Leadership and change in health and health services

Change requires people to give up things that are precious to them in favour of a brighter, but indefinite future. So 'adaptive change' – as when a health system is reorganised and requires "wrenching organisational transformation" – is a huge risk factor for leadership.

The sort of leadership required to fiddle around the edges, which they call "technical change" does not lead to threat. I recall talking to a university official who was in charge of research development and asking how he found the job. "Love it!" he said. "In my job what I do is give away little dollops of money to oil the wheels for researchers. They are all happy! I make people happy!"

This is quite unlike the answer from a reforming vice-chancellor, other senior academics or a minister for health who is seeking to effect adaptive change.

When I was dean of a medical school, a colleague asked me how long I had been doing this job. It entailed the introduction of an entirely new curriculum, as had occurred at Harvard a decade before. "Four years," I said. "Goodness!" was his reply (he also had been a dean), "and you can still bend your back?" I replied affirmatively and asked why. "By this stage most deans have so much spinal scar tissue that they can't lean forward," he replied. Adaptive leadership is dangerous.

The essay by Heifetz and Linsky is quite explicit. "To minimise threats to eliminate you," they suggest five protective steps. But the assumption underling all of this is that, if you are the leader, and things are changing substantially, you are in the firing line.

In the language of managerspeak, they first propose that the leader operate "in and above the fray. Move back and forth between the dance floor and the balcony." Become involved in the process of change, but not so obsessively that you never have time to watch and reflect, or avoid hiding in your office 24/7: Get out and about and see what is happening on the dance floor.

Second, they suggest that leaders executing change need to "court the uncommitted," the silent majority who are neither loudly for nor against change. Politicians often overlook this 80% of the community. Accepting a degree of personal responsibility for the need for painful change can be a good move, showing the leader experiencing some of the pain.

A third element of self-protective change management involves living with the ambiguity and discomfort of conflict. "Conflict, is a necessary part of the change process, and if handled properly, can serve as the engine of progress. The conflict needs to be 'cooked," not burned, say Heifetz and Linsky. But, the heat must be high enough for people to sense the need for adaptive change. Short-term heat reduction is sometimes needed and can be achieved by tackling straightforward technical problems or slowing the pace of change.

The fourth attribute of the leader who successfully negotiates adaptive change is the business of delegation – not providing all the answers, not doing all the writing or talking or shifting yourself, but empowering and supporting others to get in on the act. Top-down change strategies, where all the answers have been invented in the sky, frequently fail because there is no local ownership.

Fifth, managing yourself is crucial. "Restrain your desire for control and meed for importance," Heifetz and Linsky suggest. Well, easily said! The value of wise, independent counsel and support for executives leading change is established with several powerful examples.

"The hard truth," they conclude, "is that it is not possible to know the rewards and joys of leadership without experiencing the pain as well. But staying in the game and bearing the pain is worth it, not only for the positive changes you can make in the lives of others but also for the meaning it gives your own."

Good leadership, I once heard said, is the art of helping those you lead to achieve things that exceed their expectations of themselves. That sounds like progress!