There’s a quiet type of leadership that never makes it into strategy documents or press releases. It’s found not in titles or job descriptions, but in those unspoken moments of coordination, compromise, and care — when a system under pressure still finds a way to deliver for its patients.
At our recent Trauma & Orthopaedics Away Day, I was reminded that leadership isn’t a role. It’s a behaviour. And it’s a behaviour I saw everywhere — among consultants, nurses, therapists, admin teams — each trying to do the right thing with limited time, space, and resources.
But it also laid bare a difficult truth: we are only able to lead well when we are allowed to.
We Work Within Our Resource Envelope — But the Envelope Is Thin
Every idea discussed that day was designed with realism in mind. We weren’t asking for fantasy fixes. The proposals — ward round prioritisation, trauma continuity, virtual fracture clinics, patient ownership structures — were all grounded in what is possible with current staffing and bed numbers.
But let’s not kid ourselves: we’re working within a resource envelope that is uncomfortably tight. Our inpatient demand often exceeds our footprint by 40%. Clinics overflow. Gaps persist at every staffing level. The truth is, our capacity has not kept pace with clinical need. This isn’t just true for us but echoed throughout the entire NHS.
And while we accept that resources are finite, we cannot accept that patients and staff become secondary to the balance sheet.
This is where executive leadership matters most — not as gatekeepers of policy, but as allies in the trenches, who listen, understand, and advocate for the real-world decisions that need backing.
When We’re Facilitated, We Fly
I’ve written about this before. My work with the PGVLE has given me assurance in my own capabilities but also allows me to see the talent in the room and the potential of those around me. Very little succeeds because someone at the top dictated a vision. Things succeed when they are given just enough room to make it happen — with trust, not red tape.
It’s a pattern I’ve seen time and again. Whether we’re redesigning a fracture clinic or recalibrating trauma on-call models, the common denominator in progress is permission and trust. The role of leadership isn’t always to lead from the front. Sometimes it’s to clear the path for others to lead.
When people are enabled rather than managed, they outperform expectations. That’s not theory — that’s lived experience.
Collegiality Is Our Competitive Advantage
What really stood out at the Away Day wasn’t just the content, but the tone. Consultants who often work independently found common ground. Nurses and therapists contributed ideas that challenged old assumptions. Managers listened not to respond, but to understand.
That’s not compliance. That’s collegiality — and it’s the only sustainable foundation for service improvement in the NHS. We can have all the protocols in the world, but without shared intent and mutual respect, they’re just documents.
When we work together — with clarity, transparency, and a shared sense of ownership — the energy changes. Problems become solvable. Cynicism is replaced by realism. Momentum starts to build.
We Need Empathy, Not Just Efficiency
Leadership at the top must resist the trap of defaulting to the spreadsheet. Balance sheets don’t bleed. Patients do. Staff morale doesn’t show up on a KPI dashboard, but it determines everything from patient outcomes to retention.
So here’s the ask — respectful, but direct:
We don’t need you to solve every problem. But we do need you to see the problems for what they are. Walk the wards. Sit in on board rounds. Understand that sometimes the bottleneck isn’t incompetence — it’s architecture. The systems we’re asked to deliver care within were never built for the volume, complexity, or acuity we now face.
Real Leadership Takes Courage
There’s no shortage of management in the NHS. But what we need now is courageous leadership. The kind that makes decisions not because they’re palatable to NHS paymasters, but because they’re right for patients and sustainable for staff.
Sometimes that will mean spending a little more to avoid losing a lot later. Sometimes it will mean backing service models that prioritise continuity and quality over short-term efficiency metrics. Sometimes it will mean saying no to external pressures so you can say yes to your own teams.
And yes — sometimes it will mean taking flak for doing the right thing.
But that’s leadership.
Let Us Keep the Oxygen in the Room
We’re not asking for miracles. We’re asking for alignment.
Let us continue the work we’ve already started. Let us drive improvement not through control, but through facilitation, clarity, and belief. Back us when we act in patients’ interests, even if it makes the numbers uncomfortable for a while.
Because when leadership is shared — when execs join us in the trenches, even symbolically — the service gets stronger.
And so do we.