Good leaders create followers, great leaders create leaders

Peter Lees, FRCS


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Effective leadership is not coercive, but rather authoritative, affiliative, democratic, and coaching. However, the complexity of our current health care system is now so great that a leader cannot have the skills needed to lead all of the time. Instead, we need teams of insightful, empowering leaders who can promote the right culture, ensure high standards of care delivery, and pass the baton of leadership between themselves to ensure that staff and patients benefit.


KEY WORDS: followership, teamwork, leadership styles


If you have no followers, you are not a leader. If you have no willing followers, you are not a good leader. Top


The essential prerequisite for leaders to have followers causes some to argue that we have enough of the former, not enough of the latter, and a pressing need for training in followership. Some clearly have doctors in their sights in this regard — if only they would simply do as they are told! Sometimes I wish they would, often I am glad that they do not.


There is the danger in the followership argument of reducing the art of leadership to a simple case of one individual in charge of a group of people following orders. That over-simplification is, of course, the essence of coercive leadership and undoubtedly has a place in more extreme circumstances. Sadly, however, in my career, it has all too often been the default approach of many doctors, and anecdote suggests this may not have changed much. It should surprise few that Goleman1 found that the coercive leadership style correlates negatively with results, and his more persuasive styles (authoritative, affiliative, democratic, coaching) correlate positively with results. However, the latter are more time-consuming and require greater skill, which may partly explain any over-reliance on coercion. Top


Coercive leaders need to reflect on what happens when they are not present. Fear of what one’s senior will make of a decision and second-guessing their foibles were ever-present drivers in my training, but the Goleman evidence (and common sense) would suggest this is a poor and ineffective approach. Furthermore, other evidence shows a correlation between leadership and results with the creation of a positive climate, not fear, as the intermediate step.2 Good organizations and good leaders rely on building the right culture such that, whoever the leader is in a particular circumstance, the actions are in line with the ethos of the organization and led by engaged individuals who feel supported, enabled, and competent. Top


Another inadequacy of the simple leader–follower model arises with the scale of modern leadership. Pendleton and Furnham3 argue convincingly that complexity is now so great that the contemporary leader cannot have the skills to lead all of the time, an observation that also has echoes in the UK King’s Fund report, subtitled No more heroes.4 It seems logical to conclude, therefore, that the successful modern team, rather than a collection of followers and a leader, is instead a collection of leaders with the sophisticated ability to pass the baton of leadership to the most appropriate individual at the appropriate time. Some may lead more than others and one will usually be primus inter pares and hold ultimate accountability, but all team members will lead some of the time. Flatter hierarchies are, therefore, essential — perhaps another lesson the medical profession needs to learn? Top


Continuing with the complexity theme, the world facing the modern leader is neatly summarized in the acronym VUCA: volatile, uncertain, complex, ambiguous.5 Research suggests that success in the face of VUCA requires increasing levels of leadership sophistication. Torbert and Rooke6 describe seven levels. Depressingly, in their global study, 55% of leaders resided in the three least successful levels.


For doctors it is interesting to reflect on the most prevalent level within the bottom three, the expert, characterized by an overriding focus on knowledge and expertise. Watertight thinking is extremely important and experts rely heavily on hard data and logic to secure buy-in with little sensitivity and little time for those they deem less able. The obvious paradox is that, within that definition, there are undoubtedly attributes that one wants in a physician, but, historically, the system and the profession have been overly tolerant of the less attractive aspects. In short, technical brilliance does not excuse poor behaviour nor poor teamwork. Top


Furthermore, as doctors almost inevitably rise in seniority as their clinical competence grows, those stuck in the expert level will have serious shortcomings when faced with the inescapably greater leadership and management responsibility for which the profile of the expert has significant shortcomings. Leadership development must address this necessary progression and must toe a careful line, promoting clinical excellence without accepting poor behaviour. Some, perhaps many, make this progression organically but the stakes would seem too high to adopt a hit-and-miss organic approach.


Research on teamwork suggests that good decisions come from freedom to debate and freedom to challenge. In the seminal work linking teamwork and mortality,7 a key positive discriminator is the permission for team members to challenge the leader; the dangers of blind obedience, potentially reinforced through training in followership, are obvious. This too has major implications for leadership development. Top


It is time to question the value of the common approach of supporting the development of single individuals out of context and away from their fellow team members8; instead there is a need to address the complexities of the model of multiple leaders within a single team. Although logistically less convenient, leadership development has to get close to individuals who work together and focus on their issues and their challenges. Considering the practicalities of this, it seems inevitable that the focus must shift from national, even regional leadership development bodies to building local expertise at the organizational level. In short, leadership development needs to be as embedded in everyday practice as clinical development.


In conclusion, the concept of followership is outdated and fails to recognize the complexities and challenges of modern-day leadership. Globally, health care systems are facing major challenges and evidence suggests that good leadership offers solutions through improved performance. Top


Furthermore, in health care, better leadership is also associated with reduced mortality and better patient experience.9 Medicine has been slow to understand this crucial association and slow to embrace leadership development and to support its medical leaders. We need little short of a revolution in which leadership is recognized as a core skill of the good clinician. We need a medical workforce that is self-aware, focused on effective team working and knows the kind of leadership that promotes good care.


The days of the allegedly all-knowing autocratic senior doctor must be replaced by teams of insightful, empowering leaders who can promote the right culture to ensure that high standards of delivery are maintained and appropriately pass the baton of leadership between themselves to ensure that staff are fulfilled and patients get the best deal. Top



1.Goleman, D. Leadership that gets results. Harv Bus Rev 2000;Mar/Apr.

2.Brown SP, Leigh TW. A new look at psychological climate and its relationship to job involvement, effort and performance. J Appl Psychol 1996;81(4):358-68.

3.Pendleton D, Furnham A. Leadership: all you need to know. Basingstoke, UK: Palgrave Macmillan; 2012.

4.The future of leadership and management in the NHS. London: King’s Fund; 2011.

5.Bennett N, Lemoine GJ. What VUCA eeally means for you. Harv Bus Rev 2014;Jan/Feb.

6.Rooke D, Torbert WR. Seven transformations of leadership. Harv Bus Rev 2005;Apr:3-13.

7.West MA, Borrill C, Dawson J, Scully J, Carter M, Anelay S, Patterson M, Waring J. The link between the management of employees and patient mortality in acute hospitals. Int J Hum Resour Man 2002;13(8):1299-310.

8.West M. Leadership and leadership development in health care: the evidence base. London: Faculty of Medical Leadership and Management; 2015.

9.Shipton H, Armstrong C, West M; Dawson J. The impact of leadership and quality climate on hospital performance. Int J Qual Health Care 2008;20(6):439-45.



Peter Lees, MB ChB, MS, FRCS, FRCP, is chief executive and medical director of the Faculty of Medical Leadership and Management, London, UK.


Correspondence to:


This article has been reviewed by a panel of physician leaders.