, which involved being forceful and dominant in decision-making and sometimes cutting collaborative processes short (Nyberg & Sveningsson, 2014).

Therefore, depending on a manager’s natural style of leading, what we consider an ‘authentic’ leadership style may not be authentic in the sense that it is inherent or feels natural to a given leader.

Authentic leadership in healthcare

One study of skilled nursing facility administrators found that authentic leadership can be leveraged to bring about healthier and safer practice environments for nurses and their patients (Penrod, 2017).

Among the four dimensions of authentic leadership noted as important, internalized moral perspective was mentioned most often by the study’s interviewees (95%). In particular, administrators who maintained a genuine positive attitude, a willingness to ‘get their hands dirty,’ and regularly demonstrated appreciation for their employees’ work drove higher levels of job satisfaction .

Likewise, an internalized belief in the importance of patient safety among administrators would translate into better formal and informal training regarding safety procedures (Penrod, 2017).

A look at authentic leadership in education

Authentic leadership shown by principals and other education leaders can be especially powerful during challenging times of change.

One study conducted in Thailand followed the principal of a small primary school 100 kilometers west of Bangkok. Principal Somchai was recognized as an illustrative case of someone who effectively used the authentic leadership style to navigate the impact of over 20 years of nationwide educational reform (Kulophas & Hallinger, 2021).

When interviewed, Principal Somchai expressed a strong belief in involving teachers and parents in decision-making. This was reflected in the frequency with which he formally and informally engaged teachers, parents, and local community members to gather views and input on decisions.

He also noted the importance of being transparent when planned activities didn’t work out and would personally take on extra work during busy periods. Taken together, these actions motivated teachers’ engagement, reduced turnover, and nurtured a family-like atmosphere within the school community (Kulophas & Hallinger, 2021).

Authentic leadership for the future – Irving Washington III

The most appropriate style of leadership to use in any situation highly depends on the context in which a leader and team are working. Therefore, the authentic leadership style has pros and cons in different situations.

Pros of the authentic leadership style

Research has identified a combination of positive relational and performance-based outcomes associated with authentic leadership. In particular, authentic leadership has been shown to increase trust and work engagement while also facilitating more effective conflict management (Fotohabadi & Kelly, 2018; Hassan & Ahmed, 2011).

Further, authentic leaders are more aware of their strengths , weaknesses, and values, so they tend to exhibit greater social awareness and manage relationships more effectively (Pereira, 2015).

Cons of the authentic leadership style

One downside of the authentic leadership style is that it is often inappropriate in high-risk and emergency situations.

Take, for example, the commander of a submarine who is trying to ensure their crew remains undetected. Upon learning of an approaching unidentified vessel, it would be inappropriate to stop and build consensus around the most appropriate course of action as per the authentic leadership style.

Rather, this leader should adopt a commanding or directive leadership style to direct the rest of their team to take evasive action before it is too late (Goleman, Boyatzis, & McKee, 2013).

Additionally, research has shown that organizations may see diminishing returns from the authentic leadership style when it comes to innovation. This is because the apparent moral superiority of these leaders can inadvertently communicate that innovative suggestions are not needed because the leader already knows best (Černe, Sumanth, & Škerlavaj, 2016).

Training in Authentic Leadership Coaching

However, it appears that with the proper intervention, you can expect a significant increase in a client’s authentic leadership skills after just 12 one-hour sessions of training (Fusco, O’Riordan, & Palmer, 2016).

Here are seven steps that may form part of an authentic leadership coaching program (Klass, 2019):

  • Identify the leader’s unique strengths and talents Consider administering a strengths assessment or asking the leader to reflect on skills and talents that come most naturally to them and energize them.
  • Compile a list of the leader’s core values Investigate the leader’s values to help create a clear moral basis for making decisions and setting direction.
  • Gather perspectives from the client’s colleagues or boss Encourage the leader to ask for feedback from others who’ve seen their leadership in action.
  • Help clients find their authentic voice Discourage clients from mimicking styles of communication they’ve seen used by other leaders and instead find a volume and rhythm that feels most natural to them.
  • Have clients create and share powerful stories Teach your clients the power of emotive storytelling as a means to illustrate important discoveries and lessons to followers.
  • Develop an authentic leadership action plan Help clients use the information they’ve gathered about their strengths, values, and communication to set goals about how they wish to present themselves as an authentic leader.
  • Periodically reevaluate and realign the plan With each major shift in the client’s career, have them check in with themselves to ensure their current leadership style is still authentic while still meeting the needs of their work situation.

For some useful training options, check out the authentic leadership training offered by executive coach Andrea Beaulieu  or management skills training providers such as the TSW Training Group .

If you’re looking to design a training program, look at the following free exercises to develop each of the four dimensions of authentic leadership:

  • Self-Awareness Worksheet for Adults This worksheet features 15 questions prompting insight into your capabilities, traits, and life experiences.
  • The EQ 5 Point Tool This activity walks through five steps to facilitate clear and respectful communication when broaching difficult topics with others.
  • Decision-Making Worksheet for Adults This worksheet presents six questions that support balanced and effective decision-making and decision evaluation.
  • Writing Your Mission Statement This worksheet guides users through a series of four questions to help clarify links between values, skills, and the impact you wish to leave on the world.

3 Best group activities

Online group coaching , in particular, has been effective for training clients in the authentic leadership style (Fusco et al., 2016).

For resources to support your group coaching in this leadership style, check out the following free worksheets.

  • Empathy Bingo This worksheet can help leaders and their teams practice differentiating between empathy and other responses they may have during dialog with others, including interrogating, storytelling, or consoling.
  • Generating Alternative Solutions and Better Decision-Making This worksheet can help a leader and their team systematically practice better decision-making by brainstorming many alternative solutions to a problem.
  • Spotting Good Traits This worksheet can be adapted for use with a group of leaders as a way to help them spot and reflect on positive leadership traits . Consider inviting the members of your coaching group to share positive leadership traits they have observed in one another at the beginning of the exercise.

Authentic Leadership Assessments

Authentic Leadership Questionnaire

The ALQ is one of the most commonly used tools assessing authentic leadership and was developed by leading scholars in this field (Walumbwa et al., 2008).

This questionnaire features 16 statements assessing the four above-mentioned dimensions of authentic leadership style. All items are presented on five-point scales ranging from 1 (strongly disagree) to 5 (strongly agree).

Sample items from each of the questionnaire’s sub-dimensions are as follows:

Self-awareness

  • My leader seeks feedback to improve interactions with others.
  • My leader accurately describes how others view their capabilities.

Relational transparency

  • My leader says exactly what they mean.
  • My leader is willing to admit mistakes when they are made.

Balanced processing

  • My leader solicits views that challenge their deeply held positions.
  • My leader listens carefully to different points of view before coming to conclusions.

Internalized moral perspective

  • My leader demonstrates beliefs that are consistent with actions.
  • My leader makes decisions based on their core beliefs.

If you’re interested, you can purchase a copy of the ALQ through Mind Garden .

Authentic Leadership Inventory

The Authentic Leadership Inventory (ALI) was developed as an alternative to the ALQ, given concerns about the former questionnaire’s content validity and factor structure (Neider & Schriesheim, 2011).

This inventory features 14 positively worded statements that assess authentic leadership’s four sub-dimensions. All items are presented on five-point scales ranging from 1 (disagree strongly) to 5 (agree strongly).

The full set of items is as follows:

  • My leader describes accurately the way that others view their abilities.
  • My leader shows that they understand their strengths and weaknesses.
  • My leader is clearly aware of the impact they have on others.
  • My leader clearly states what they mean.
  • My leader openly shares information with others.
  • My leader expresses their ideas and thoughts clearly to others.
  • My leader asks for ideas that challenge their core beliefs.
  • My leader carefully listens to alternative perspectives before reaching a conclusion.
  • My leader objectively analyzes relevant data before making a decision.
  • My leader encourages others to voice opposing points of view.
  • My leader shows consistency between their beliefs and actions.
  • My leader uses their core beliefs to make decisions.
  • My leader resists pressure to do things contrary to their beliefs.
  • My leader is guided in their actions by internal moral standards.

Looking for a quick way to gauge your clients’ self-perceptions of authentic leadership? Consider posing the following questions adapted from the Authentic Leadership Self-Assessment Questionnaire (Northouse, 2010):

  • Can you list your three greatest weaknesses?
  • Do your actions reflect your core values?
  • Do you seek others’ opinions before making up your own mind?
  • Do you openly share your feelings with others?
  • Can you list your three greatest strengths?
  • Do you allow group pressure to control you?
  • Do you listen closely to the ideas of those who disagree with you?
  • Do you let others know who you truly are as a person?

You can access the full questionnaire and scoring information from the University of North Carolina Wilmington website .

Here are some of our favorite practical books for integrating the principles of authentic leadership in your work.

1. Dare to Lead: Brave Work. Tough Conversations. Whole Hearts – Brené Brown

Dare to lead

Authentic leaders recognize the value of openness, curiosity, and vulnerability as keys to bringing out the potential of their followers.

In this book, New York Times bestselling author Brené Brown draws on two decades of research to reveal the keys to cultivating a work culture of empathy and connection.

Accessible and loaded with moving anecdotes from global leaders, this book is a must-have resource for anyone looking to overcome fear and begin leading with authenticity and courage.

Find the book on Amazon .

2. Authentic Leadership: How to Lead With Nothing to Hide, Nothing to Prove & Nothing to Lose – Dan Owolabi

Authentic Leadership

Even the most well-respected leaders experience moments of fear and insecurity, but that need not be the case.

In this book, Dan Owolabi breaks down the timeless principles of authentic leadership through stories, research findings, and a range of practical examples.

In particular, this book will teach you how to lead from a place of genuine confidence by first learning the skills to lead yourself .

3. True North: Discover Your Authentic Leadership – Bill George and Peter Sims

True North

In this book, the authors present the results of interviews with 125 top leaders, presenting five focus areas for realizing success as a leader.

Among these is the importance of clarifying your values and seeking integration across your life to bring about authenticity and groundedness as a leader.

The first step to becoming an authentic leader is to know thyself .

From this place of genuine understanding about your own values, limitations, and strengths, you’ll be in a better position to hear and integrate the perspectives of those you lead. You’ll also be better able to weigh up decisions and take action in ways that align with your values and those of the collective you represent.

We hope this article has given you a better understanding of the authentic leadership style and inspired you to strengthen your own leadership capabilities. And be sure to let us know in the comments if you’ve tried any of the exercises listed or explored the further reading.

And don’t forget to download our three Positive Leadership Exercises for free .

  • Brown. B. (2018).  Dare to lead: Brave work. Tough conversations. Whole hearts.  Random House.
  • Černe, M., Sumanth, J., & Škerlavaj, M. (2016). Everything in moderation: Authentic leadership, leader-member exchange and idea implementation. In M. Škerlavaj, M. Černe, A. Dysvik, & A. Carlsen (Eds.), Capitalizing on creativity at work (pp. 126–138). Edward Elgar.
  • Fotohabadi, M., & Kelly, L. (2018). Making conflict work: Authentic leadership and reactive and reflective management styles. Journal of General Management , 43 (2), 70–78.
  • Fusco, T., O’Riordan, S., & Palmer, S. (2016). Assessing the efficacy of authentic leadership group-coaching. International Coaching Psychology Review , 11 (2), 118–128.
  • Gardner, W. L., Avolio, B. J., Luthans, F., May, D. R., & Walumbwa, F. (2005). “Can you see the real me?” A self-based model of authentic leader and follower development. The Leadership Quarterly , 16 (3), 343–372.
  • George, B., & Sims, P. (2007).  True north: Discover your authentic leadership.  Jossey-Bass.
  • Goleman, D. (1995). Emotional intelligence: Why it can matter more than IQ . Bantam Books.
  • Goleman, D., Boyatzis, R. E., & McKee, A. (2013). Primal leadership: Unleashing the power of emotional intelligence . Harvard Business Press.
  • Hassan, A., & Ahmed, F. (2011). Authentic leadership, trust and work engagement. International Journal of Human and Social Sciences , 6 (3), 164–170.
  • Kernis, M. H. (2003). Toward a conceptualization of optimal self-esteem. Psychological Inquiry , 14 (1), 1–26.
  • Klass, T. (2019, July 2). 7 Strategies to showcase your authentic leadership . Training Industry. Retrieved from https://trainingindustry.com/articles/leadership/7-strategies-to-showcase-your-authentic-leadership/
  • Kotzé, M., & Nel, P. (2017). Personal factor effects on authentic leadership. Journal of Psychology in Africa , 27 (1), 47–53.
  • Kulophas, D., & Hallinger, P. (2021). Leading when the mouth and heart are in unison: A case study of authentic school leadership in Thailand. International Journal of Leadership in Education , 24 (2), 145–156.
  • Luthans, F., & Avolio, B. J. (2003). Authentic leadership development. In K. S. Cameron, J. E. Dutton, & R. E. Quinn (Eds.), Positive organizational scholarship (pp. 241–258). Berrett-Koehler.
  • May, D. R., Chan, A. Y., Hodges, T. D., & Avolio, B. J. (2003). Developing the moral component of authentic leadership. Organizational Dynamics , 32 (3), 247–260.
  • Miao, C., Humphrey, R. H., & Qian, S. (2018). Emotional intelligence and authentic leadership: A meta-analysis. Leadership & Organization Development Journal , 39 (5), 679–690.
  • Neider, L. L., & Schriesheim, C. A. (2011). The authentic leadership inventory (ALI): Development and empirical tests. The Leadership Quarterly , 22 (6), 1146–1164.
  • Northouse, P. G. (2010). Leadership: Theory and practice (5th ed.). Sage.
  • Nyberg, D., & Sveningsson, S. (2014). Paradoxes of authentic leadership: Leader identity struggles. Leadership , 10 (4), 437–455.
  • Owolabi, D. (2020).  Authentic leadership: How to lead with nothing to hide, nothing to prove & nothing to lose.  Authentic Leadership.
  • Penrod, A. K. (2017). Authentic leadership in US skilled nursing facilities: A multiple case study (Doctoral dissertation). Capella University, Minneapolis, Minnesota.
  • Pereira, B. (2015, May 18). Authentic leadership: Benefits and qualities . LinkedIn. Retrieved from https://www.linkedin.com/pulse/authentic-leadership-benefits-qualities-dr-bruce-r-pereira/
  • Walumbwa, F. O., Avolio, B. J., Gardner, W. L., Wernsing, T. S., & Peterson, S. J. (2008). Authentic leadership: Development and validation of a theory-based measure. Journal of Management , 34 (1), 89–126.

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Adapt Your Leadership Style to Your Situation

There’s not one leadership style that works for all contexts. For example, in some situations, it’ll make sense to tell people what to do, whereas asking open-ended questions will work better in others. You might need to adjust goals as new information emerges, or, under certain circumstances, stick exactly to the plan. You should adjust […]

There’s not one leadership style that works for all contexts. For example, in some situations, it’ll make sense to tell people what to do, whereas asking open-ended questions will work better in others. You might need to adjust goals as new information emerges, or, under certain circumstances, stick exactly to the plan. You should adjust your style based on the people you’re managing, the context in which you’re leading, and the outside pressures you’re under. To navigate tensions like these, you need a good deal of self-awareness. So understand your natural tendencies. What’s your default position? Do you tend to be more of a traditional leader, or do you align with a more adaptive, fluid style? If you’re not sure, get feedback from others. Then learn, adapt, practice. The goal is to develop a portfolio of micro-behaviors you can employ when the situation demands you use a different style. And look to your employees for signals on when it’s appropriate to favor one approach over another.

Source: This tip is adapted from “Every Leader Needs to Navigate These 7 Tensions,” by Jennifer Jordan, Michael Wade, and Elizabeth Teracino

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How To Write A Leadership Case Study (Sample) 

Table of Contents

Writing a case study isn’t as straightforward as writing essays. But it has proven to be an effective way of teaching complex topics, even in organizations. Want to know how to write a leadership case study ? That’s not surprising. Leadership is a dynamic topic. Hence, a case study simplifies the analysis of various leadership techniques and complexities. Since you’ve got to learn how to write one, let’s talk leadership case studies .

What Is a Case Study?

A case study is a research method that analyzes an in-depth, detailed look at a particular situation or event . It may involve examining specific events or contexts in detail and considering their implications for similar events. A case study may require gathering information from multiple sources, like interviews or observations, to understand the context of a problem or phenomenon. The research results help you develop insights and an understanding of how individual experiences fit into the broader framework of their environment. Case studies are commonly used in business research, social science, education, psychology, and health sciences.

Benefits Of Case Study In Leadership

Case reports are time-consuming and tiring. But is it worth the stress? What are the benefits of the case study? Case studies in leadership can be highly beneficial, offering invaluable lessons and insights into becoming an effective leader. They provide a practical approach to understanding the complexities of real-world leadership experiences. Here are some of the benefits that case study in leadership provides: 1) Increased knowledge – By examining specific examples from history or current events, leaders can gain new perspectives on various leadership styles. 2) Improved decision-making – Case studies allow for critical analysis of existing data. It also covers potential future scenarios, which helps leaders make more informed decisions. 3) Greater self-awareness – Examining other leaders’ successes and failures gives insight into our values, beliefs, and biases, leading to better self-knowledge and development. 4) Enhanced problem-solving skills – Studying successful strategies used by other leaders provides ideas and frameworks for dealing with similar challenges in the future. 5) Increased collaboration – Through discussions surrounding case studies, team members can develop a greater understanding of each others’ viewpoints and work together more effectively.

Person holding on red pen while writing on book

How To Write A Leadership Case Study

A leadership case study effectively shares real-life leadership success or failure. To write such a study, one should include inspiring and educational details for readers. Begin by researching the subject thoroughly to ensure accuracy in facts and figures. Then, craft the narrative around this data, adding a personal flair with anecdotes and quotes from those who have worked directly with the subject. Emphasize key points with relevant examples and create impactful transitions between ideas. Finally, consider providing insight into possible lessons learned from the experience to help others facing similar challenges.

Leadership Case Study Example

Kiara, a tech executive at a startup, is an exemplary leader. She has been in her position for over two years and continues to be successful despite the challenges of managing a rapidly growing team. Kiara’s leadership style is based on empathy and trust-building. Her primary focus is creating an environment where each person can reach their fullest potential and feel supported by their colleagues. Kiara frequently facilitates meetings with open dialogue and encourages her team to voice their opinions without fear of judgment. She also emphasizes direct communication whenever possible so that everyone knows what is expected of them and feels connected to one another. Kiara puts forth additional effort when it comes to decision-making. Before any significant changes or initiatives are implemented, she thoroughly researches and solicits feedback from other leaders. She also consults experts within the company. This ensures that choices are well thought out and align with the organization’s mission. Kiara seeks regular employee feedback to continue fostering a healthy work culture. She holds weekly “check-ins” with individuals and teams to address issues as they arise. Ultimately she creates a congenial working atmosphere for all. Kiara exemplifies authentic leadership – putting the needs of her team before her own. She takes calculated risks, trusts her gut intuition, and communicates effectively with those around her. Through these actions, she demonstrates excellent tenacity and selflessness while pushing her team toward success. This case study highlights the importance of feedback and seeking quality counsel to make appropriate decisions for your organization. It shows that leaders who are willing to put more effort into communication can find ways to thrive even under challenging circumstances.

Final Words

A good leadership case study should be an engaging read. It’s crucial to present your expertise in clear language that is easy for readers to follow. Include real examples of successes or failures when possible, as this adds substance to your writing. Draw inspiration from the sample in this article to learn how to write a leadership case study . Or use INK’s Command Mode to craft a personalized case study!

How To Write A Leadership Case Study (Sample) 

Abir Ghenaiet

Abir is a data analyst and researcher. Among her interests are artificial intelligence, machine learning, and natural language processing. As a humanitarian and educator, she actively supports women in tech and promotes diversity.

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Storey J, Holti R, Hartley J, et al. Clinical leadership in service redesign using Clinical Commissioning Groups: a mixed-methods study. Southampton (UK): NIHR Journals Library; 2018 Jan. (Health Services and Delivery Research, No. 6.2.)

Cover of Clinical leadership in service redesign using Clinical Commissioning Groups: a mixed-methods study

Clinical leadership in service redesign using Clinical Commissioning Groups: a mixed-methods study.

Chapter 4 findings from the case studies.

In this chapter we present the findings from the six main CCG case studies. Their geographies covered the North, South and Midlands of England. Rural and urban areas were covered as well as a mix of deprived and affluent areas.

The case research complemented the survey findings reported in the previous chapter by adding insight into the ways in which clinical leadership for service redesign was practised using the CCG platform. Although the cases are based around CCGs, our prime unit of analysis when researching the cases on the ground were specific service redesign attempts taking place within these settings. One or, in some circumstances, two significant redesign instances were selected for study in each of the CCGs depending on local circumstances. This approach allowed us to move beyond abstract discussion of ‘leadership’ to a more grounded analysis of leadership in action.

Most of the research effort was directed at teasing out the origins, design and delivery of specified service redesign attempts. This allowed a focus on actor behaviours in relation to real events. The CCGs were researched as part of the context but the main focus was on the role played by clinicians and the extent to which this amounted to a process of leadership. As a result of the prime focus on acts of clinical leadership within specific service redesign attempts, we arrived at eight ‘cases’ (of leadership in service redesign), because in two of the CCGs we tracked change leadership across two different service areas.

We found initiatives were being launched above, below and around CCGs. ‘Above’ were regional groupings, ‘below’ were localities and ‘around’ were various forms of collaborations with neighbouring CCGs, LAs, provider institutions and other agencies (including voluntary sector bodies). Some of the initiatives studied involved a handful of collaborating managers and clinicians – often straddling primary care and other providers in secondary care, LAs and the voluntary sector. Sometimes these initiatives were sponsored by the CCG and allocated formally to one or more clinical leads. At other times the innovations were only loosely connected to the CCG and were driven by clinical leaders from other settings, such as GP federations. The case study narratives cover these different kinds of development. Each, in their different way, helps shed light on the contours and nature of the system – the role of the CCGs, the role of providers and the parts played by managers and clinicians.

Although many barriers and blockages were revealed, in what follows we place special emphasis on tracking and clarifying how some actors have shown themselves able to surmount – at least to some degree – these difficulties. Hence, these cases offer clues to the nature of clinical leadership and thus they point to lessons from which others can learn – whatever the particular institutional form might happen to be.

In order to facilitate cross-case comparisons, each case write-up is structured in accordance with a standard framework: the context within which the CCG operates; an account of the service redesign attempt being studied; emerging insights about clinical leadership; and the overall lessons and conclusions from the case. Systematic cross-case comparisons are made in the following chapter.

  • The analytical framework

Drawing on the findings from the 15 scoping CCGs in phase 1 and the findings from the two national surveys, we were aware that clinical leadership in service redesign was being enacted in different arenas. By ‘arenas’ we refer to the settings and domains where leadership is exercised. 85 This may be a physical space (such as a board room), but just as often it will be a social space (such as different communities of practice). These arenas may be temporary and sporadic or relatively stable. Crucially, in a health service context where there are multiple overlapping organisations and professional groups that periodically come together or are brought together, the arena is a realm of interaction. In the kinds of health service redesign attempts we were investigating, influence extended in varying degrees across organisational boundaries, across formal lines of authority and across looser informal groupings. Indeed, as CCGs are decidedly not conventional hierarchical organisations, exercising ‘leadership’ in and around them is of a very different order to that found in an organisation, such as an acute hospital or a public limited company.

In and around CCGs it appears that clinical leadership was located in each of our eight case studies in three main types of arena. One of these arenas was at the strategic, policy-making level, typically located at the CCG governing body, but sometimes also involving other strategic bodies above this level. A second was found in the setting of programme boards and similar bodies responsible within a CCG for the operational commissioning of particular groups of services. A third was in the delivery setting, where clinicians involved in providing innovative services worked on the operational and practice aspects. Figure 24 displays these types of arenas in a schematic way.

Three arenas of clinical leadership.

The depiction of three different kinds of arena as points of a triangle containing clinical leadership is intended to convey a richer understanding, beyond the idea that there is a hierarchy of clinical inputs corresponding to a hierarchy of NHS authority. Our cases demonstrate that clinical leadership is needed in each of these arenas, but that the system works in an interdependent way. The relationships between the arenas are constructed through a mix of collegial, professional network mechanisms and market relationships, as well as, indeed rather more than, through hierarchical command and control relationships.

The first arena for the potential exercise of clinical leadership (point 1 of the triangle in Figure 24 ) was concerned with the development of service priorities for the whole population living within a defined geography and with the strategic approach to meeting these priorities. In the original conception of CCGs, this strategic arena was the governing body of a CCG. This is where GPs and others were originally meant to be making a difference. They were to be allocated a budget to meet the needs of a population and expected to proceed with the whole commissioning cycle, including assessing need, reviewing service provision, deciding priorities, designing services, shaping the structure of supply, planning capacity and managing demand, managing performance and seeking public views. This cycle of activity was supposed to be ongoing. From the cases studies we found that practice was rarely quite so systematic. Opportunistic funding and, in some cases, financially straitened circumstances intervened.

We found that, in three of our eight cases, tasks in this strategic arena were undertaken by clusters of neighbouring CCGs acting in concert. In one case this was a collaboration between all CCGs active within a county-wide footprint. In another case the strategic work to redesign integrated services for the elderly and those with more severe long-term conditions was done at the level of a collaboration of four neighbouring CCGs working together with their LAs. Yet, in a third case the dominant strategic arena was a collaboration between the CCG and a coterminous LA. In all cases there was a drift towards, and pressure towards, shifting some strategic issues to a higher level, such as strategic reference groups and STPs.

Across all eight cases, we were able to track instances of the nature of clinical leadership within this kind of strategic arena. The normal key focus in these arenas was putting ‘the clinical case’ for major service development initiatives, such as an integrated care initiative or a primary care development initiative. Strategic clinical inputs of this nature can be seen as paving the way for further and rather different modes of clinical leadership needed to produce service redesign, in the second and third kinds of arena. At the same time, we found that this strategic level of commissioning leadership was perhaps less emphatically provided by clinicians than might have been expected from the original aspirations attached to CCGs. Professional managers, with support from CSUs, were likely to be attempting at least some of this.

The second arena (point 2 on the triangle) allowed the exercise of clinical leadership in the matters of operational commissioning. The cases showed that much of this work took place within ‘programme boards’. These bodies were allocated the responsibility for progressing tranches of work by the CCG, each typically concerning delivering services addressing broad categories of health need, such as mental health, urgent care, or care for the frail and elderly. The programme boards sought to bring together key stakeholders. Their remit was to review current provision and identify problems and gaps in that provision, to shape initiatives, develop detailed policies, recommended contracts and monitor performance. In the cases we followed, there was evidence of work within the tradition of collaborative supply chain activity; provider clinicians as well as GP commissioning leads for the area concerned were represented on these boards and were in a position to bring to the table both the legitimate concerns about viability being experienced by providers and ideas for how to deliver services more cost-effectively. Collaborative, clinically informed discussions about the best way of meeting needs could then provide the basis for formal contracts between the CCG and provider organisations, which the programme board would then monitor and manage.

The third arena (point 3 on the triangle) is where we found clinical leaders, usually based in provider organisations, engaging in what might be termed ‘implementation leadership’. It is also where we found much of the PPI taking place. The implementation and practice arena is hugely important because grand plans would count for little if GPs, community and acute clinicians failed to respond to and enact the new ways of working called for by their colleagues in commissioning roles. Indeed, all of our cases in some way illustrate that this work at the sharp end was where most work needed to be accomplished. In practice, the exercise of clinical leadership in this arena of delivery went well beyond ‘mere’ implementation of a new service specification. Although individual provider clinicians had key roles in fleshing out the detailed clinical practices, our cases also revealed the importance of new collaborative forums for working out operational detail in integrated services. We found fascinating examples of learning occurring between different acute providers. We also saw the creation of practice networks in primary care, where learning was shared between practices about how to improve services and standards. Peer pressure, peer-to-peer role modelling, the development of a shared moral ethos and mutual learning were all vital, especially in such instances. In some cases, this arena of service delivery leadership extended beyond primary and acute health service providers and took in additional service providers, such as adult social care, housing and employment support.

An essential point of Figure 24 is that clinical leadership is exercised in different arenas and depends on different capabilities. Clinical expertise and experience had important distinctive roles to play in each arena. However, there were also crucial interconnections, grounded in the nature of clinical expertise and experience. Clinical perspectives served as an important integrative mechanism. Clinicians with knowledge of the practical conditions for implementation were in some of our cases crucial in ‘selling’ big ideas within strategic arenas and making sure that operational commissioning took a viable form. Conversely, clinicians who had worked on developing service strategies to address the unmet health needs in the local population played key roles in convincing front-line staff of the underlying rationale and ethos of service innovation.

  • Introduction to the cases

Within the context of CCGs, our focus was on service redesign in selected areas: mental health, urgent care and integrated care (especially directed at the frail elderly). These tended to be areas of focal interest for a large number of CCGs. Sometimes the way they were framed and presented varied but the core issues were widespread. Hence, we found that many CCGs were working on various forms of extended general practice and this often included attempts to redesign the provision of services for people with long term-conditions and the frail elderly, and these initiatives often involved collaborative work with community services, social services and others. In four of the CCGs we focused on just one main service redesign attempt of this kind; however, in two of them, as there were significant service redesign attempts which matched our core areas of interest, we tracked two initiatives rather than one. Hence, in total, we studied eight service redesign ‘cases’ from the six CCGs. Table 4 shows an outline of the cases.

TABLE 4

Outline of the main case studies

Below we provide a first level of analysis of the cases; the following chapter provides a further analytical discussion of the insights into the nature of clinical leadership emerging from a comparison across the cases.

  • Case A: innovating in mental health and urgent care

Case A was one of the inner-London CCGs. The CCG leadership team had been successful in making innovative use of non-recurrent central funding and it had a track record of piloting new models of service delivery. The CCG case analysis below is divided into two parts reflecting two different service redesign initiatives. The first (case A1) focuses on a mental health redesign initiative and the second (case A2) on an urgent care redesign initiative.

Case A1: innovating in mental health services through establishing provider alliances

There was clear unmet need in mental health provision, but alongside this was fragmented provision with a range of different statutory and voluntary sector providers treating different levels of severity in Child and Adolescent Mental Health Services (CAMHS) and offering psychological therapies for adults (PTA). It was in this context that a particular GP who occupied a clinical lead role in the CCG began to design a new approach to all these services by taking a collaborative approach with a range of service providers.

This case reveals the power of distributed leadership when used in combination with an initial vision, top-down determination and associated funding activity. Following the launch of the collaborative alliances the leadership and ownership was transferred, in the main to the collaborating partners.

Initiation of mental health provider alliances

The mental health programme board of the CCG worked with existing mental health providers in the statutory and voluntary sectors to form a set of alliances. These were seen as having the potential to offer a more co-ordinated and holistic approach.

The CCG’s mental health programme board clinical chairperson (a GP) worked with the transformation director to develop the alliance concept. They drew on non-recurrent funding and convened meetings of diverse current providers to form shadow alliance boards. They challenged these boards to identify a number of objectives and discrete projects that would contribute to better integration over a funding period. A proportion of the funding was earmarked as dependent on successful progress, providing a basis for further funding of activities.

Three alliances were established:

  • psychological therapies alliance – formed of seven member organisations – this included a major acute mental health trust; a mental health service provider offering mainly talking therapies for mild-to-moderate mental health issues using the IAPT national funding programme; a provider operating from within an acute medical trust; a specialist primary care therapy service; three voluntary sector organisations providing therapy; and a voluntary sector body specialising in matching people with volunteer activities available across the borough
  • dementia – this comprised three member organisations, which were an acute medical trust; an acute mental health trust; and a voluntary sector organisation providing support and activities in the community
  • CAMHS – this comprised three member organisations, which were an acute mental health trust; a ‘first steps’ child and family psychology provider operating from within the children’s division of the acute medical trust; and a voluntary sector provider specialising in creative therapies.

As is evident from the listing of the various alliance member bodies, the CCG had within its territory a very complex array of mental health services. Each of the new alliances was steered by an alliance provider board. Each of these had a senior clinical and managerial representative from each provider. In addition, there were CCG representatives in the form of the mental health programme director and transformation director. Each alliance met monthly and were, from time to time, attended by the CCG mental health programme board clinical chairperson. Governance came from the represented bodies, but the initial impetus and vision came from the clinical leadership from within the CCG.

Implementation

Over a 15-month period, each of the three provider alliances completed a number of collaborative projects, which were formulated and agreed during the first quarter of alliance activity.

The psychological therapies alliance worked on an improved system for managing referrals. It also worked on joint projects with the third sector concerned with improving access for particular ethnic groups and with preparation for employment.

The dementia alliance worked on reminiscence pods, awareness training and treatments for improving cognitive abilities. It also designed an improved navigation procedure.

The CAMHS worked on more consistent use of clinical outcome measures, clarifying referral pathways, and offering targeted training and professional development workshops. This alliance also designed a new common triage system.

The three initiatives were viewed as successful, at least to the extent that they merited continued support. Clinical leadership within the programme board, an operational commissioning arena, supported by a dedicated manager, was seen as effective in bringing some order and coherence to a complicated set of activities and services which had grown in a disorderly manner and which resulted in overlap and duplication. At the same time, leadership within this operational commissioning arena needed to be matched by clinical leadership within various provider bodies involved in implementing alliance working.

Achievements reported

From the interviews with participants across the alliance membership, it was evident that the alliance initiative was viewed in a highly positive manner. As a result of participating in collaborative projects, service providers reported a greater openness to understanding each other’s services and expertise and were much more willing to co-operate with each other. Statutory and third-sector providers that had not previously worked together reported much improved working relationships and understanding of each other’s services.

There was enthusiasm across the alliance members offering PTA and psychological therapies for children and adolescents for the ‘complex cases referrals’ meetings that became established within each of these alliances. Here, clinicians from different providers brought cases they felt the need to be referred on elsewhere. These meetings were seen as producing rich professional discussion that would not otherwise have happened and a greater sense of connection between clinicians in different services. Clinicians reported much greater confidence in referring patients on now that they understand better how colleagues elsewhere work. One participant observed:

. . . it doesn’t feel such an unknown anymore or kind of, ‘I’m sending you off, but I don’t know if they’re going to look after you like I did . . . Clinical psychologist

Alliance activities were widely felt to have built confidence for further collaboration. Clinicians in different settings had overwhelmingly positive experiences on collaborative projects and felt that they had a realistic understanding of each other’s capabilities – both strengths and weaknesses – which provided a basis for further joint working. The collection of outcome measures for these pilots contributed to this sense of achievement.

Challenges encountered

Some board members in all three alliances expressed concerns about the short-term focus. Delivery of the specific projects detailed in the alliance specifications was supposed to happen in just 15 months. This short-term focus was experienced as sapping energy from thinking about how longer-term and deeper collaboration could further overall service delivery and pursuit of alliance objectives.

However, this view was often held alongside a seemingly contradictory perspective that the achievements of these limited collaborative projects had built trust and confidence between alliance members and stimulated their appetite for further collaboration. There was also recognition that the CCG had a legitimate role in asserting the kinds of areas and priorities for collaboration that are most important for service users in the longer term.

Clinical leadership across different arenas

Interviews revealed the exercise of clinical leadership in a number of ways across the different kinds of arena identified in Figure 24 .

The initial basis for the alliances was established by a leadership dyad at the apex of the CCG, operating within an operational commissioning arena, a programme board. This consisted of the GP clinical chairperson of the mental health programme board and her managerial counterpart, the mental health programme director. The clinical chairperson articulated the objectives and mechanisms of the alliances in terms of providers working out together how best to meet the needs of their user population rather than each provider defensively retreating to the scope and categories of patients specified in their existing provider contracts. This articulation also included members of the alliance taking mutual responsibility for managing each other’s performance, rather than seeing this as something that happened bilaterally between each provider and the CCG. As the CCG clinical lead stated:

Our mantra as commissioners is assess and then treat, because for years as a GP I watched how patients get bounced around. Oh, it’s not for our service, oh, just too bad for us, oh, not bad enough for us . . . what we’ve said, and I go on about, is the John Lewis model . . . if somebody comes in this door and asks and this is not the right department, they get shown to the right department . . . for me, it’s that very basic visceral thought about what an alliance is and that should be, on a clinical level, all the people trusting each other’s assessments, having very good working relationships . . . CCG clinical lead

The CCG GP clinical leader had a vision of how the complex array of mental health services could work better and had a theory of how to bring this about. But the development of the theory and its realisation was then to be handed over to the alliance members. The main function of the theorising on the part of the GP clinical chairperson can therefore be seen as holding out a vision of how services could work together differently, without specifying detailed mechanisms for how to achieve this: the provider organisations in the alliance should take responsibility for meeting the adaptive challenge.

The strategic commissioning arena relevant to this initiative was that of the CCG governing body. The mental health clinical lead was also a member of this board and obtained backing from this board. In terms of institutional work, clinical leadership in this arena can be seen as involving advocacy and achieving the vesting of resources and responsibilities in alliance working.

Clinical leadership and institutional work also took place in the operational delivery arenas as senior provider clinicians shaped the actual practices of working in alliance mode. Without exception, providers saw the work of the alliances as improving collaboration between the separately commissioned services, but they wished to maintain the distinct identities, competencies and the connections that each separate provider workforce draws on:

The model of separate organisations forming an alliance I’m for. But the model of separate organisations all coming under one host organisation and being subsumed, I am not for . . . Clinical psychologist

An underlying tension derived from the different professional ethos of providers that are closer to the medical model associated with psychiatry as opposed to clinical psychology or family therapy which work with a more socially based therapeutic approach. Staff in each provider preferred to continue to manage the professional tensions and syntheses they already knew, rather than be cast into more direct interaction with clinical and managerial traditions they knew less well.

A key element of leadership among senior provider clinicians working in operational commisioning arena was in reconciling commitment to collaborative working within the alliance with continued efforts to develop the distinctive capabilities, ethos and, indeed, funding of their ‘home’ organisation and service. This was a form of institutional work: developing the interfaces between the patterns of service activities offered by each alliance member.

This institutional work involved the development of a normative network of clinicians across each alliance. We have already described how clinicians cohered around the shared articulation of providing a more integrated experience for service users. The development of this normative commitment was fuelled to a considerable extent by the dissatisfaction of many clinicians with the kind of contract-driven performance management they experienced in their ‘home’ services, where their performance was scrutinised by the CCG in terms of metrics (e.g. numbers of people receiving and completing programmes of therapy of defined length and recovery rates based on user-assessed clinical outcome measures).

The institutional ‘interface work’ of provider clinicians within the alliances can be understood as involving a reinterpretation and blurring of these apparently neatly defined categories of severity, of ways of measuring progress with the improvement of symptoms. Rather than seeking to define new ways of treating mental illness, these clinicians were involved in advocating and developing new ways of blending or combining existing definitions. Clinicians held that the degree of need of particular people was difficult to assess at the outset and often proved difficult to match with a particular ‘mild to moderate’ or even ‘severe mental illness’ categorisation of services. As one interviewee observed:

. . . to get into any one of the teams or the wards, you’re not IAPT . . . you’re ill, you’re really ill. But then . . . people might be getting better. And I really think this is one of the problems with the whole PbR [payment by results] system is that somebody could drop down to the wrong cluster, and then you begin to get worried about how long you can continue to see them for . . . The other sort of confusing thing about clients is that sometimes you feel that they’re very cut off from their difficulties. And so it’s difficult to know where to cluster them . . . Senior clinical psychologist

This meant that a key feature of an effective system of provision was finding ways of combining different therapeutic approaches and helping users manage transitions between them.

A further manifestation of this clinical leadership work of undoing existing definitions of users and services took the form of what was described as ‘pushing back’ on the commissioners. Alliance members said that they needed to articulate the need for the most effective intervention models for the clientele being seen, for example making the case for models that go beyond the six-session brief therapy model as the standard, given the complexity and severity of many cases. There was thus a degree of ‘reverse leadership’ with the institutional work of theorising and design coming from ‘below’.

There was also evidence of productive tension between the clinical leadership perspectives of commissioners and providers. Although both groups embraced the overall goals of providing seamless and comprehensive services for users, commissioners tended to emphasise the collective responsibility of providers to fill gaps by working creatively with existing resources, whereas providers emphasised the responsibilities of commissioners to fill specifically identified gaps. A feature of clinical leadership on both sides was the willingness to work through such tensions.

Case A2: innovating in urgent care – a combined general practitioner and paramedic service

Across the country as a whole, urgent and emergency care has been a recognised problem across the health service for some time. There has been rising demand and the service has found it difficult to cope with the numbers and the expense. A consistent case has been made for the need to reduce the numbers attending A&E departments. Many different ideas have been put forward about how to resolve the problem. In this case study we focus on one specific innovation which seeks to tackle the issue. It is a study of leadership from the CCG in the redesign of one focused aspect of urgent care. It involved stakeholders from the ambulance service as well as local GPs.

Leadership at the initiation stage

This urgent care initiative emerged from discussions at the CCG urgent care programme board. This was chaired by a GP, from the CCG governing body, and its deputy chairperson was the clinical lead consultant in emergency medicine from the acute hospital. The board included a range of other clinicians: a senior nurse from the acute hospital emergency department; senior paramedics from the regional ambulance trust; and senior GPs from an urgent primary care centre co-located with the acute hospital emergency department and from the out-of-hours GP provider. Its membership also included a patient representative and managers from the CCG and from the various providers involved in urgent and emergency care.

The idea was to set up a ‘blue light’ car operated by the ambulance trust but crewed by a paramedic and a GP. This in effect meant that selected 999 calls were allocated to primary care. The idea emerged from the urgent care programme board. Further theorising work for this initiative was undertaken by a senior paramedic (employed by the ambulance service), in conjunction with the clinical lead from the emergency department of the local hospital.

They were aware that paramedics often felt frustrated in their attempts to keep patients from being conveyed to hospital because they could not find a way to refer effectively to any local services which could provide care to patients at home.

Shortly after the production of an initial scoping document, the ambulance trust manager invited the GP chairperson of the urgent care board to go on an ambulance shift to see the kinds of cases that ambulances are called to and to assess for herself how a GP within an ambulance crew could intervene to treat patients at home and avoid the need to carry them to A&E. That GP-led alternative service was at the heart of the idea.

The main target group from the outset was elderly people with complex conditions and multiple medications. Ambulance crews often did not feel confident that they could leave such patients at home, and so they tended to play safe and transfer such cases to A&E. However, with a GP as a member of a paramedic crew, it was judged that they would have the professional knowledge and skills to make an informed assessment and to allow some immediate treatment decisions to be made. These GP crew members would also be able to directly refer patients rapidly to other services that could provide care at home. These wider services included a multidisciplinary, first-response duty team, specialist teams for respiratory conditions and heart failure and out-of-hours community nurses who can deal with dressings and catheter problems.

Such services meant that many patients can receive the same treatment at home as they would in hospital, without having all their home-based care plans cancelled and their independence undermined. Paramedics are typically less familiar with the well-developed range of home-oriented care services in the borough, and in any case may not have the experience to refer patients to them in the same rapid manner as a GP.

The wider context of establishing the pilot is that, across London, ambulance crews were perceived as commonly experiencing difficulty in getting support from primary care when they encountered a patient whom they judged could be cared for outside of hospital. They sometimes conveyed patients to hospital in the full knowledge that it would be better not to. There was a perceived culture of believing that GPs would not respond, even within normal surgery hours, based on reports of a few bad experiences that circulated widely. Furthermore, ambulance trust managers wanted to increase awareness among GPs of the range of help that their paramedics can offer, beyond carrying patients to hospital.

Implementation: activities and achievements

The service consisted of a car operating from late afternoon into the early hours of the morning, crewed from a roster of four GPs and four paramedics. Several aspects of the new service were developed incrementally in the context of its practical operation. The incremental nature of the initiative reflects the kind of ‘adaptive leadership’ we discussed in Chapter 1 .

Leadership, in this phase, came from the clinical lead GP from the out-of-hours service, working with the four paramedics, the ambulance area manager – also a paramedic – and the ambulance trust medical director responsible for clinical governance. This grouping worked on defining operational issues, such as clinical record keeping, activity monitoring and clinical governance, particularly the circumstances in which the GP or paramedic had lead responsibility for a patient. This group developed and documented a range of clinical procedures appropriate for a GP–paramedic team, including taking urine and blood samples and getting results from the hospital laboratory during the same shift, if this was relevant to immediate treatment. Otherwise, tests were followed up by the patient’s own GP the next day.

Calls for the new service initially came through one of two routes. First, other ambulance crews or ‘first-response’ cars who attended a patient and assessed them as appropriate for the new service could make a request to the ambulance control room. A second route came via direct allocation by the control room based on their initial call triage. After a few months into the trial a third route for jobs emerged when crews on the service were concerned that they were not getting enough appropriate calls. The GP lead and paramedic crew members realised that they could use their own mobile visual display of the ambulance trust’s computerised job tracker system to view annotated details and locations of jobs currently awaiting dispatch, and from this self-identify appropriate jobs in a proactive rather than reactive manner.

Interviewees cited the achievements of the pilot service as the proven value of the GP–paramedic service; that unnecessary hospital admissions were being avoided; that the regular ambulance resource had been kept available for other jobs; shared knowledge was enhanced; and skills upgraded.

There was debate as to where the boundary should lie between patients who have a clear need of the combined skills of the paramedic and GP and those who perhaps could call the out-of-hours GP. Some argued the case that there are patients with long-term conditions, or their carers, who become panicked at a particular event or symptom and feel disempowered to use their usual coping strategies. They may also have felt that their GP has not been responsive in some way. Such people call ambulances in desperation.

The case for continuing the service after the pilot period was widely linked to increasing the number of suitable jobs each shift. By the end of the pilot period, the service was attending an average of around five patients per 12-hour shift. The CCG wanted this to be six or seven; the typical attendance for other ambulances and first-response cars was around 12 per shift. Although it was recognised by both the CCG and the ambulance trust that the service attendances were likely to take longer than regular emergency calls involving conveyance to hospital because of the treatment and possible onward referrals involved, there was acceptance that the number of jobs per shift needed to be greater.

As a result of shortages of paramedics, the ambulance service and CCG agreed to take forward a modified version of the service which consists of a GP accompanied by a driver. This now operates from the local ambulance garage so that links with paramedics and other ambulance crew are maintained.

Two kinds of clinical leadership were found to be important in this case:

  • within an operational commissioning arena in the form of the urgent care programme board, there was leadership from a CCG GP, supported by a managerial programme director
  • leadership from provider–clinician members of the programme board, in particular emergency medicine doctors and paramedics in defining novel service solutions within an operational delivery arena.

The CCG urgent care lead GP and corresponding programme director were able to carry the case for funding this initiative to the strategic commissioning arena of the CCG governing body. This institutional work of achieving the vesting of resources in a new initiative was vital.

Characteristics of clinical leadership for service redesign with this Clinical Commissioning Group

Together, these two cases illustrate the distinctive roles of clinical leadership in first articulating the conception of a new approach to service delivery and then defining the operational realities of the new service. They show that the former aspect of clinical leadership can take place effectively in an arena such as a CCG programme board with operational responsibility for commissioning. The operational realities then need to be worked out in more practical detail by lead front-line clinicians in provider organisations. This second mode of leadership is of an adaptive kind. There is a need to bring the learning from operational experience with the new arrangement back into the commissioning arena. This can be seen as a further integrative element of clinical leadership, spanning the commissioning and provider roles.

  • Case B: redesigning general practice and primary care

This CCG is located in a part of Birmingham where the health of the population is generally worse than the England average. The CCG, which formed the site of this case study, derived its GP practices from three different former PCTs. The associated variability in practice and expectation is an important element in the case narrative. The CCG inherited huge variation in standards and coverage of care across its patch. The potential for GP practices that were to become unhappy with attempts at reform to renounce membership and join another CCG is also a significant feature. Loss of GP practices meant loss of income for the CCG. This was a very large CCG with > 100 GP practices and, as such, it saw a need to allow the localities a greater degree of influence than was often the case in other CCGs.

Focus and theme of the case: the primary care improvement programme

The research in this CCG focused on a major attempt that was made to redesign primary care across the whole patch. The particular focus of that initiative were the services provided by GP surgeries. The programme is of special interest here because it represents a service redesign initiative driven at the CCG strategic level and it used the official channels of the CCG.

The problems to be tackled included unacceptable variation in the range and quality of care offered in GP practices across the CCG. There was also a lack of uniformity in the pattern of payments: practices were paid at differential rates for the same kind of work. It was the chairperson of the CCG and the accountable officer (both GPs) acting in concert who took the lead in identifying these issues as a priority. It is noteworthy that at the time (2014–15) many other CCGs were not viewing GP services and primary care as a main concern. It may be speculated that it was the ‘new broom’ aspect – with new leaders of a new territory – which allowed and prompted this dispassionate appraisal of these primary care services. Conversely, those CCGs with established teams of people who had a long history of working together in, for example, the previous PCTs may have been less inclined to make such a new determined effort. (Conversely, the benefits deriving from long-established working relationships were noted by others in different circumstances.)

The service redesign solution was a three-step approach to reform. The first step was a baseline which all the practices were required to meet. This was a mandatory requirement to remain a member of this CCG. The second step was to standardise the local enhanced services offer. This meant that practices (in cluster form if necessary) were asked to improve their range of services so as to meet an acceptable standard. This started out as a voluntary exercise but increasingly became a requirement. The third step was a higher level of innovation in services offered. The CCG used a budget provided from the centre, which was geared towards care for the elderly, to invite bids for new enhanced services in this area.

We first describe the primary care improvement programme (a pseudonym of the title actually used by this CCG) as it was presented in official terms. We then present an analysis of how the programme was received and understood by multiple agents, including some of the designers of the programme and those who were the recipients.

The official picture

The main initiative driven by this CCG was a service improvement programme designed to make a step change in the quality of primary care. The key declared objective was to:

Reduce the level of variation in general practice and bring all practices up to the same standards of primary care. Through [primary care improvement programme] we will ensure there is universal coverage of services across our member practices and that these services are available for all patients, regardless of where they live. Case B: CCG policy document

Attention focused on holistic care, integrated care, long-term conditions management and better care for the elderly and vulnerable. The constituent elements of the new model of primary care included universal coverage of some basic service standards across the whole CCG population; an overarching framework that allowed the freedom to identify creative solutions for how patients receive their care while ensuring accountability for care remains with practices; delivery of a patient-centred and integrated approach to improving primary care management of long-term conditions; and an up-skilled general practice workforce to deliver services that had previously been provided by secondary/community providers.

This was a 3-year programme which commenced even before the CCG was formally and officially invited to become involved in primary care co-commissioning. It required an investment of approximately £25M. Integration, access to mental health services and a transformation of urgent care were all elements of the total package of reform.

The programme rationale noted that the previous scheme of enhanced service contracts had ‘not delivered improvements’. Interviewees told us that this was because the previous scheme had been ‘too transactional’ and was based on process measures which were too mechanistic. The new plan from the top leadership duo was for a more integrated system built around general practices. This included new models of care with GPs and others working in new ways with support from secondary care, while also bringing in associated community services, community nursing and district nursing. Supporting elements included data sharing and use of the BCF to integrate social care. The problems of pressures on general practice, fragmentation and lack of a universal and equitable service provision were further reasons justifying action.

In exchange for extra funding and support, the GP practices in the CCG were expected to offer care closer to home, delivering a wider range of tests and investigations in primary care settings, such as electrocardiography, spirometry and insulin initiation. These steps were expected to reduce referrals to secondary care. Each service area, such as diabetes care, chronic obstructive pulmonary disease and asthma, had an associated set of target outcomes. For example, the plan stated that 90% of patients with type 2 diabetes should be managed outside the acute trust. The plans also included a place for appraisal of practices in relation to their conformance.

None of these interventions was without controversy. A number of GPs were very reluctant to accept the changes. The leadership skills of the CCG chairperson and accountable officer were very necessary. They undertook institutional work in conceptualising the required nature of the changes and in the creation of new institutional forms in place of long-standing and embedded institutional practices, which tended to emphasise and privilege professional autonomy.

The programme included some elements of PPI and, as was indicated in the survey results, clinicians are sometimes leaders of this process, as in this case. Part of this was through ongoing channels, as in the cases of respiratory and mental health, but in addition there were some special stakeholder consultation events. These included talks with the Patients Council and other patient participation groups. The part played by clinicians as front communicators was seen as very important in this context.

We encountered similar service redesign programmes in other CCGs, albeit rather less well elaborated and systemic than in this case. In the next section we analyse how various actors sought to lead these initiatives and how actors on the receiving end experienced them and how they responded.

Findings from the interviews and observations

The focus of attention for this CCG was without doubt on primary care itself. This large measure was because the CCG realised it was inheriting disparate systems and an uneven scope of services across practices as well as uneven levels of quality of service. The incoming leaders of this CCG held no attachment to the inherited systems and felt an urgent and pressing need to resolve the evident issues in primary care provision across its territory. Unevenness in the quality and range of primary care services across the different GP practices was the stated reason for a call to action. This point of focus is interesting because, at the time of its commencement, this initiative preceded the co-commissioning of primary care. In the many cases where CCGs largely represented pre-existing teams and localities, this prompt for change may not have been felt.

The initiative was widely viewed as having merit, but it was the availability of special funding which prompted the move to action:

We had funding available. What did we want practices to do? It was really interesting. So, people were throwing in ideas. It’s something that I never saw happen in PCT days where there would always be a specific problem to solve. This was a general performance approach and people were throwing in lots of ideas. I genuinely believe it ended up being the most successful piece of quality improvement I’ve ever seen. GP governing body

The leadership was identified, by numerous informants, as essentially stemming from three persons at the head of the CCG: the accountable officer, the chairperson and the deputy accountable offer. All three were GPs. As a team they carried a great deal of credibility. One issue was that they all came from larger and more successful practices, and some of the smaller, less successful, practices at times felt that their situation was not so well understood. Nonetheless, there was little doubt from the interviewing across the wide range of informants that this CCG was seen as ‘clinically led’.

The number of accountable officers who are GPs has been in steady decline across the country. In this case it was argued:

A GP accountable officer carries more credibility with the clinicians. However, I think the clinicians in those roles find it quite tough sometimes because it is not something that clinicians are trained for. A governing board member

The resistance from some of the smaller practices to the raised expectations for higher standards across all GP practices was seen by the proponents of change as defensive and a desire to continue with long-standing ways of working. The fact that the changes were being driven by fellow clinicians made it difficult for the resisters to argue that the initiative was a political or bureaucratic attack on the profession. Instead, the point of contention was that the clinicians who were leading the changes were somehow ‘different’ in that they came from more privileged, better-resourced and larger practices and, as a result, were insufficiently aware of the challenges faced by smaller practices in difficult areas.

There was an also an additional view that those GPs who had accepted leadership roles, either at locality level or at the CCG, were in danger of switching their identity and their allegiances from being first and foremost ‘a working GP’ to a rather different stance of being ‘leader–manager–clinician’. Some of the ‘ordinary’ GPs who were interviewed made the point that these role holders were in danger of losing touch with the day-to-day demands of the work in general practice. Notably, even some of the interviews at CCG level also accepted that there was a challenge in this regard. They normally expressed this by saying that such a shift in perspective might arise if the clinical leader ‘stayed in the role too long’. Moreover, they accepted that as a result of the innovation in primary care, the role of the locality leads had undergone a shift in nature. As one GP who sat on the CCG board commented:

I think that these roles [the locality leads] have emerged into being roles that are less clinical and more performance and operational orientated . I commend the people who have taken those roles on, they are doing a difficult job. It is also worth noting that these roles are still emerging, in terms of capability and conduct. A governing board member (emphasis added in bold)

As a result of the drive to push through the primary care improvement programme, the nature of the leadership adopted was seen by some informants as essentially ‘directive’. The baseline level of the improvement programme (i.e. the absolute minimum, must-have scope of services and the quality-assurance measures) was mandatory. The time when mere transparent comparative measures and implicit peer pressure was judged as a sufficient ‘nudge’ for practices to be persuaded to come up to the mark was gone. To remain a member practice of this CCG it was necessary to conform to a formal service-level agreement.

The second level of the improvement programme (the offer of a range of extended services, such as electrocardiography, spirometry and diabetes treatment) was semi-mandatory in the sense that, although individual practices did not necessarily have to provide these themselves, they had to do so in partnership with other practices. This opened the way to a third level, which was to encourage bids for innovative services. These tended to involve some transfer of work from the acute providers into general practice. This was optional, but peer pressure and demonstration was helping to drive up standards all round – with a few exceptions of around half a dozen practices which were seen as needing more direct attention. In this sense, the case illustrates a step-by-step approach. To some degree the initiative has characteristics of being mainly a service quality improvement programme, but in other ways it has some features of a service redesign. The crucial point in terms of our analytical framework is that institutional work was being done which was creating a new set of working norms. This was effected through two main arenas of clinical leadership: the central CCG based around three GPs as core leaders and out in the localities where GP leaders had adapted their role from being primarily representatives of those localities and as prime channels of communication up and down the chain, to a new role of determined drivers of change insisting that the new standards of service were being developed and delivered. This also meant, as we saw in the previous quotation, that a more ‘performance management’ element was being introduced into the primary care arena.

Given the nature of the service redesign initiative, performance management was a key element. The CCG had its own system of assurance visits. It wanted to be sure that its payments were being matched by the required services being offered. The CQC was seen to be an additional quality control and the CCG welcomed and used that extra leverage.

There were some concerns about conflicts of interest. This was seen most clearly with regard to the expanded services (at levels 2 and 3). These services were offered by local provider groups – sometimes known as delivery units. These local units were the same bodies as the commissioning locality bodies. Hence, the local network lead (a commissioning role) would often be the person leading the design of the expanded service (a provider role). Meetings of these locality groups were often divided into two parts so that both roles could be addressed at the same meeting with the same personnel. As one CCG manager observed:

Conflicts of interest are huge at the moment, and it does concern me. I think whether you have real or perceived conflicts of interest you need to have a policy and a strategy for dealing with that. So I think what [this CCG] has done with their GPs is really good but the mechanism by which it’s been done could be challenged: was there a tender process? You know, why did the CCG support one organisation and nobody else? So there is that kind of challenge that would be legitimate, I don’t think you’d have many other providers coming forward to do it but the process needs to be quite transparent and clear, doesn’t it? CCG manager

Part of the issue was seen as the urgency of the problem to be solved:

I think there’s been a rush and so it has been poorly planned at times. Desperation even, we are in a really tough economic climate, we’ve got to transform radically, quickly and at scale. So you’ve just got to get on with it and not have the barriers in place, which I think in one sense is a good thing, we’ve got to get rid of barriers. But on the other hand, you’ve got to have assurance and safeguards in the system and that’s been developed subsequently to new models emerging and I think it should have been done beforehand. Regional-level player view

A related view came from a secondary care doctor:

I think that, generally, clinical leadership has to be system wide, it has to be unconflicted and, I would say, mostly void of commissioning or provider responsibility. I think that’s where I see myself sitting and I am seen as a fairly impartial voice, but I think at CCG level it’s really tough for the clinical leaders to be seen as impartial system leaders because they are not, because the system is designed in order to prevent that. I think it’s good to have clinical leadership in the system, there is no doubt that is the right thing to do. I think real clinicians have the interests of patients and populations at heart but all we sometimes see emerging is clinicians who get into those roles who suddenly have the interests of their organisations at heart, rather than the patients and populations. Secondary care doctor

There was uncertainty about the sustainability of these arrangements. In general, it was believed that the direction of travel was towards the provider role. Indeed, a popular interpretation was that the primary care improvement programme, through its challenges and demands, had stimulated a new provider landscape in general practice and that the logical outcome would be the creation of accountable care organisations (ACOs).

The concerns about conflicts of interest and the related concerns about whether or not there was appropriate open tendering to allow potential alternative providers the chance to come forward reflect, in large measure, the wider institutional field prevailing at the time. The logic of open competition and challenge sat alongside an alternative logic based on the idea of improving services, although more effective collaboration among current providers. The institutional field altered during 2016–17 in that the erstwhile emphasis on the competition/challenge logic has been subsumed in favour of the planning and collaboration logic, as seen in the support for STP from the centre and the altered stance from NHS Improvement.

The lessons about the process of change include a view that the CCGs offered a mechanism to exert peer pressure more effectively. There was regular reference to some version of the 20–60–20 rule. The first category were those GPs and related professionals keen to effect a change to a better service. The second category were those seen as willing to be persuaded if the transitionary complications could be resolved. The third category were seen as laggards and even ‘troublesome’.

The membership nature of the CCGs meant that the process of change had to be handled cautiously, although at the same time it also could be used to lever change if the middle group could be persuaded to agree. The membership character also meant that malcontents could ‘jump ship’ if they were dissatisfied. They might negotiate transfer to another CCG. In one respect the CCG leadership welcomed this safety valve, it offered a means to be free of troublesome members. However, on the other hand, it came at a cost, as loss of these practices meant a reduced income stream for the CCG.

There was a view that, although the CCG was undoubtedly doing a valuable job through its single-minded commitment to primary care improvement and that the CCGs were an effective mechanism to enable that to occur, there were limits to this tool. The wider challenge was seen as a fragmented system with perverse incentives and vested interests which would resist these kinds of interventions beyond a certain point. This need was identified prior to the STPs. One of the interviewees on the periphery of this CCG made this point:

The NHS is so fragmented in terms of regulation, accountability and the rest, it needs to be unified. We have taken steps to bring together our clinical leaders across the [region] from both CCGs and providers. It also includes things like clinical networks, clinical reference groups, Health Education England, academic health science networks, Public Health England. All those bits that have been so fragmented. I’m trying to pull that together. A regional stakeholder

That task was made extra difficult by the lack of coherence of the various bodies, as one informant said, ‘there is serious lack of co-terminosity’. That aspect has arguably been party addressed by the STP initiative. The need for such changes were being identified by the actors in this case. A further example of this prescience was the informant who argued:

I think that the new models of care aspire towards becoming ACOs, and to me it doesn’t matter from which direction you tackle that. So, whether you have MCPs [multispecialty community providers] or PACS [primary and acute care system] it doesn’t matter, often they are going be ACOs anyway. There is a lot of support for MCPs in the system whereas people often feel quite threatened by the PACS model. The initiative to generate primary care provider organisations is sensible. However, it is worth noting that the PACS model, with a hospital base, has the advantage of a better resourced and professional management structure and capability. Secondary care clinical lead

The new models of care were generally welcomed by all those whom we interviewed. They were regarded as mechanisms which could help resolve many of the issues associated with the CCG initiatives taken to date as discussed earlier. The level 3 element of the programme, which involved innovations which could transfer appropriate services from hospitals to primary care, was recognised as precarious. Where clinicians talked to clinicians (GPs to consultants), it was argued that they could often identify areas of agreement about which services could be transferred. The consultants were pleased to be rid of much of the high-volume routine work. However, there was the question of the implications on the income flow into the hospitals and the means by which funds would be transferred to match changes in activity. The finance managers were cautious but, given the penalties imposed for breaches of performance targets, they too could be persuaded to relinquish some of this kind of work. The scheme’s funding was based, at the higher levels, on a matching fall in activity and cost in secondary care. The money to primary care was paid upfront. At the time of our research at this site there was huge uncertainty whether or not the corresponding alterations to activity in the acute sector were happening. There was no doubt, however, that general practice across the CCG had been improved even though there was more to do. A few general practices decided to transfer to a neighbouring CCG in order to avoid the change programme.

Summary: clinical leadership across different arenas

Clinical leadership was present in this case in the form of a determined push by a close group of three GPs at the summit of the CCG to reform primary care as a whole and general practice in particular. This leadership was enacted in all three arenas outlined in the analytical framework presented at the start of this chapter (see The analytical framework and Figure 24 ). The strategic planning was undertaken in the arena of the CCG central governing body. The operational activity was undertaken in the programme board for primary care and in the locality groups. The third arena for institutional work was at the practice level; here, the distributed clinical leadership was of a more variable nature and some GP practices moved ahead in delivering the primary care improvement programme much more fully and rapidly than others.

Notably, the kind of institutional work being undertaken by the leaders in this CCG was bounded by the institutional reach which they judged they could attain. They challenged existing practices, prescribed new versions of acceptable practice and set new levels of attainment. This required a complex mix of joint problem identification, joint problem-solving, visioning, contingent reward and, ultimately, prescription and monitoring.

  • Case C: redesigning early intervention services for mental health

Focus and narrative of the case

This CCG sought to transform mental health services through the design and launch of a ‘hub and spoke’ model of mental health provision. The hub component was a ‘well-being hub’ which operated under the broad umbrella of a mental health service in which intended service users were those with mild and moderate mental health issues. Many of these service users were often experiencing one or more other difficulties in life, such as family or financial problems. The prime purpose of the well-being hub was to bring a number of services together so that complex social, as well as mental well-being, issues could be tackled in a holistic manner. It provided the more established treatments, such as counselling and cognitive–behavioural therapy, and it also offered services such as employment support and chaplaincy. As a ‘hub’, it operated a triage system that was able to refer patients out to one or more local ‘spoke’ services. There was a single initial point of contact and a central database of patients’ records, administered centrally by the hub. The records were selectively shared with the spokes so that the patient did not need to undergo multiple assessments.

The initiation of this project was widely attributed to a single individual: a respected GP with a long-standing interest in mental health and also the CCG’s current clinical lead for the area. A senior manager described this leader as ‘driven and passionate’. Another interviewee connected to the hub identified ‘a strong sense of moral responsibility’, while also highlighting the leader’s networking skills and persuasiveness. One key figure from the third sector, a chief executive of one of the hub’s spokes and also on its board, corroborates these observations in describing how:

You couldn’t fail to be, you know, swept along by what he was saying about the need for this service, about the solutions, about the options, and about what works. Third sector chief executive

According to this testimony, the clinical leader in this case appears to have undertaken institutional work which cuts across a number of the categories in Lawrence and Suddaby’s classification. 70 This work included ‘disrupting’ prevailing institutional arrangements, ‘theorising’ alternative vision and ‘creating’ a new set of institutional arrangements. These were accomplished in a manner which engaged, indeed ‘swept along’, the diverse players in the wider system.

Reports relating to the start and the background of this service redesign initiative for mental health care often mentioned the clinical lead’s personal professional history in the area of mental health, as he had a significant role leading mental health during the days of PCTs. In other words, prior reputation added to the credibility of the clinical leader’s suggestions. Yet, at the same time, his known history included a willingness to step aside on grounds of principle when he dissented from a course of action. It was reported that he had resigned from his PCT role because he was ‘disillusioned with the role’. It was stated that ‘working with the mental health trust around contract management – it was just not [his] thing’. As a result, he did not simply crossover from the PCT to the CCG as mental health lead during primary care’s restructure, but stood for the role relatively recently when he ‘just got absolutely fed up with waiting for the system to catch up with him and he saw the opportunity offered by the CCG’.

Interestingly, this reveals the mixed opinions about the way this individual operates as a clinical commissioner. One senior manager, working specifically in mental health (and with the counterpart clinical leads in neighbouring CCGs), described how this clinical lead had the critical combination of:

Understanding the commissioning process and being respectful of that process and understanding that there are steps that we need to take to make sure that we don’t leave ourselves exposed, organisationally, to be challenged. Manager

In other words, this clinical leader had won the respect of managers through a demonstrated knowledge and understanding of commissioning and the risks and pitfalls associated with it. Managers made the point that passion, although important, on its own is not enough; the leadership that they observed on the basis of this example requires credibility won through awareness of the complexities surrounding mental health services that cut across multiple providers and agencies.

Despite the deep knowledge demonstrated by this clinical leader, the point was also made that, even in such a case, management support was crucial if real change was to occur. Partnership between manager and clinician was frequently reported as being required and indeed as being indispensable. Although the clinical lead brought forth the ideas and passion, the registrar followed up expressions of interest to attract ‘spokes’ into the hub arrangement, developed a business case for the CCG to pilot the model and helped to figure out how to construct an evidence base which would justify the ongoing funding and support for the new model.

Networking and relationships were a significant part of the hub’s foundation and continued survival. The clinical lead explained how he:

Just pulled loads of people in, people that I’ve known for ages, like the third sector organisations, people from the children’s mental health services, adult mental health services, from the police, from, anyone who was interested and wanted to be involved.

This quotation illustrates the power of an extended network around the clinical leader – a form of social capital. He described himself as playing a ‘facilitative’ role, one of ‘co-ordination, linking people together and getting them to find out what could be done’. This personal account was echoed by our other informants.

Turning passionate leadership and supportive relationships into something tangible required resources. Here, the localism of the CCG proved critical. Presenting the specific needs of the local population for the hub and testifying to both the collaboration of local practices as well as the need for funding, one long-standing GP said:

We felt that the needs of our patients were unique, they were a very transient, mobile population, quite deprived – we service three big council estates . . . So we started talking about this a good 10 years ago. A few models were set up, and at least twice, I think, we got together to work out some kind of a working model but on both occasions, due to commissioning failures, to funding failures and for other reasons, things fell apart. It was very difficult to untangle the money that was actually in the community.

The locality networks were given a pot of money by the CCG:

To spend on what they want to do as long as they can account for it. They can spend it on running their network or doing local network projects or whatever else they see fit to make the new model work. CCG manager

From the CCG’s perspective, ‘the way [the clinical lead] really got it going was by influencing his fellow GPs in his network to support it’. Once this was established, the CCG’s role was to ‘provide fire cover for this commissioning and growth of new services in the communities’ (CCG manager).

A small amount of funding was allocated to a third sector organisation, which administered the city’s mental health consortium, to cover the construction of the database and the processing of applications from potential spoke services (with members of the mental health consortium being automatically eligible). Part of the funding was also reserved for two research projects: one to help capture and structurally develop the model as it progressed, effectively articulating the ‘proof of concept’; and a second to evaluate the hub against outcomes at a later date. The hub began operation as a 2-year pilot with 14 spoke services, the majority of which were working on the basis of goodwill, subsidising their participation through their patchwork of other funding because of their belief in the project and their hope that a successful pilot phase would lead to the hub becoming a formally commissioned service. This way of working illustrates the power of goodwill once the disparate organisations were convinced of the value of the new arrangements.

Patients were signposted to the hub by GPs from six GP practices. Users could also self-refer if they lived in the locality. Once initial contact was made with the hub they then underwent a triage process. This triage service was staffed on an alternating basis by individuals from one of the five spoke services. That there were five spoke services sharing the triage function (1 day a week each) was a result of the lack of funding and the abundance of goodwill to make the model work. It was argued that in an ideal world, a fully costed and commissioned service would have one central point of contact that would manage the patient’s data and journey, seamlessly, around the spoke services.

In the live pilot, not everything went smoothly. There were disruptions in the sharing of data between spokes and inconsistencies in their approach to triage. Although initially seen as ‘teething problems’, this data entry and management at the point of triage and subsequently (once the patient had been referred to and used a spoke service) was actually critical because completion of the hub’s well-being measurement tool at both these points would serve to provide data on the services’ outcomes. These data were important because they were used to evaluate the success of the arrangement and, ultimately, whether or not it could be justifiably commissioned on a continuing basis.

It was reported that the registrar’s completion of her training and her departure from the CCG around the middle of the hub’s first pilot year was a significant loss to the project because it undermined the daily driving force and compromised operational oversight. It was argued that, since her departure ‘things seem to have just got all snagged up in CCG governance issues’. This indicates that, running alongside powerful clinical leadership in terms of vision, plans and advocacy, if a new service is to be maintained over the long run it also requires efficient and competent administrative and managerial support services.

One of the organisations which offered one of the spoke services (the main mental health trust) eventually exhausted its goodwill and it withdrew its service. The IAPT service provided by the mental health foundation trust provided the hub’s triage function 1 day a week and, being the main provider for popular therapies, such as counselling and cognitive–behavioural therapy, it received the vast majority of the hub’s referrals. It was stated that the lack of funding was an obvious hindrance. However, additionally, the oversight and measurement regime proved to be too demanding. A manager in that service told us:

I can’t train 100 staff in another set of outcome measures. We just don’t have the resources, or the need, to do that, and, you know, we’ve got so many outcome measures and targets that we’ve got to fulfil anyway. It was just impossible to make sure that every patient that came from the Hub . . . given that we were the largest receiver of referrals, had these outcome measures used on them, pre and post treatment, by us. We just couldn’t do it as a service. We couldn’t include more outcome measures, when we’ve already got so many that are mandatory. So that was why we pulled out. Mental health trust manager

Though this was a setback to the hub’s development, it is worth noting that its inclusion in the model was questioned by some at the outset because it effectively went against the grain of the idea of the hub. The point was to provide an alternative, even preventative, and holistic service for well-being, rather than treatment for mental health issues per se. In addition, from a strict commissioning perspective, its inclusion as a spoke was problematic if the hub was deemed successful enough to be a commissionable service because it could be viewed as a competitor. Providing a strategic overview to the complexity of commissioning here, senior interviewee concluded that ‘it may be a good thing [that the mental health trust pulled out]’ because the essential concept of the new service ‘was a completely different thing to [traditional] mental health services’.

The CCG was widely seen to have been supportive of the hub throughout its development. Indeed, as our study at this site was concluding in late 2016, further funding was agreed to keep the service operating. In fact, there was an upgrade in that the central triage was to be staffed by a qualified psychotherapist.

The idea of the hub was to bring together a diverse range of scattered, fragmented partial services. The new service was to be more holistic, more person centred and more widely cast to include well-being and sustainable living. The idea was to move away from an overt medicalised approach to mental health problems.

Clinical leadership was present in this case in the form of a credible, knowledgeable and committed leader operating in the operational arena who was able to harness the power of his diverse network and, as a consequence of that, to win support from the CCG strategic level. Yet even with a credible leader and widespread support there were significant institutional challenges.

Although the creative institutional work was seen to be efficient and effective, there was the legacy effect of the extant services to be taken into account. There was pressure on the clinical lead not to ‘destabilise’ the system too much. The CCG was working across a spectrum of services that they could influence through clinical commissioning. Even within mental health, other developments were taking place which the CCG saw as equally important. One of these focused on CAMHS, which was being extended beyond the normal age range to take in young adults up to the age of 25 years, whereas previously patients would transfer into adult mental health services at either 16 or 18 years of age, depending on their position in other services (social services or educational services). This was ground-breaking work, and some in the CCGs regarded this as the main ‘flagship’ service redesign. It demonstrates the difficulty faced by clinical commissioners trying to look after whole health economies within a transactional framework. It is a stark example of coexisting competing logics. The institutional work of the CCG’s actors was complicated by the need to operate with these competing logics in mind.

  • Case D: system and multilevel redesign

Case D illustrates many important aspects of the current reality of the leadership of multilevel service redesign attempts in the English NHS. The unit of analysis in this case was the area which became the new STP footprint. It comprised six CCGs, a county council, a city council and a collection of acute hospital trusts and community trusts. They are analysed as one unit here because these particular CCGs had made strenuous efforts to work together and indeed had been prompted to do so.

They all operated within one large, mainly rural, county and had worked together in pairs, in triads and indeed across all six CCGs. Case D covers a population of approximately 1 million people. The health system in the region is in deficit and it is considered not sustainable without radical reform. The context is also one of major change to hospital services following the dissolution of one of its hospital trusts and there were difficulties in recruiting clinical staff in both primary and secondary care.

The health economy so defined was identified as one of the 11 national challenged economies. There was a £140M deficit (2015/16), that is 7% of the funding available. It was forecast that if no change was made this would increase to £240M (11%) per annum over the next 5 years with an accumulated deficit of > £1B. The extent and severity of the challenges helps explain why these neighbouring CCGs were impelled to work together beyond the norm for CCGs nationally. The analysis that follows works through service redesign attempts at different levels and in different arenas starting with GP practices and moving up through localities, the CCG level and then the supra-CCG level.

Practice level

We investigated, in some depth, an example of very active service redesign activity originating within one general practice but extending into a multipractice initiative. Ironically, the context was one of general conservativism. For example, one interviewee observed:

Practices see themselves as individual businesses just getting on with the job. In the main they just follow the traditional model which is, you know, well, just what general practice was 20 years ago. But there’s one practice that has been more innovative about looking at what they do . . . behind that sits a very big issue of property and surgery ownership. As an individual practice over a number of years they have redesigned the way they work, redesigned their staffing structures, and redesigned the way that they do things. GP locality lead and CCG board representative

The ‘unique’ practice innovator case was led by a highly entrepreneurial GP from his own practice base. The emphasis on concerted action led to the formation of a GP federation. This GP, with close colleagues, bid successfully to be a rapid test site for the ‘primary care home’ initiative. This initiative was launched by the National Association of Primary Care.

As a rapid test pilot site, the Case D group of GP practices is designing and trialling a new enhanced primary care service based around a ‘complete clinical community’. This includes an integrated primary, secondary and social care workforce providing more personalised and better-co-ordinated care closer to home. The initiative is designed to pilot and test a different and expanded mode of primary care. It includes a new workforce profile, less dependent on GPs, with an expanded array of services supported by new and enhanced training and development for the wide array of roles.

This initiative works to a model devised at national level but the detailed design and implementation is dependent on local initiative and activity by local leaders. Realising the concept and making it work is also dependent on a number of bodies, including educational and training bodies, such as Health Education England, working through community education provider networks.

The new model is designed to galvanise primary care, community health and social care professionals to work in partnership with specialists so as to provide out-of-hospital care in a holistic way. It has similarities with the multispecialty community provider (MCP) model as described in the Five Year Forward View . 12

The model is based around new workforce roles (such as physician associates and health-care assistants) leading to a new ‘community workforce’. Physician associates take postgraduate training under the supervision of a doctor, so as to equip the role holder with the skills to take medical histories, perform examinations, diagnose illnesses, analyse test results and develop management plans. The emergent model in the organisation we studied also had a focus on ‘urgent care practitioners’ and a further focus on the redesign of the nursing workforce, both new roles designed to fill urgent care gaps. The urgent care practitioners have a nursing or paramedic background. Accreditation and assurance is being arranged through existing Nursing and Midwifery Council and the Health and Care Professions Council regulatory bodies. Just one of the implementation leadership complexities includes the issue of indemnity. Steps were being taken to enable this to be covered by an existing provider who would also provide the necessary supervision. A further important element is an increased use of telemedicine and information technology allowing diagnostic tests without GP presence.

As all of the above indicates, the redesign of primary care services in the GP practices that we studied required many complex interlocking aspects: reimagining the nature of primary care in relation to other services, such as community care, social care and secondary care; redesigning the workforce to match the new service profile; arranging the necessary training, supervisory and indemnity arrangements; and designing and operationalising the required technology support.

Few GPs were in a position to take the lead on such an ambitious agenda. It required imagination, creativity, funding and persistence to even get such a package launched. It also required networking skills to bring on board not only fellow professionals, but also professionals from related but separate disciplines.

In the case we studied, the GP leaders had also to negotiate with the CCG in order to gain some assurance of ongoing support and eventual ongoing funding for the new model of primary care. This was not an easy task. The CCG leaders had their own priorities and they were reluctant to devolve funding to the local leaders of this initiative. At the time of the study, although there was ‘in principle’ support, the question of the devolved budget, which the local GPs said was necessary for them to act in an entrepreneurial way, remained open and uncertain. This provided a stark example of clinical leaders needing to exercise unusual levels of capacity in managing ambiguity and uncertainty. Not all of those who were taking a leadership role in this venture displayed the same level of tenacity in the face of setbacks. Some were inclined to step back and revert to business as usual (that is to retreat to their normal clinical role) when faced with lack of support, but one or two were very different in that they showed persistence and determination to continue in the face of adversity.

Locality level

The locality level was the sublevel of the CCG where groups of practices came together to share experiences and to act as a communication channel with the CCG. It was a potential arena for the exercise of clinical leadership. As we will see, the kind of leadership that was exercised here was what might be termed ‘implementation leadership’, but we found this to be very patchy across the different localities.

Although some informants suggested the locality level was where most GPs actually ‘engaged’ with the CCG, there was little hard evidence that any significant service changes have been triggered at this level. We interviewed a number of locality directors; the quotation below captures the essence of what most of them were saying:

Well, with the locality structure, and indeed the reason why I’ve stayed involved in this sort of stuff, is really there, partly, to protect the interests of [name of locality]; there needed to be a person and a group to bang the drum for [this locality]. So part of the [rationale] is to represent the local practices , with me as a sort of figurehead to feed things in, and represent the locality at CCG level. And indeed for me to represent CCGs in the bigger picture at locality and practice level. Locality director (emphasis added in bold)

Locality working is not new. In some ways it could be argued that the influence of the locality level has decreased in this county, rather than increased, with the emergence of CCGs. This point is suggested by another locality director:

The locality has no dedicated support staff. In the past it existed as an entity, as part of a primary care trust and at that time it was seen as a meaningful organisation that had staff of its own and a programme of work. Locality director

A practice nurse who was interviewed endorsed this view. She observed that activity at locality level had limited impact. She remarked ‘there have been some good ideas but they don’t seem to add up to anything’. She described how wound care at locality level could have been integrated with district nursing, but ‘a year later we are still talking about it’.

An influential manager working across three of the CCGs noted:

My concerns about locality working is that localities can become a bit anarchic if you let them go off. You have to keep them corporate as well as giving them some freedom. I don’t think they should have all the freedom because we need to have a grip on the corporate message and things like that so it’s a really fine balance. Because we don’t want them to go off and develop services that we don’t need or that we can’t pay for. CCG manager

In summary, the localities (as a subsidiary level of the CCGs) are often where ordinary GPs have most direct contact with the CCG, but this is not a level where service redesign or clinical leadership had occurred to any significant degree. The exercise of clinical leadership was concentrated elsewhere.

Clinical Commissioning Group level

This section includes the initiatives pursued both by individual CCGs and CCGs working in concert with others. There were instances in this arena of the CCG boards of some bold and significant service redesign plans and attempts. These included some unusually large outcome-based contracts which handed significant areas of service provision to new-entrant provider organisations, as well as other bold moves to reconfigure services across the county. The radical nature of these moves could be regarded as proportional to the exceptional nature of the challenges in this health economy. The extent of the ‘challenge’ (some informants talked of crisis conditions) seemed to impel the degree of response. The national centre was taking a very direct and active interest and local leadership in the form of the senior managers were thus empowered to take the lead in an assertive way. This meant that some of the more emergent, bottom-up, clinician-led approaches to service redesign found in other cases were rather crowded out in this case, as the top-down plans were prioritised.

There was substantial evidence in the interviews to testify that management in this case area was more influential than clinicians. Furthermore, it was clear that getting the finances back under control was regarded as a priority in this health economy. This may have contributed to the control taken by, and acceded to, professional managers. As a GP board member argued:

Managers are in charge, and everything is driven by [them]. I think because it’s been going on for such a long time you can see the disengagement by the GPs. You come to a stage where you think, there is no point me saying anything or talking about anything when the management’s going to do what they have to do . . . the financial recovery plan governs everything.

Another assessment was:

A lot of people are disillusioned and they don’t want to get involved. I mean, they’ve advertised so many times for governing body members because we need more clinicians. GP member of CCG governing body

This problem of a depleted clinical leadership pipeline was frequently noted in this case, as indeed in others, but to a lesser extent than in this case.

The Clinical Commissioning Groups in relation to other bodies

The rise of an influential GP federation was seen to implicate all the GPs as having a conflict of interest; this too was used to justify further tilting the balance of influence in management’s direction.

A CCG chairperson argued that a lot of time had been spent on aligning practices and getting them engaged.

We’ve had external consultants who came in and produced a fairly critical report about how the local organisations failed to work co-operatively. And so, out of that came a plan to try and do everything just once rather than six times and we’re sort of starting to try and do that. Although that’s actually just throwing up issues of how you make six autonomous organisations in terms of the six CCGs agree on things and whether that just slows down the sort of decision making and also how it works in terms of the governance of the organisations.

This chairperson then described priority actions by this CCG:

So, we have a primary care strategy which is divided into six work streams . . . There’s a stream around urgent care and one around the structure of primary care, and meds [medications] management, etc.

However, tellingly, he then goes on to describe how the local federation has won funding which enables them to set another primary care agenda:

Within the organisation there’s different thinking in different places. My thinking, as the director of primary care, is in a slightly different place from other managers within the organisation and some of the clinical leads. So, I think part of the challenge is to try and get some corporate thinking around this. Our local federation has worked with another provider and secured a very large fund bid. So that feels like that’s been sort of parachuted in above us. The challenge for us is sustainability and what this does in terms of our CCG operational plan and so on.

This interview extract reveals starkly the tension between multiple logics and multiple agents. The CCG representative here makes clear the view from the CCG that the primary care redesign initiative that was described in Practice level and Locality level was seen by the CCG leaders as, in a way, imposed on them uninvited, ‘sort of parachuted in above us’. He states that this short-term funded initiative, which was parachuted in, presented a challenge that needed to be counterbalanced with ‘some corporate thinking’. Thus, not all clinically led innovations – even those that brought in extra funding – were necessarily welcomed and celebrated. The service redesign initiatives, which were led using a different arena from the official CCGs, had the potential to compete with, and complicate, the CCGs’ own plans. In this instance, the federation’s initiative appeared to disrupt the ongoing CCGs’ primary care operational plan.

It was interesting to note that, from a CCG perspective, the authority of the GP federation and its use of due process could be questioned:

There is a suspicion around whether there’s equity in terms of the involvement of different practices and the rewards to different practices. You know, I guess like any sort of new organisation, it doesn’t have complete engagement from practices and some people are suspicious that this is just a vehicle to take over their businesses. GP CCG board member

To add to the uncertainty, there were other initiatives and proposals, including some from the secondary care providers, which also had the potential to compete and vie with the CCG’s own plans:

At the moment the noise has been very much around the sort of multispecialty provider, this [pan-county] bid seems to be the biggest thing around. There has been talk by the local acute provider about moving into primary care services. There is a plan to put in a bid around urgent care which will be provider driven. Again we need to assess how all this fits within our own wider plan. CCG chairperson

These observations from the chairperson of one of the more influential CCGs in the county raises questions about the difficulties in aligning the plurality of initiatives being encouraged and launched in different arenas. Hence, once again we see the complexities of leadership in practice when the context is given proper consideration.

The state of uncertainty about who is driving change, using what model and with what end point in mind, is reflected further in the next extract from the interviews:

As a CCG we don’t have sort of end point in mind, we just sort of follow the models [from the Five Year Forward View ]. I think we’re fairly neutral on which model. I think we’re just wanting to see a development and an evolution. I suspect it will sort of be a natural move in one direction or the other. Senior CCG official

This quotation is very revealing. It suggests a ‘neutral’ stance regarding the big service redesign questions and suggests the lack of an overarching strategy despite the extent of the challenges as already described. The admissions from the CCGs that they lack the wherewithal to tackle the fundamental redesign of health-care systems which the Vanguards are seeking to deliver was made apparent by the individual CCGs in this case. Nonetheless, the extent of the arm’s-length, detached stance which is signalled by the above interview extract is still surprising. More than 3 years into the CCG experiment, it indicates the extent and nature of CCG ambitions. Given such a context it can be readily seen that, on the one hand, there is an apparent open space and scope for ambitious clinical leaders to ‘step up’ and offer creative solutions but, on the other hand, if and when they do, the context is such that there is so much contestation and uncertainty that to make any service redesign endure is highly problematical.

We can elaborate on this important point by providing an illustration of just such a bottom-up, GP-led service redesign that was initially supported and then unsupported. We were informed of a new dementia service which located more care in GP practices and which therefore allowed patients to be treated locally rather than having to travel to the mental health trust. The redesign involved employment of care facilitators. Funding came jointly from the CCG and the mental health trust. However, despite apparent success and positive feedback, the initiative was ended and dementia services were taken away from primary care and returned solely into the hands of the acute sector, the mental health trust. Some GPs claimed that this resulted from pressure from the mental health trust which the CCG was unable to resist given its parlous financial state and the power of the trust.

As interviewees noted, the federation had, so far, remained on the periphery of the core GP business of the General Medical Services and Personal Medical Services contracts. One CCG board member observed, ‘the practices at the moment don’t particularly see it as a mechanism to provide, you know, their core services. So it hasn’t got into the sort of real federation working which would be sort of the front-line main contracts’. However, he noted that the access to extended hours work could catalyse a change as it creates a new workforce which would share information and patients across practices.

Activity and clinical leadership at a neighbouring CCG were even less developed. Practice in this particular CCG reflected that found in many others which we encountered at the scoping phase of the study where little advantage was being taken of the CCG institution as a platform for change. Instead, it was treated as just another administrative unit. Thus, even the accountable officer made the assessment that:

The function of the CCG to date, by and large, has been to fulfil statutory duties. In the early days of the CCG there were a large number of high-level strategies written around a number of things . . . those haven’t really been delivered . . . They’ve stayed at strategic level rather than developed into operational level. And the financial crisis has crept up on the CCG . . . about 18 months ago, it really hit, and since then that’s been the total focus of the organisation. So everything for the last year has been driven by the financial position in the CCG. It seems like we’ve been blinded by the headlights. Accountable officer

This CCG is now in the hands of a managerial team which also manages two other CCGs. As a result, a similar situation prevails across this cluster of three CCGs:

There’s a much tighter grip on the finances but with regards to service redesigning, I can’t see much instance of that happening or having happened to date. A lot of stuff’s been talked about, but if you said give me some examples of that, I would find it much more difficult. CCG chairperson

Asked if the CCG had taken a serious look at the organisation of primary care and general practice, the response was an emphatic ‘no’. The informant was asked, ‘So what has the CCG done then? If it’s not been looking at secondary care, and it’s not been looking at primary care and general practice, what has it been doing?’ The answer:

Well . . . as I said, it set out as a new organisation. It has to build itself and embed itself. It did a lot of work around high-level strategy. And then the finances got out of control. And then since then it’s been, been the overwhelming challenge. So that’s basically what it’s done. CCG chairperson

Thus, in these instances, the work of the agents – managers and clinical leaders – in these new bodies was focused primarily on institution building. This included appointing chairpersons, accountable officers and other key figures plus the wider representation for the governing body. A practice nurse representative on this CCG likewise confirmed that assessment. When asked if the CCG had achieved much, she replied ‘No, I have to say, sadly. Sad to be part of it and have to say that’. A GP likewise observed, ‘ever since we became a CCG we have been firefighting, we have a historic debt, it’s frustrating, we haven’t made the progress I would like to have seen . . . we have been assured out of existence by the NHSE regional team’.

What these data suggest is that simply providing a new institutional platform with a general direction to allow GPs and other clinicians to ‘step up’ and lead the required service redesign is evidently not sufficient. Lack of resources and continued assertive intervention from the national centre had, in these cases, crowded out the hoped-for local leadership. The prime arena of the CCG, despite its statutory backing, was not enough in these cases to prompt the emergence of effective clinical leadership. In response to this increasingly evident lacuna, the national-level authority, in the shape of NHSE, initially encouraged much more cross-CCG collaboration and then moved more radically to offer firmer guidance in the shape of the models of collaboration outlined in the Five Year Forward View 12 and then even more forthrightly with the creation (indeed imposition) of the STPs.

However, not all of the six CCGS in the county were quite so passive and reactive. Despite the financial and other challenges, some local leaders were able to use the new institutions as a means of devising local solutions. The CCG chairperson of one of the CCGs said that his GPs were ‘just going to get on with it’ and attempt transformation, especially of community services. He said he wanted to re-engineer the use of their two community hospitals. His vision was to transform their use from being ‘dumping grounds for the acute trusts’ to being sites for new outpatient work run by primary care including diagnostics instead of consultant led, to stop our patients leaking into secondary care’.

However, one of the hybrid clinical managers working across three of the CCGs reported:

There is a definite lack of clinical leadership and engagement in practices in [this CCG]. There’s a lot of distrust. There’s concerns about mismanagement, poor communication. So that’s what I’m focusing on: building relationships, making sure we’re open and transparent, we need to build a bit of confidence in the management team because I think that’s partly why they haven’t been able to make change happen. The clinical leaders are hidden. They haven’t been attending meetings. Goodness knows where they are. So that’s my priority. Hybrid manager across three CCGs

Thus, overall, the picture that emerged from the CCG level (the apex of Figure 24 ) in case D was that, in a number of CCGs, the senior teams (managers, clinicians and hybrids) had failed to utilise the privileged statutory positon, resources and power of the CCG board-level arena as a means to bring about a redesign of local services in the way that had been hoped by the national policy-makers. However, other teams had used the same arena to make a difference both in reforming primary care and in reimagining the roles of acute and community services. Increasingly, these more innovative teams were given power by NHSE to take over the agenda-setting for the more passive CCGs.

Sustainability and transformation plan level

As momentum built behind STPs from mid-2016, all actors involved in any significant service redesign attempts had to consider how these would align with the emerging STP systems architecture. This process – occurring over a relatively short period of less than 12 months – revealed a great deal about the multilevel power dynamics in service redesign. We observed meetings as NHSE-funded management consultants facilitated the process of exploring and choosing between a number of ‘system architecture options’. Six main options were presented. They represented a spectrum offering varying degrees of integration across the system: from a loose association of providers and commissioners at one end, to a unified ACO at the other.

The loose end of the spectrum was based on what was termed the ‘status quo’ (i.e. with > 20 localities/hubs based on population sizes of between 10,000 to 50,000, continuing to operate alongside existing acute hospital providers, a mental health provider and a social care provider). The hubs would offer co-ordinated out-of-hours primary care services. The middling options were essentially variants of a new service architecture based on between one and three overarching MCPs catering for populations of approximately 500,000 with a set of localities/hubs or primary care homes sitting beneath them looking after populations of around 30,000 to 50,000.

Notably, most of the options assumed the continuing separation of acute hospital services on the one hand and primary/community care on the other. The subvariants essentially amounted to options relating to the number (and hence size) of the constituent MCPs and hubs. Our informants (clinical leaders and managers at CCG level) reported that they felt this exercise was taking place to a large extent beyond their sphere of influence. Nonetheless, a number of clinical leaders interviewed were keen to work within the templates offered by MCPs and the primary care home locality/hub models.

Thus, there were tendencies acting to pull the CCGs in two different directions: (1) the high-level STP work, which is driving strategy across much larger populations and (2) the considerable activity from below, such as that triggered by the Vanguards with MCPs. These and the acute-led services are heading towards ACOs. These bodies, if fully launched, lead to questions about the continued role for the CCGs.

Case D was instructive in revealing the scattered and tremendously varied nature of clinical leadership in and around CCGs. The local context in this case was of a financially challenged health economy with additional problems arising because of the difficulties in recruiting and retaining clinical staff in the primary care and acute sectors alike. Leaders of the CCGs, both mangers and clinicians, found that they spent a great deal of time doing what they described as ‘firefighting’. The extent and nature of the challenges also mean that these CCGs were being pressed to work together so as to begin to tackle system-wide issues. Thus, single CCGs were found not to be powerful platforms for change in this area.

The case reveals that, when a health system is under challenge, the scope for decisive leadership of service redesign is very much dependent on the power exercised by national bodies – most notably NHSE and the Department of Health – but also by the regulators such as NHS Improvement and the CQC. Hence, clinicians, even if willing to make a difference through adopting a leadership role, need to take account of the scope for action given, the ongoing and planned activity at any or all of these levels and forms. A clinician who wants to make a contribution faces uncertainty about what level and in what setting to make that contribution.

Some of the most impressive service redesign initiatives that we tracked in this case were time bound and contingent on special temporary funding. Pilots are to be evaluated, and hence ongoing sustained funding may not be forthcoming. An optimistic interpretation would be that the wide variation allows for multiple and diverse experiments, with bottom-up initiatives being encouraged. A more pessimistic interpretation is that the duplication and complexity crowds out creative action by clinicians and facilitates waste and duplication. We found both opportunity and constraint. The instances of the exercise of clinical leadership within these were all the more interesting.

Case D exposed the very mixed use of the strategic CCG-level arena by clinical leaders. In those instances where this opportunity had not been utilised, the main reasons offered were the financial challenges, which led to firefighting and perceived uncertainty about the scope for action given the extent of activity and review coming from other quarters – especially from the NHSE. The most impressive and far-reaching examples of clinical leadership in this case were found in the operational and practice arenas, where some entrepreneurial GPs had seized the opportunity to tackle specific service problems, such as dementia care and other forms of long-term condition management. They used their knowledge and their networks to offer more patient-oriented services at lower cost than was charged by the acute trusts (both mental health and general hospital trusts). However, even in these instances, these local leaders found that they were at the mercy of the precarious ongoing support from the CCG as holders of the purse strings. They discovered that funding could be withdrawn if other considerations and priorities arose – such as the pressure on the CCG not to ‘destabilise’ significant local provider organisations.

  • Case E: redesigning integrated care and urgent care

This case study was carried out in one of the London CCGs. It is located in a densely populated, inner-city area. Its geography was coterminous with its local borough council. The CCG remains in financial balance despite the pressures of supporting one of the most financially challenged acute trusts in the country.

This case study focuses on two key service redesign initiatives: integrated care and urgent care. Both provide useful insights into the origins, nature and outcomes of clinical leadership.

Case E1: the integrated care initiative

The cluster of initiatives designed to integrate care was manifest primarily in a large-scale programme carried out in partnership with neighbouring boroughs. There was a strong philosophical and normative base to the clinical leadership advocating integrated care, manifested within the strategic arena of the CCG governing body.

The institutional work of advocating and vesting resources in integrated care spanned wider strategic arenas in addition to the CCG. The regional integrated care programme was one of the largest integrated care transformation initiatives in the country. The programme involved all of the relevant health and social care organisations in this part of London (three CCGs, one acute provider, two mental health and community providers, all general practices and three LAs) across the area served by the acute provider.

The integrated care programme aims to ensure consistency and efficiency across physical health, mental health and social care. Interventions focus primarily on the top 20% of patients most at risk of hospital admission, a group responsible for approximately 80% of the activity and costs across health and social care in all three boroughs. The work targets the population in a phased approach, beginning with those at very high risk of hospital admission (the top 2% of people at highest risk), and working downwards to cover the full 20% over a 5-year period.

The programme is supported by a programme management office. There are workstreams on contracting and reimbursement, informatics and information technology, and evaluation. The programme management office also supports the local implementation of integrated care within the three localities. Integrated care boards within each CCG are responsible for the operational design and commissioning of their local programmes. Members of these boards include health service commissioners, LA representatives, public health representatives, voluntary and community sector representatives, and representatives from the locality’s provider organisations, including senior clinicians.

The three lead CCGs work in partnership, but also retain a high degree of autonomy within the wider programme. This has implications for the case study CCG, which informants claimed to be the most mature of the partners, particularly in terms of the emphasis placed on clinical leadership. CCG informants reported that they felt constrained by the slower pace of change in the other two areas.

The chairperson of the CCG, the lead for the GP network, the local medical committee representative and the named CCG integrated care lead were widely seen as each having a particularly important role in advocating for integrated care not only in strategic arenas, but also to their colleagues involved in delivering primary care. They were perceived to be dedicated to ‘selling’ the benefits to colleagues and framing a range of local activities as being part of a wider intent to reduce fragmented care for patients.

However, there was evidence of a disconnect between the clinical leadership and institutional work of advocating and resourcing integrated care in strategic arenas and the level of engagement of many of the front-line clinical staff with delivering the various aspects of the programme.

There was one clinically led fundamental challenge to the integrated care programme, when a respected GP questioned the evidence base for focusing on unplanned hospital admissions. This can be seen as an instance of counter-implementation leadership, whereby a provider clinician actively opposes implementation of the new service model. The GP complained that if reducing unplanned admissions to hospital was a key rationale for the programme (which at a national level it is) then, on the basis of past evidence, the programme was probably doomed to failure. Instead, he felt that the CCG should be focusing on evidence-based, disease-focused interventions to manage the rising demand for hospital care, specifically by greater use of statins to reduce cholesterol and more effective management of atrial fibrillation. The GP arranged a meeting of key clinicians to discuss the issue and he gained some support from colleagues, although not enough to derail the wider integrated care programme.

Case E2: urgent care

The urgent care work in this case aimed to produce a single point of access for patients rather than the current array, which included a hospital A&E department, two walk-in centres, NHS 111 as an urgent telephone consultation and triage service, a GP out-of-hours service, a number of minor injuries centres and an urgent care centre. The ends or break clauses of the contracts for these commissioned services were aligned by the CCG in a way that enabled a system-level review of provision, its overlaps and its variation in per head/per visit cost. The plan was to use this to retender all urgent care services and achieve a more coherent and cost-effective result. This review involved a number of different partners, including the clinical leads of these services, A&E staff, the lead for extended GP hours (which is being funded nationally), and also a number of staff from the local CSU and a senior CCG manager responsible for urgent care. The review was carried out through a series of workshops facilitated by the CSU. In terms of Figure 24 , the review can be seen as taking place in an operational commissioning arena, with commissioners and providers coming together to consider the future pattern of services. It remained in progress at the end of our fieldwork period.

There were a number of important local contextual factors affecting this urgent care review. First, and the biggest issue for the CCG, was the rapid increase in the population and the potential impact of this increase on future demand for urgent care services. A second factor was the co-location in the local acute hospital of traditional A&E services alongside some of the newer community-led services. This arrangement carried the potential for novel ideas in the way services were provided. Third, the distribution of urgent care services across the CCG area was at the time asymmetrical, and the desire to distribute all kinds of urgent care services evenly across this geography created logistical, estates and financial challenges for the CCG. Finally, the role of general practice in providing emergency services changed as the review was being carried out, most notably because local practices were awarded funding from the Prime Minister’s Access Fund to create four locality hubs open from 08.00 to 20.00 hours on weekdays and weekends as well as a virtual hub for web-based self-care and online consultations. This initiative raised the profile of urgent care redesign led by GPs, many of whom had been arguing that general practice should be the first port of call for patients requiring urgent care services.

Some provider clinicians felt their services to be under threat. Others complained of a lack of clarity about how differing costs between the various existing out-of-hours or urgent care providers would be rationalised and how the pressure on the local A&E service would be solved. As the review progressed there was a growing consensus that a single point of access using a telephone or online service was desirable, with patients triaged to the most appropriate service for their needs. Some provider clinicians expressed concern that this would not, however, meet the expectation of many service users for a ‘walk-in’ service as the first point of access.

Clearly, in this case, clinical leadership in the operational commissioning arena took the form of combining advocacy for more integrated and patient-centred services with arguing for the preservation of existing clinical services and the capabilities they had developed. The relatively early stage of service redesign in this case meant that there was no opportunity for us to study clinical leadership in operational delivery arenas – the initiative was not yet entering the stage of implementation.

Features of clinical leadership from these two cases

These two cases illustrate a well-developed pattern of clinical leadership in strategic and operational commissioning arenas, with mechanisms put in place to engage with clinicians in operational delivery roles. Although the latter mechanisms appear to have been problematic, this CCG illustrates some key features of clinical leadership in commissioning. These are now described.

Collaboration between clinical and non-clinical leaders

The working relationships between clinicians and managers working within both strategic and operational commissioning arenas in this case study were built on high levels of trust and mutual respect. Clinical leadership was seen as not just desirable but a core defining characteristic of what made the CCG successful. A strong emphasis was placed on face-to-face meetings, and the conversational style in these meetings was informal and friendly. This enabled significant challenges and passionate debates to be voiced in ways that were usually not perceived to be threatening.

The non-clinical managers were clear and explicit about what the clinical leaders on the CCG board brought to the conversation:

So I think they are [the clinicians on the board] quite good at going back to the fundamental principles and, again, a lot of our GPs on our board often remind us about, so what’s the evidence base? What are the outcomes that we’re expecting to get? How do we demonstrate value for money? And actually, bring an added level of vigour and rigour in relation to that process. Senior manager

They also spoke explicitly about the ways in which clinical leaders had more traction with their colleagues than non-clinical managers. They tended to be effective at turning what might be perceived to be a managerial issue (such as a budget overspend) into a clinical one.

Challenging established assumptions

Many of the GPs in leadership roles in strategic and operational commissioning roles in this CCG had a long history of anti-establishment radicalism. They used this identity to differentiate themselves and thereby to create a strong ethos of common cause based on consistent principles. It appeared that they actually enjoyed challenging governmental authority and NHS bureaucracy. They enjoyed challenging what one informant called ‘corporate guff’. There was some evidence that clinicians were encouraging their managerial colleagues to also push back on directives from NHSE, empowering them to do what they thought was right rather than what they were told they must do.

They had started to question the medicalisation of the health service and were beginning to have discussions about how they might influence the broader determinants of health. A number of references were made to clinicians’ roles in ‘blurring the boundaries’ between what traditionally happened in primary care and other sectors. The clinical leaders in the locality were much less interested in defining detailed care processes than they perceived non-clinical managers had been in the past, placing a strong emphasis on outcomes and leaving clinical teams to determine how to deliver them.

Both the clinical and non-clinical leaders saw merit in the development of local networks of practices as ways to engage clinicians. The ‘offer’ to clinicians was better managerial support – a decentralisation of the CCG management resource, but the ‘ask’ was greater professional ownership of performance. Radical changes in ways of managing unacceptable performance and incentivising collective behaviours were introduced:

You cannot federate unless you really seriously tackle the very poor performance . . . because if you’re asking people . . . you know, if people’s income is going to depend on the performance of their peer network, you have to at least be in with a fighting chance, and if you have a total rotten apple in the barrel, it’s just not fair. GP

In another example of professionally led challenge, clinicians countered the threatened withdrawal of the Minimum Practice Income Guarantee funding for struggling practices, launching a high-profile public campaign to highlight the problems of government policy in this area, and this appeared to have been successful in securing additional resources.

Working across boundaries

The emphasis of this case study on urgent care and integrated care demonstrated the CCG’s commitment to ‘working across boundaries’, a term used by several informants as an organising principle for the CCG. Indeed, the number of partnership-related initiatives in the CCG suggested a strong commitment to looking outside the boundaries of the CCG and of primary care. Much of this approach was driven by a strong clinical voice, supported by a robust strategy developed in partnership with non-clinical managers:

I think what would be very powerful . . . would be [local acute provider] saying, we want to help you deliver some efficiencies and some financial efficiencies. We want to reduce our bed base, we want to get people out of hospital, but we can only do it if your primary care is up to scratch and you deliver it for us. Senior manager

Engaging general practitioners as Clinical Commissioning Group members

What came across strongly from the interviews was a very purposeful and planned approach to engagement of GPs as CCG members:

We need to manage members politically, and we need to shape members’ expectations . . . there has to be a purpose behind engagement. And everyone’s just too busy for engagement for engagement’s sake. GP lead on CCG

In addition, a strong emphasis was placed on open communication so that clinicians were less likely to be in a position to complain that they did not know what was going on:

I think in every case when we’ve had an opportunity to talk it through . . . our strategy, this is our approach and . . . we haven’t been trying to do things in a Machiavellian way, which of course I think tends to worry people. We’ve been open about how we do business. Senior manager

The CCG valued a widespread and inclusive leadership model, promoting leadership roles and behaviours widely. The CCG chairperson claimed that ‘50% of clinicians have leadership roles’, although the shift from disease-based to comorbidity group-based leaders might reduce the total number of clinicians in leadership positions. Leadership roles among clinicians were therefore the norm, rather than the exception, and it is possible that this may be helpful in removing any suggestion of elitism among those who are appointed to formal leadership roles.

There was a dominant historical narrative relating to sustained and coherent change over decades (‘we got rid of our most poorly performing practices 15 years ago and that was key to our success now’), irrespective of political drivers and NHS structures. Several informants described how their model of change would be difficult to replicate in other parts of the country which did not have a long history of focused effort. (Yet, as Case B revealed, there is an argument for a clean slate so that previous mistakes and compromises can be swept away.) In the present case there was the advantage that a consistent pattern of strong clinical leadership had demonstrated its ability to operate across diverse and changing organisational forms.

Strong leadership training and talent management programmes were in place and there was a willingness to invest in sending selected staff on expensive training courses outside the CCG as well as developing their own local leadership training (at the time of writing the CCG was considering establishing a ‘staff college’ for leadership development). Some clinicians placed much higher value on ‘learning by doing’ and creating ‘an environment in which young leaders can make mistakes and learn’. New clinical leadership roles, when advertised, were usually competitive despite the pressures of clinical workload in most practices, although there was some suggestion that this might be changing more recently.

Summary: clinical leadership across different arenas in the two cases

The integrated care programme provided a particularly good insight into the challenges of clinical leadership. On the one hand, it was a vehicle for a number of innovative work streams led and owned by clinicians, such as pathway development, care planning and out-of-hospital care initiatives. Clinical leaders played prominent roles in strategic arenas, articulating the concept and moral ethos of a new or improved service. This led to programme-level work in further articulating the new service and establishing a framework for bringing providers on board. However, on the other hand, clinicians involved in delivery appear not to have adequately understood the integrated care model being advocated. There was evidence that the overall planning and delivery of the programme was more top down in nature and more influenced by a managerial ethos from outside the CCG than clinically led from within.

In the urgent care case, there was similar evidence of a lack of connection between the clinically led strategic ethos of the CCG and clinical leadership in delivery of service redesign. Provider clinicians continued to query the concept of the single point of entry for urgent and emergency care.

The CCG has made a strategic, long-term and focused investment in promoting clinical leadership. Successive generations of local leaders over a period of at least two decades have developed a vision of integrated health care, promoted a set of values, driven up standards in primary care and launched a series of service redesign initiatives, promoting clinical engagement. The espoused belief is that, once clinicians believe that they really are responsible for what happens and have some authority, then they appear to be more willing to work through the challenges of leading in a complex and demanding environment. Being a leader then becomes part of their professional identity and something of which they are proud. Alongside this apparently positive dynamic, however, there appears to be a reality that this virtuous cycle of strengthening clinical engagement has not penetrated service redesign practice. In both cases studied, this remained vulnerable to a conflicting dynamic whereby clinicians perceived initiatives as issuing from a distant managerial authority and failing to connect with the realities of delivering effective care and maintaining the staffing and capabilities to do so.

  • Case F: towards an accountable care organisation

This case (named here ‘Northern Borough’) was selected for two reasons. The first was based on demographic and geographical criteria; the second reason was to illustrate important policy developments taking place jointly in health and social care. The CCG selected was one of the 12 CCGs in Greater Manchester [i.e. it was part of Manchester Devolution (‘DevoManc’)].

The case study CCG with its coterminous borough council has a population of > 228,000. Much of the population is located in areas of high density and relatively poor housing. Both the CCG and council have to deal with large disparities in economic, social and health indicators and situations.

There are three elements of the context which are particularly striking in this case and which affect the opportunities and challenges for clinical leadership.

First, many clinicians and managers and other actors in the wider network have been employed within the region for many years and have a close identity with the place.

Second, DevoManc is having a major impact on health and social care and has required considerable strategic attention from both the CCG and the LA as they work with their counterparts across the region to develop the strategic agenda, the new governance arrangements and the financial arrangements. The CCG leaders in this context have been able to use these developments and opportunities to accelerate ideas about the development of an ACO. However, on the other hand, so much activity at a higher level has tended to remove some of the local ownership and accountability for driving change.

Third, the devolution agenda mandates each of the boroughs to produce a locality plan, which has encouraged closer working between a number of agencies, including health, the LA, the fire and rescue service, Greater Manchester Police and housing associations. The LA in Northern Borough is one which had already developed a strong strategy based on ‘place making’ (an approach to public services well rehearsed in local government in the previous decade) and it has been active in working with the CCG to develop a joint approach. The ACO initiative is able to build on these place-based foundations. The devolution agenda has also led to a leadership development programme across the combined authority, strengthening cross-sectoral and place-based leadership. These are fertile conditions for the ACO initiative.

There is a huge challenge because the budgetary forecast under devolution is less than current spend and so it will leave health and social care with a major financial deficit within 5 years. There are considerable pressures to find ways of integrating services across geographical boundaries, across service sectors (e.g. health and LA), and with system improvements (e.g. improving housing will affect the health side of the budget substantially). Northern Borough with its poor health indicators could be particularly at risk in this.

Clinical leadership in strategic arenas

A powerful force within the CCG is the accountable officer, a GP who is also chief clinical officer. It was noted by several interviewees that this leader was brought up in the local area and was committed to it. He was full of ideas, plans, initiatives and actions which aim to address the poor health of the local population. Supporting this GP leader was a managing director, a quiet strategic thinker with a strong focus on health care.

The GP accountable officer and the managing director worked closely together with a high level of trust. They had occupied similar roles in the former PCT. They referred to each other’s work regularly. Together they focused their leadership on the institutional work of advocating collaboration with agencies, such as social care and housing, relevant to the wider agenda of improving population health.

At a macro level, beyond specific service initiatives, was a concern in the CCG to ensure that primary care services helped both with the preventative agenda and also with ensuring that patients were treated at scale – one of the clinical directors was appointed to lead on this. On the prevention (or mitigation) front, an initiative between the CCG, the LA and the local housing association had led to a ‘Warm Homes’ initiative. This involved the pooling of some of the budgets across these three organisations to help with insulation and heating measures; advice on energy use, switching tariffs and obtaining pre-payment meters. This is an example of partnership working on health and well-being in the locality and the CCG say that this has helped with respiratory illnesses and also for frail elderly patients in particular.

There were elements of a wider commitment to better primary care. This sought to place patients at the centre of such care and to reduce dependence on secondary care. Patient care management was an objective. Nonetheless, although the formal plans pointed to such a strategy, many of the people we interviewed indicated that the central thrust of activity was coming from the devolution agenda. These elements came together in the initiative to set up an ‘accountable managed care organisation’.

The accountable managed care organisation

The impetus within the CCG to develop the ACO had taken on added vigour because of the Five Year Forward View 12 and the new models of care. In addition, the Greater Manchester devolution plan, as noted, required each district to produce a locality plan, and this was seen to be an opportunity to promote the ACO. As the emphasis moved towards the idea of increased joint working and accountability between the CCG and the LA, the idea transitioned into an ‘accountable managed care organisation’ in recognition of the joint governance concerns.

This may be seen as an example of leadership making use of a ‘policy window’ to push forward plans which had been hatching for some time.

A document from Northern Borough’s locality plan noted that:

Simply put, an accountable care organisation is an alliance . . . where all members in the ACO share the risk and assume accountability for the resources spent caring for a population and for the quality of that care.
The goal is to engage and regulate providers in a way that encourages them to work together, to pay providers in a way that does not encourage supplier induced demand, and to create a balanced system of commissioned services and suppliers that can be rewarded for providing high quality care.

Originally, these ideas for an ACO were about creating a legal structure to provide integrated care that includes GPs (and GP practices), other primary care clinicians and, potentially, over time, other types of NHS physicians and social care professionals, with its own in-house management support systems. However, the structure would not include hospitals, thus giving the ACO a strong primary care and public health focus.

Two events shaped the interest in this institutional structure further. The devolution agenda brought this to the foreground, making possible arguments for an ACO and also showing that, unless Northern Borough moved proactively and quickly, devolution could have risks in terms of financial share and reputation. Second, the developing partnership with the LA had helped to enlarge the conception of what the ACO would and could be.

There is now a leadership board that brings together the key players across the locality. They posed the question to their colleagues:

Are you a team of leaders that come together every now and then and talk about specific issues or are you a strategic leadership team for a place?

Initially, this idea was slow to get traction but:

The CCG has been really strong on that. Not just sitting in the health and well-being space . . . but bringing it into the broader team arena.

The LA recognised that nearly £2B of annual public sector spend is on various aspects of health and well-being. It recognised that:

We need an increasingly strong relationship with the CCG . . . Actually, can you sustain two separate commissioners? What’s the point of that? . . . So our single accountable care, health and care organisation, we’re not at the moment saying a new separate entity. But it could be.

The closer involvement of the LA in the ACO has led to a greater emphasis on the governance arrangements. At the time of the research the ACO details were still being worked through.

The pattern of clinical leadership across different arenas

The overall focus is on a profound transformation of the institutions involved in managing the health of the population, as well as on the redesign of particular services. This is reflected in our finding that clinical leadership was most strongly present in various strategic arenas, where clinicians are involved in formulating ideas and theories about new ways of promoting health in collaboration with other agencies. Given this focus on establishing collaborations across traditional agency and professional boundaries, it is important to capture the complexity of the interconnected strategic arenas that clinical leaders worked within. This is shown in Figure 25 .

Strategic arenas of leadership in case F.

Leadership is part of the mobilising of attention, resources and commitment to particular plans and values within those arenas.

Figure 25 shows how the clinical and managerial leaders of the CCG were working jointly on conceptualising new kinds of services and mechanisms for delivering better health for the population, building collaborations simultaneously in a number of different directions.

The thought leadership exercised by the GP accountable officer jointly with the managing director drew on long experience of the locality combined with an international and entrepreneurial outlook, to create new visions, values and activities for the CCG. Clinical experience and judgement combined with managerial skills to create a view of health which was innovative and integrative.

Our interviews suggested that this visionary leadership was exercised strongly in strategic arenas. However, its connection with operational commissioning and delivery was, as yet, partial.

The Warm Homes scheme provided an example where thinking and acting holistically had achieved implementation. However, this implementation did not need to involve clinicians, as the scheme involved improving homes. More generally, we found that clinicians often understood that an ACO was in the process of being created. However, they appeared to see little connection between the ACO and the day-to-day improvement of the services they were working on. They appeared to be more embedded in their specialisms and were making incremental progress on service redesign.

Overall, the arena of patient services was dwarfed by the enormity of the DevoManc initiative, which was changing on an almost daily basis during the case study. The DevoManc initiative occupied a lot of the attention of the clinical and managerial leaders in this case study.

Devolution creates a lot to play for political positioning and reputation, budget surpluses or deficits, the quality and standards which will be applied across the combined authority and the governance levers open to the CCGs across Manchester and the LAs across Manchester. If poorly designed, devolution could lead to worsening services. However, if well designed it could create an integrated system across health and social care, bring in extra investment to the city region and improve the lives, the longevity and the health and well-being of local populations and patients.

To engage with devolution required local NHS leaders to work closely with the local authority. The circumstances were fortunate here because such collaboration had occurred for some considerable time in this borough, commencing even before the formation of the CCG. It had been initiated by the Northern Borough council, with its bigger vision of place leadership. The council has acted as a convener, not only of health partnerships, but of partnerships with other relevant sectors, such as housing, the voluntary sector, fire and police. The successful experience of Warm Homes inspired greater confidence to work together further. It appeared to be the council which has steered and opened up the debate about joint governance of the ACO. The clinical leadership of the CCG has embraced this partnership. However, engagement in the political processes of the council (HWB, Health Scrutiny) has perhaps been more statutory than enthusiastic.

The final arena is working with other stakeholders, such as the voluntary sector, the universities, and so on. This arena is rather diverse, and stronger relationships have been fostered with some more than others. The outward-facing and entrepreneurial nature of the CCG has meant a series of connections where the leadership can see key priorities which are relevant to it (e.g. around innovation and service improvement). However, the relationship with the voluntary sector is still being worked on. The voluntary sector is very complex and there are many layers, they tend to work directly with individual GP practices rather than with the CCG as a whole.

Examining leadership in terms of the competing demands of different arenas, one can see that the pull is towards devolution, and towards the council in particular.

  • Cite this Page Storey J, Holti R, Hartley J, et al. Clinical leadership in service redesign using Clinical Commissioning Groups: a mixed-methods study. Southampton (UK): NIHR Journals Library; 2018 Jan. (Health Services and Delivery Research, No. 6.2.) Chapter 4, Findings from the case studies.
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Hertz CEO Kathryn Marinello with CFO Jamere Jackson and other members of the executive team in 2017

Top 40 Most Popular Case Studies of 2021

Two cases about Hertz claimed top spots in 2021's Top 40 Most Popular Case Studies

Two cases on the uses of debt and equity at Hertz claimed top spots in the CRDT’s (Case Research and Development Team) 2021 top 40 review of cases.

Hertz (A) took the top spot. The case details the financial structure of the rental car company through the end of 2019. Hertz (B), which ranked third in CRDT’s list, describes the company’s struggles during the early part of the COVID pandemic and its eventual need to enter Chapter 11 bankruptcy. 

The success of the Hertz cases was unprecedented for the top 40 list. Usually, cases take a number of years to gain popularity, but the Hertz cases claimed top spots in their first year of release. Hertz (A) also became the first ‘cooked’ case to top the annual review, as all of the other winners had been web-based ‘raw’ cases.

Besides introducing students to the complicated financing required to maintain an enormous fleet of cars, the Hertz cases also expanded the diversity of case protagonists. Kathyrn Marinello was the CEO of Hertz during this period and the CFO, Jamere Jackson is black.

Sandwiched between the two Hertz cases, Coffee 2016, a perennial best seller, finished second. “Glory, Glory, Man United!” a case about an English football team’s IPO made a surprise move to number four.  Cases on search fund boards, the future of malls,  Norway’s Sovereign Wealth fund, Prodigy Finance, the Mayo Clinic, and Cadbury rounded out the top ten.

Other year-end data for 2021 showed:

  • Online “raw” case usage remained steady as compared to 2020 with over 35K users from 170 countries and all 50 U.S. states interacting with 196 cases.
  • Fifty four percent of raw case users came from outside the U.S..
  • The Yale School of Management (SOM) case study directory pages received over 160K page views from 177 countries with approximately a third originating in India followed by the U.S. and the Philippines.
  • Twenty-six of the cases in the list are raw cases.
  • A third of the cases feature a woman protagonist.
  • Orders for Yale SOM case studies increased by almost 50% compared to 2020.
  • The top 40 cases were supervised by 19 different Yale SOM faculty members, several supervising multiple cases.

CRDT compiled the Top 40 list by combining data from its case store, Google Analytics, and other measures of interest and adoption.

All of this year’s Top 40 cases are available for purchase from the Yale Management Media store .

And the Top 40 cases studies of 2021 are:

1.   Hertz Global Holdings (A): Uses of Debt and Equity

2.   Coffee 2016

3.   Hertz Global Holdings (B): Uses of Debt and Equity 2020

4.   Glory, Glory Man United!

5.   Search Fund Company Boards: How CEOs Can Build Boards to Help Them Thrive

6.   The Future of Malls: Was Decline Inevitable?

7.   Strategy for Norway's Pension Fund Global

8.   Prodigy Finance

9.   Design at Mayo

10. Cadbury

11. City Hospital Emergency Room

13. Volkswagen

14. Marina Bay Sands

15. Shake Shack IPO

16. Mastercard

17. Netflix

18. Ant Financial

19. AXA: Creating the New CR Metrics

20. IBM Corporate Service Corps

21. Business Leadership in South Africa's 1994 Reforms

22. Alternative Meat Industry

23. Children's Premier

24. Khalil Tawil and Umi (A)

25. Palm Oil 2016

26. Teach For All: Designing a Global Network

27. What's Next? Search Fund Entrepreneurs Reflect on Life After Exit

28. Searching for a Search Fund Structure: A Student Takes a Tour of Various Options

30. Project Sammaan

31. Commonfund ESG

32. Polaroid

33. Connecticut Green Bank 2018: After the Raid

34. FieldFresh Foods

35. The Alibaba Group

36. 360 State Street: Real Options

37. Herman Miller

38. AgBiome

39. Nathan Cummings Foundation

40. Toyota 2010

Leadership Case Study

Learn about theories, skills, and the impact of world leaders in this case study about leadership.

Introduction

Leadership theories, steve jobs leadership, skills approach leadership, list of references.

Leadership is one of the concepts in the world, which has received massive coverage and attention. Although there are several reasons behind this trend, the commonest one is the fact that leaders have a significant influence in the society. Not to mention that some people and organizations have become what they are today because of the impact of certain leaders (Grint 2010, p. 1).

Even though there is a wide range of definitions that describe a leader, it has been universally agreed that a leader is a person who gives direction to others in order to attain a common goal (Gallos 2008, p. 1). This is mainly achieved through setting a pace in serving as a role model and creation of a working environment that allows members of the organization or employees to feel honored as part of the advancement process.

Importantly, a leader cannot be viewed as a boss since he or she remains committed to the full course of achieving set goals and objectives. It is noteworthy that there are numerous qualities, which define the character of a good leader. While these factors may vary from one person to another, common traits include being a good listener, focused, organized, available, ready to delegate duties, confident and decisive (Gallos 2008, p. 2).

Twentieth century saw the demand and interest in leadership rise to an advanced stage. While early leaders laid emphasis on existing differences between leaders and followers in terms of their qualities, subsequent leadership theorists approached the issue by considering certain variable like qualifications and situations in establishing an understanding of leadership traits (Grint 2010, p. 1). Some of these theories have been discussed under this segment of the analysis.

The first one is the “great man” theory, which assumes that good leaders are born and that what is considered to be good traits are naturally obtained. In other words, these leaders are born, which is against the notion that favors making of leaders. This school of thought normally depicts leaders to be heroic and ready to take up leadership positions in the corporate world whenever there is need.

It is also paramount to note that the term was developed when the society thought that leadership was strictly meant for males (Bolden et al. 2003). This theory is believed to have been first developed by Thomas Carlyle, a time when gender equality was not being talked about as it is today. Men were therefore given leadership preference as women dominated other domestic areas of society management.

It is also believed that the trait theory resembles the great man philosophy, as it assumes that certain qualities observed among some leaders are inherited, thus making them better than other leaders. This theory generally focuses on a behavior or trait, which is common among leaders. Even though this has been the case, it is hard to explain the existence of some of these qualities among people who are not leaders (Bolden et al. 2003). This is considered as the main obstacle in adopting this theory when explaining the concept of leadership.

On the other hand, contingency theories address certain variables, which are connected to the environment and influence the type of leadership style suitable for a given situation. A very important fact under this theory is that situations in life cannot be addressed by one leadership style.

This is based on a wide range of ways in which the situations are manifested. Basically, success is coupled with leadership styles, different situational aspects and traits carried by followers (Bolden et al. 2003). This leadership theory is closely related to situational theories, which affirm that situational variables are key in influencing the decision made by leaders. It follows that a decision-making process may require several leadership styles to ensure that the best position is reached.

Unlike of the ideas discussed above, behavioral theories of leadership are inclined towards the fact that good leaders are made. It is solely based on behaviorism and the overall manner in which leaders act. In essence, the theory suggests that good leadership can be attained through learning and observation as opposed to being natural traits in human beings (Bolden et al. 2003).

Moreover, participative theories of leadership support the fact good leadership seeks to incorporate the ideas of others in decision-making. They motivate other people to be part of the course of achieving set goals and objectives. Nevertheless, a leader may choose not to consider the input of his or her followers.

Management leadership focuses on concepts of performance, supervision and organization. It is founded on the use of rewards and punishments in ensuring that the course is retained by all parties involved. This is the commonest leadership theory in business, where employees are recognized according to their input.

The last theory of leadership is the relationship theory, which is also referred to as transformational theory. This emphasizes on the bond between leaders and their followers. Through motivation, these leaders show their followers the benefits, which are hidden in the future. As much as they are concerned with performance, exploitation of each person’s potential is always at the heart of their performance. These leaders equally possess high standards in terms of ethics and morality (Bass & Riggio 2006).

The name of Steve Paul Jobs has dominated the world of leadership especially in the 21 st century; at the peak of technological advancements in computer technology. Born in 1955, Steve Jobs was a man of his caliber in terms of innovation of business ideas. Until his death in 2011, Jobs remained an icon of transformational leadership (Peña 2005).

Among other successes and leadership positions, Jobs was well known for as the chairman and co-founder of the famous Apple Inc. Unlike his counterparts who have a clear-cut of their leadership styles, Jobs could not be described by a single style of leadership; he was endowed with several qualities, which helped him to traverse the business world, to achieve such massive success. Importantly, his life experiences right from teenage played a major role in molding his personality, having failed to graduate from college.

In his 2005 address at the Stanford University, Steve Jobs highlighted several life experiences, which had shaped his life and challenged graduates to see success and opportunities in setbacks, which life offers. He believed in having faith, by connecting dots in life even during hard moments and hardly regretted for his decisions, including the selection of an expensive college that became a challenge to his parents in paying tuition fees.

As a result, he dropped out, and registered for calligraphy, which was significant in designing fonts while designing the first Macintosh. The love for his job was unwavering. Together with his friend, they founded Apple and even after being kicked out of the company, he moved on to launch NeXT Software Inc., which was acquired by Apple in 1997, giving a chance to rejoin Apple. His ill-health was a further source of inspiration in life.

After surviving a pancreatic surgery necessitated by cancer, he considered it as a wakeup call; to maximize the use of available time in doing what he loved most (Peña 2005). It is this path that shaped Steve Paul Jobs to become a leader with countless styles and qualities.

Firstly, Jobs was a charismatic leader. He was widely known for his ability to give captivating speeches, a trait that was equally employed in his career. His storytelling skills favored him capturing the attention of not only his audience but also his employees at Apple and other companies (Kramer 2010).

He was able to communicate the benefits of using Apple products as compared to other products by use of metaphors and analogies. His charismatic nature was essential in developing enthusiastic leaders who remained focused towards achieving that which seemed impossible in the eyes of many and convince his customers that his company had the best products in the market.

Jobs inherent and learned traits seemed to define his character and leadership path. Due to this, he earned himself several titles, which mainly described his attachment to perfection (Kramer 2010). His leadership was therefore described as personalized; he sometimes expected too much from an employee.

According to Jobs, he was interested in making people better, a leadership approach that was sometimes misinterpreted as being autocratic and rude especially in meetings. As an autocratic leader, Jobs insisted on being in control and showing people what to do even as a role model. While at Apple, Jobs had over a hundred employees who directly reported to him directly. His degree as a participatory leader was therefore low (Peña 2005).

Importantly, Steve Jobs remains an icon of transformational leadership. Throughout his career, Steve Jobs managed to transform different companies like Pixar. He also led by example, showing employees and other managers what was to be done in order to overcome the challenges of a competitive business world (Kramer 2010). This was essential in bringing out the best in every employee and promoting performance.

He is the founder of Amazon.com, its CEO and chair of the company’s board. Bezos is highly recognized in the money market and was valued at $3.6 billion, according to Forbes’ survey in the year 2006. He was listed as the personality of the year in 1999 by the Time magazine. Besides Amazon.com, Jeff Bezos founded Blue Origin, with an aim of promoting tourism. He is definitely influential and his leadership style is worth studying to understand his success secrets.

Unlike some of company owners who choose to delegate managerial positions, Bezos runs Amazon.com as its founder and CEO. He therefore battles out by transiting from a small company to the head of thousands of employees.

He is generally overwhelmed with fun and innovations, having carried his laughing character to the company. In analyzing his leadership qualities, Bezos has been described using a wide range of approaches (‘Taking the long view’ 2012).

He is a transformational leader. Based on the path he has used to get Amazon.com where it is today, it is doubtless that he has been instrumental in promoting the company’s performance. He has always made choices based on his desire to move to another level, a reasons he gives for marrying his wife. His visionary has definitely landed him to a place he dreamed, decades ago.

He is also concerned in the performance of managers and other company employees. In order to impact his management team, he organizes weekly meeting, reporting on experiences and answering questions from him. The Just Do It program launched by Bezos was highly applauded for promoting participatory management at Amazon (‘Taking the long view’ 2012).

According to the program, managers are promoted for their innovative ideas, which are aimed at improving the company’s performance. His perfectionism in performance means that he has to higher new managers consistently, who are intelligent and highly skilled.

This approach is mainly leader-centered. In other words, it focuses on certain skills, which can be learned and improve the leadership potential of an individual. It is obvious that knowledge and skills are essential for one to be recognized as a strong leader. Furthermore, skills denote what is achievable by a leader, while traits mainly focus on a leader’s identity ( Leadership Skills Approach 2012). This leadership approach requires a leader to master three important areas, which are conceptual, technical and human.

Technical skills determine a leader’s proficiency in performing certain tasks. For instance, Steve Jobs’ skills as a computer scientist were paramount in navigating through the world of computers. Despite his lack of a college degree, he had relevant knowledge in the world of technology (Peña 2005).

He also had innovative skills, which transformed several companies including Apple Inc. Mr. Bezos equally has computer skills in science and business, which have been significant in internet business, marketing and cloud computing. Bezos has experience in garage operations, having been a garage inventor during his early years of entrepreneurship.

Skills approach of leadership further emphasizes on human skills, which are vital in dealing with people ( Leadership Skills Approach 2012). Although Steve Jobs was sometimes considered to be rude autocratic in handing employees, his sense of charisma made him an outstanding leader in handling people. He was a role model and encouraged his employees to exploit their potential. On the other hand, Bezos enhances his human skills through weekly training and hiring of intelligent and smart employees.

The last aspect is having conceptual skills, which are necessary in making long-term decisions ( Leadership Skills Approach 2012). Steve jobs had a long-term vision and remained focused on the course despite his failure to graduate from university. While serving with various companies, he invested in getting higher.

He transformed Apple, making it one of the leading technological companies in the world. Similarly, Amazon culture is dominated with long-term strategies. Since its inception, Amazon always invests its short-term profits for long-term benefits. Bezos takes risks, venturing into fields, which are less considered. These included cloud computing and the Blue Origin.

The question we need to ask is how Steve Jobs and Jeff Bezos would lead a conservative industry like banking or construction. As mentioned before, the contingency theory of leadership focuses on external and internal factors, which determine the kind of leadership necessary. In other words, it may require the application of several styles in order to achieve reputable skills.

The success of the two would not be limited, by the fact that their leadership styles are more diverse. For instance, Steve Jobs had several leadership styles, which would be important in taking a contingent approach. However, they would be limited in innovation; their success stories revolve around innovative ideas, which might not have a place in a conservative environment.

While starting a company like Apple or Amazon with five employees, it would be important to apply transformational leadership in order to realize success. This is because transformational approach focuses on having a vision to advance to higher levels in future. It further nurtures talents and skills among employees for maximum performance (Bass & Riggio 2006).

Transformational leadership was highly employed by Jobs and Bezos. This helped in changing their small businesses into multinational companies. Nevertheless, this styles wastes a lot of time since leaders have to share their goals with follower. It can also be misused especially by dictatorial leaders.

From the above report, it is clear that leadership is a major concept in the society. Additionally, the success of leaders largely depends of their leadership qualities and styles. Leadership theorists argue that every leader can be grouped into a particular class of leadership. In this case study, it was revealed that several leadership styles contributed to the success of Steve Jobs and Jeff Bezos, to become world leading CEOs in the 21 st century.

To thrive in this competitive environment, they adopted several leadership styles. Moreover, transformational leadership qualities were key in developing their success story. It is worth noting that different companies may require varying leadership styles for their success.

Bass, B & Riggio, R 2006, Transformational Leadership , Routledge, London.

Bolden et al. 2003, A Review of Leadership Theory and Competency Frameworks . Web.

Gallos, J 2008, Business Leadership: A Jossey-Bass Reader , John Wiley and Sons, New Jersey.

Grint, K 2010, Leadership: A Very Short Introduction , Oxford University Press, London.

Kramer, D 2010, Leadership Behaviors and Attitudes of Steve Jobs . Web.

Leadership Skills Approach . 2012. Web.

Peña, M, 2005, Steve Jobs to 2005 graduates: ‘Stay hungry, stay foolish . Web.

‘Taking the long view’ 2012 The Economist (US), vol. 402, p. 1-3.

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Mark Sanborn

JANUARY 12, 2022

For example , he studied the flow of students between classes. . Inspiration by Example . Examples include: Steve Wozniak : Apple Co-founder and HPU Innovator-in-Residence. The recurring theme here is to lead by example . Leadership by Being Engaged. Walking in single file,” he noticed. “

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Executive Evolution: How Performance Coaching Transforms Leadership

N2Growth Blog

OCTOBER 26, 2023

Case Studies : Real-Life Examples of Executive Evolution Through Coaching In the world of executive coaching, case studies serve as powerful tools to demonstrate the impact and effectiveness of high-impact performance coaching in driving executive development and evolution.

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SOLVEDcards self-coaching progress example

Mike Cardus

MAY 23, 2021

SOLVEDcards self-coaching progress example . The post SOLVEDcards self-coaching progress example appeared first on mikecardus.com. Throughout these exercises, Mike helps individuals and organizations quickly find what they would like to happen, identify what skills they already have, and identify a small progress step. SOLVED CARDS.

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Developing a Leadership Training Program for High Potentials: A Case Study

Great Leadership By Dan

SEPTEMBER 15, 2011

Developing a Leadership Training Program for High Potentials: A Case Study . There are many examples of companies that have successful leadership training programs in place, such as Bank of America, General Electric, Microsoft, Philip Morris, Novartis International, and Marriott International to name just a few. (Yes,

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Digital Transformation in Healthcare

MAY 12, 2023

Case Study 1 One example is an organization disrupting the sector with a Patient Engagement Platform. Case Study 2 Another real-world lesson comes from a Prescription Benefits Manager (PBM) headquartered in Puerto Rico.

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Managerial-Leadership Case Study: Contextual Goals Matter

MAY 31, 2013

I asked for an example . Anthony is the manager of IT and Frank’s manager. One day Anthony and I were talking and he stated that he has seen a rapid decline in Frank’s output and quality of his work. Anthony, “Two months ago I asked Frank to complete a task that I felt was simple.

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Your Top 5 Motivation Questions Answered

Lead Change Blog

SEPTEMBER 9, 2020

Susan’s expert teaching is based on motivational best practices derived from solid science communicated through compelling storytelling, case studies , and real-life examples . Susan Fowler, author, trainer, and professor, explores the lessons from her book Why Motivating People Doesn’t Work…and What Does.

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Always Day One

JUNE 25, 2020

He presents case studies of these five tech giants in Always Day One. The case studies also provide ample examples of pitfalls we should avoid too. The robots are the most visual example of Bezos’s obsession with automating whatever he can to free his employees to work on more creative tasks.”.

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Team Building & Leadership: Case Study; Increased Trust=Faster.

JANUARY 25, 2011

Design by 12GrainStudio Team Building & Leadership: Case Study ; Increased Trust=Faster Implementation of Decisions & Problems Solved Cheaper Tuesday, January 25th, 2011 Posted by: mike The following is a true story, of value added results that come from Create-Learning’s Team Building & Leadership Processes. Jan 2011 Guy.

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Managerial-Leadership Case Study: Employee Engagement Requires Sufficient Autonomy

OCTOBER 30, 2013

This is an example of remaining autonomous or self-directed. By all measurements Mike is an engaged employee. The manager states, “Mike I know this is not ideal for you and you have always been a top employee here. I cannot tell you what to do, you have to decide.”.

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Systems Thinking: The Superpower You Didn't Know You Needed.

MAY 7, 2023

For example , imagine you're trying to lose weight. Case Study Example : Reducing Food Waste in a School Cafeteria Part 1: The Challenge At Sunshine Elementary School, the cafeteria faced a significant problem: a considerable amount of food was wasted daily.

How Do You Influence and Inspire People?

JUNE 14, 2021

Set the Example . What are the top three examples you want to set for your team? Include rational arguments, market research, customer surveys, and case studies . Next, move to specific examples and more discussion of the facts. Leaders influence and inspire people to make positive changes. Then use these tactics.

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The Cost of Ignoring Employees? 120% Of Annual Income or $0.35 / Share, Southwest Airlines Discovers

Modern Servant Leader

DECEMBER 18, 2023

The result is a case study in the cost of ignoring employees. The incident reflects a classic example of focusing too narrowly on one stakeholder group – in this case , shareholders – at the expense of others, notably employees and customers. The root-cause of Southwest’s meltdown?

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6 Types of B2B Marketing Videos Your Business Needs in 2021

AUGUST 5, 2021

For example , you might teach your target market how using your product improves their company’s bottom line or improves their HR processes. For example , in this video , Mailchimp teaches how its customers can set up email campaigns. The Whiteboard Friday series from Moz is an excellent example of using tutorial video content.

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First Look: Leadership Books for November 2023

NOVEMBER 1, 2023

Through a sequence of engaging stories and pithy examples , he shows how we can use our newfound grasp of the unchanging to see around corners, not by squinting harder through the uncertain landscape of the future, but by looking backwards, being more broad-sighted, and focusing instead on what is permanently true.

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Speak Out and Stand Out: How to Complain and Climb the Corporate Ladder.

AUGUST 14, 2023

Be Specific and Objective : When you voice your concerns, provide clear examples and avoid making them personal. Case Study : Emily's Dilemma Emily was an account manager at a mid-sized marketing firm. Weigh the pros and cons, and decide if it's worth bringing up. Phrases like "I feel that…" or "I've noticed…" can be effective.

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Leaders Coaching Leaders: One Secret to Sustainable Leadership Development

Let's Grow Leaders

MAY 2, 2022

For example , some of our clients use a 7-10 month team accelerator program to supplement our instructor-led leadership development program. Between sessions, the manager and team members watch for opportunities to celebrate when they follow through on their commitments and call each other back to their agreement when they don’t fulfill it.

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Embracing Emotional Intelligence: The Art of Leading as a Feeling Being Who Thinks

DECEMBER 15, 2023

A Real-World Case Study A notable example is a global tech company that implemented an emotional intelligence program for its management team. This case study , detailed in a Forbes article , underscores the transformative power of leaders who embrace their role as feeling beings that think.

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Your New Leader 100-Day Action Plan

MARCH 4, 2023

The book is packed with: Examples and case studies Action plans Tools, techniques and tricks of the trade The authors also explain why you need to start even before your official first day on the job. And, if you miss one or more of the critical tasks that must be accomplished in your first 100 days, you'll likely fail.

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The Transformative Power of Executive Coaching Services

JANUARY 19, 2024

Executive Coaching in Action: Real-World Case Studies In a case study involving a Fortune 500 company, executive coaching led to a marked improvement in team leadership performance. They offer insightful feedback, pose thought-provoking questions, and guide the leader towards achieving their objectives.

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The State of Leadership and Management in Education Report

NOVEMBER 15, 2023

Drawing on new survey data, existing research and case studies , the Top of the Class? Explore the findings The State of Leadership and Management in Education Drawing on new survey data, existing research and case studies , the Top of the Class?

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A Technology Case Study: Implementing What the Customer Wants

JULY 27, 2011

Dirty Little Secrets offers dozens of examples to clarify precisely how buying decisions can be facilitated through the right kind of questions, including an in-depth case study of a marketing manager who recognizes the need for a better website and wants to bring in an external design team. She lives in Austin, Texas.

Pacing for Growth

FEBRUARY 20, 2019

She brings over 30 years of physiological and psychological research, in-depth business case studies , examples from real leaders, practical tools and her own endurance training stories to help you lay the foundations for enduring success.

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Management and leadership in local government report

JANUARY 17, 2024

This report, leveraging insights from an expert roundtable, recent survey data, and case studies , delves into the performance and challenges of leadership and management in local government.

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Anti-Age Discrimination Policies Fail To Make A Difference At Work

The Horizons Tracker

AUGUST 29, 2023

A recent case study of anti-age discrimination policies in the UK has exposed their inadequacies in effectively serving their intended purpose, thus causing neglect of the very individuals they are designed to assist. .

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Beyond Recruitment: N2Growth’s COO Search Solutions Enhance Organizational Performance

JANUARY 6, 2024

Case Studies : Evidence of N2Growth’s Impact on Organizational Performance In a notable case , a healthcare conglomerate sought N2Growth’s guidance to find a competent COO capable of steering its operational framework effectively amidst a challenging landscape.

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Executive Business Coaching Minneapolis

DECEMBER 14, 2023

Case Study : Transforming Leadership in Minneapolis A notable example in Minneapolis involves a tech startup CEO who sought executive coaching to enhance her leadership skills. Through this process, she not only improved her decision-making and strategic thinking abilities but also fostered a more cohesive and motivated team.

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Are You Ready to Deliver a Great Presentation?

MARCH 18, 2021

Variety— Use a variety of techniques (data, facts, statistics, observations, case studies , surveys, results from pilot programs, and testimonials) to explain and support your ideas. For example , Dr. Jill Bolte-Taylor rehearsed her extraordinarily successful TED talk 200 times before presenting it. Fewer conflicts?

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Knowing and Doing: Closing the Gap

MARCH 23, 2018

” Leading by example – a personal case study . For example , on a recent interim assignment, staff were astonished, in response to a need for staff cover of a particular delivery session, when I stepped into the role. one member of staff squeaked, in a somewhat startled voice. That’s right,” I replied. “I

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Sage Advice For The First-Time Leader

Terry Starbucker

MAY 21, 2019

There are so many things that you can’t find in any school textbooks, case studies , business simulations, best-selling leadership books, podcasts, and any other outside source in your pre-leadership world that will make the difference on whether you achieve your professional dreams. Next, make stress your friend.

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A Picture of Health?

JULY 1, 2023

Read the report Research Findings Key Recommendations Read the full report Drawing on new survey data, existing research and case studies the report seeks to better understand existing deficits - and the potential - of effective management. Good and outstanding managers in the NHS make a critical difference to our health.

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Can AI Help Us Understand Whether To Bail Out Banks?

APRIL 11, 2023

Smarter decision making They showed in one case study that a government bailout would only be the right course of action if the ultimate stakes taken were greater than a critical threshold value. This short-term cost is justified to the taxpayer because the long-term costs of bank defaults would be more harmful.

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Reality Coaching – Real Coaching – A Case Study

OCTOBER 11, 2012

The above dialogue is an example only not a true record of the session. – I generally do well in the qualifying but do not seem to be able to carry it through to the races themselves. Can you imagine a time in the near future when you can see yourself winning? No not really….

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Work-culture that attracts trust – 7 interactional strategies

APRIL 2, 2023

Highlight success stories : Examples of other organizations or teams that have successfully improved their work-culture can be powerful tools for learning. Share success stories of implemented changes, case studies , or interviews.

How Collective Intelligence And AI Can Make Citizens’ Lives Better

NOVEMBER 27, 2019

The report includes five detailed case studies with a further eight examples from around the world that explore how AI and collective intelligence can function together. Firstly, the field is very early on, with each of the five case studies at an early stage.

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Unlocking Digital Leadership: CIO Executive Search

Once you have determined the key traits and skills needed for digital leadership, it is vital to scan the market, starting from within your industry and working outward, for examples of successful digital transformation or implementation of digital strategies.

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The Transformative Power of Virtual Coaching in Today’s Dynamic Leadership Landscape

DECEMBER 20, 2023

Real-World Impact: A Case Study A notable example is the case of a multinational corporation that implemented virtual coaching for its executives. This case study highlights the tangible benefits of integrating digital strategies into leadership development.

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Collaboration for Change: Multi-Sector Partnerships in Sustainable Medical and Sharps Waste Management

OCTOBER 13, 2023

Case Study : Houston’s Multi-Sector Approach In Houston, this collaborative spirit is palpable. The Global Perspective: Lessons from Abroad While Houston offers a compelling case study , it’s essential to recognize global efforts.

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Is a Lack of Intentionality Holding You Back?

NOVEMBER 8, 2019

Connection with your team, your example , empathy, linking purpose to work, providing challenges and education, appreciation, and a good story are among the ten. Al of the examples point to the fact that inspiration, culture, and emotion, are created and maintained with intentional leadership. Sanborn offers ten tools for inspiration.

Choosing the Best Motivational Leadership Speakers

Career Advancement

JULY 22, 2019

Some are purely motivational—firing up your employees to perform—and some offer factual case studies and industry examples to show how to elevate managing skills, build a cohesive team, or maximize productivity. No two speakers on leadership are alike. Everyone has a different style and technique.

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What a Mechanical Shark Can Teach Us About Leadership and Innovation

DECEMBER 17, 2018

As I watched the documentary, I was struck by how closely the story mirrored case studies from the business world, and how perfectly it illustrated the points I try to emphasize in the leadership and innovation class I teach at MIT. No, those fresh, once-in-a-lifetime ideas are examples of pure and raw creativity.

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The Top Six Benefits of an Online MBA

MARCH 9, 2023

For example , you can tackle challenging assignments in the morning when your mind is most alert. Online MBA programs often involve internships and experiential learning like case studies , field trips, and simulations. Working on a live case study or project will give you the confidence to tackle future business challenges.

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COMMENTS

  1. PDF Leadership Theories and Case Studies

    Leadership Styles and Traits Chapter Five ............................................................................................ 101 Building a Strong Executive Team Chapter Six .............................................................................................. 117 Hiring the Right People

  2. Leadership Case Studies

    Learn from three instructive and impactful case studies from the book, Leadership Case Studies, that cover different leadership styles and challenges. The book also includes 16 role-plays and six articles on leadership skills and traits.

  3. Leadership Style: Articles, Research, & Case Studies on Leadership

    By making sensitive self-disclosures, leaders can enhance how authentic their followers perceive them to be, leading to positive interpersonal outcomes and potentially organizational ones as well. Aside from the obvious costs of disclosing weaknesses, leaders may also reap surprising benefits from doing so. 03 Feb 2020.

  4. PDF Case study: Steve Jobs as a transformational leader

    Case study: Steve Jobs as a transformational leader Steve Jobs is an example of a leader who is often associated with transformational leadership, in particular when it comes to his charismatic and inspirational qualities (e.g. Bryant, 2003; Bass and Riggio, 2005).

  5. Analysis of Leadership Style in Organizations: A Case Study of the

    For example, when a turnaround is imminent or when a hostile takeover is imminent. To be effective, he suggests that leaders master at least four types, including authoritative, democratic, affiliative, and coaching, and be able to move between them quickly.

  6. How to Make Different Business Leadership Styles Work (With Case Studies)

    According to , the basic assumptions of transactional leadership are the following: When giving assignments, the business leader must be clear when it comes to the instructions, rewards and consequences, as well as giving feedback. 6. Transformational Leadership Style.

  7. Case study

    Case study 2016 - CASE Preview text Introduction: The following case comprises of comprehensive comparison between Virgin and Foxconn, where the leadership style and behaviors of the CEO's of both the companies, Terry Gou and Richard Branson, differ.

  8. Leadership Articles, Research, & Case Studies

    02 Jan 2024 What Do You Think? Do Boomerang CEOs Get a Bad Rap? by James Heskett Several companies have brought back formerly successful CEOs in hopes of breathing new life into their organizations—with mixed results. But are we even measuring the boomerang CEOs' performance properly? asks James Heskett. Open for comment; 1 Comment posted.

  9. The Ethical Leadership Case Study Collection

    Learn from real-life scenarios of ethical dilemmas and decision-making in the workplace with the Ted Rogers Leadership Centre's Case Collection. The cases are free to instructors and cover topics such as stakeholder analysis, communication, and organisational development.

  10. Leadership Cases

    The teaching cases in this section are designed to provoke critical thinking on various domestic and international leadership challenges. Students will find themselves in the shoes of leaders from many positions—whether it be in the nonprofit or public sectors—and will have to navigate the complex reality of what it means to be an effective leader.

  11. What Is the Authentic Leadership Style? 3 Real-Life Examples

    Investigate the leader's values to help create a clear moral basis for making decisions and setting direction. Gather perspectives from the client's colleagues or boss. Encourage the leader to ask for feedback from others who've seen their leadership in action. Help clients find their authentic voice.

  12. Adapt Your Leadership Style to Your Situation

    If you're not sure, get feedback from others. Then learn, adapt, practice. The goal is to develop a portfolio of micro-behaviors you can employ when the situation demands you use a different ...

  13. PDF Case study Unlocking Leadership Potential

    Design and planning: Weekly check-ins to discuss participant engagement / feedback and coordinated communications to the participants Executed on plan to collect and synthesize feedback, including delivering results to senior leadership Collaborated with Talent Development team to support senior leaders to reinforce learnings through small-group

  14. PDF Case study Unlocking Leadership Potential

    Case Study: Chairman-sponsored leadership program for senior leaders Blended: workshops, online learning, field work Experiential: in-person sessions to practice skills learned in digital courses Focused on mindsets and behaviors Incorporating leaders as teachers Reinforced: regular communication from Chairman to participants

  15. How To Write A Leadership Case Study (Sample)

    Photo by lilartsy on Unsplash How To Write A Leadership Case Study A leadership case study effectively shares real-life leadership success or failure. To write such a study, one should include inspiring and educational details for readers. Begin by researching the subject thoroughly to ensure accuracy in facts and figures.

  16. PDF A Casebook on School Leadership

    distinguished expert on school leadership and teacher development, was awarded one of the first grants of the HCII fund. She proposed to assemble teams of school principals and universities to develop a book of cases by school principals themselves to provide real-life case studies to be used for in-service

  17. ESMT Case Study Recognizing Leadership styles: Inspection copy

    The case is designed to help undergraduate and graduate students, as well as participants in executive education programs recognize the differences between six leadership styles identified by the ...

  18. Marissa Mayer: A Case Study In Poor Leadership

    Both Mayer and the board are culpable of poor leadership. Much of my personal practice deals with CEO succession, and the misadventures of Mayer represents the classic case of picking the wrong ...

  19. Findings from the case studies

    A consistent case has been made for the need to reduce the numbers attending A&E departments. Many different ideas have been put forward about how to resolve the problem. In this case study we focus on one specific innovation which seeks to tackle the issue. It is a study of leadership from the CCG in the redesign of one focused aspect of ...

  20. Top 40 Most Popular Case Studies of 2021

    Fifty four percent of raw case users came from outside the U.S.. The Yale School of Management (SOM) case study directory pages received over 160K page views from 177 countries with approximately a third originating in India followed by the U.S. and the Philippines. Twenty-six of the cases in the list are raw cases.

  21. Mark Zuckerberg's Leadership Style

    According to Hiriyappa, Mark Zuckerberg possesses the following qualities: intelligence, self-confidence, determination and integrity (211). In summarizing Mark Zuckerberg's leadership qualities, Tim Bajarin, President of Creative Strategies, Inc., said "the number one thing we've learned from Zuckerberg is to take the vision you have ...

  22. Leadership Case Study

    This leadership approach requires a leader to master three important areas, which are conceptual, technical and human. Technical skills determine a leader's proficiency in performing certain tasks. For instance, Steve Jobs' skills as a computer scientist were paramount in navigating through the world of computers.

  23. Case Study and Examples

    ChMC Case Study: Marco Amitrano. Chartered Management Institute. OCTOBER 16, 2023. ChMC Case Study: Marco Amitrano Managing Partner and Head of Clients & Markets at PWC UK Chartered Management Consultant Award: The way forward for the consultancy industry.Leading by example, empowering others and being part of a senior leadership team that is supportive of Chartership is an important focus at ...