Article Summary
Successful NHS transformation depends on more than a clear plan. Shared direction, honest conversations and a culture where people feel able to speak up can all influence whether change moves from intention to delivery. Samantha Knollys, Managing Director at SK Clarity Ltd and former NHS Board Director and Consulting Partner, explores why leadership culture matters to transformation, and how greater clarity can give leaders the confidence to challenge assumptions, address difficult issues and say no to activity that does not support the intended outcome.
NHS transformation is often approached through the formal mechanisms of change: defining the case for improvement, establishing a programme, allocating resources and setting out what needs to be delivered. These are necessary foundations, but they do not determine how effectively an organisation will navigate the decisions, tensions and competing priorities that emerge once change is underway. For Samantha Knollys, Managing Director at SK Clarity Ltd and former NHS Executive Board Director and Consulting Partner, this is where leadership culture becomes an important part of delivery. Her experience of transformation, operational and financial improvement has shown that progress depends not only on having the right plan, but on whether senior teams share a clear understanding of what they are trying to achieve and are prepared to have honest conversations about what may be preventing them from getting there.
That need for a clear and shared destination is central to Sam’s work, and alignment, for her, provides the starting point. A capital programme, technology investment or pathway redesign may have a defined objective on paper, but differences in how that objective is understood can become increasingly significant as change moves through an organisation. Establishing a shared destination gives teams a clearer basis for making decisions, resolving competing priorities and testing whether investment and activity are contributing to the intended outcome.
That clarity also creates the basis for challenge. Transformation inevitably brings difficult decisions, dependencies and pressures to the surface. If concerns remain unspoken, leaders risk making decisions without a realistic view of the factors affecting delivery. Creating a culture in which people can question assumptions, raise problems and have constructive but sometimes uncomfortable conversations is therefore not separate from transformation; it is part of the conditions required to deliver it.
Alignment must come before transformation
If you’re on different tracks, you won’t get to the same destination
For Sam, alignment begins with ensuring that senior leaders have a genuinely shared understanding of what they are trying to achieve. This can require creating space away from immediate operational pressures to establish common priorities, understand different perspectives and resolve differences before they become embedded in delivery.
That time can be difficult to justify when organisations are under pressure. Yet, as one Medical Director reflected after a board away day: “It felt too indulgent to have a board away day given the operational pressures, but we’ve achieved so much by getting to know each other and can now shortcut decisions together on our objectives.” The value, in this case, came through the ability to make decisions more easily afterwards because the people involved had developed a clearer understanding of one another and their shared objectives.
Sam also believes the language used to describe a change needs the same level of attention. Terms such as performance improvement, financial turnaround, operational reset and patient quality improvement can appear to describe broadly similar programmes, but they can create different expectations about what needs to change, where priorities lie and what success looks like. Being deliberate about that language can therefore help establish a common understanding across the organisation. As Sam puts it: “Words do matter.”
Honest conversations should be part of delivery
Clarity about the destination does not remove the need to challenge what happens along the way. Sam sees radical candour as one of the differences between transformation that moves successfully and at pace and programmes that stall. Drawing on the concept developed by Kim Scott, she describes the importance of combining honesty with kindness: creating psychological safety without allowing difficult conversations to be avoided. In healthcare, Sam believes being nice can sometimes be confused with being kind. Yet kindness can also mean having the honesty to say what needs to be said, particularly when avoiding an issue could ultimately affect delivery or patient care.
A conversation between a GP and an A&E consultant about patient referrals illustrates what this can look like in practice. After taking the time to understand each other’s perspective, one reflected: “We’ve achieved more in a two-hour ‘real’ conversation than in the last two years in heated debate … I’ve been able to walk in their shoes and the penny has dropped.” In other words, the conversation gave both sides greater insight into an issue affecting performance and helped move it beyond the assumptions that had surrounded it.
The challenge is that these conversations can be uncomfortable. Sam points to what Scott describes as ruinous empathy: when a desire to avoid discomfort or protect relationships prevents an issue from being addressed openly. In practice, this can create a gap between what a team knows is happening and what is actually being discussed. For leaders responsible for delivery and the teams on the ground delivering change, that gap matters. Unspoken concerns about people, timelines, dependencies, budgets, behaviours or expectations can make it harder to establish a realistic picture of whether a programme is on track and what may be preventing progress.
The aim is not to create a confrontational culture, but one in which constructive challenge is expected, and difficult issues can be raised early. When the purpose of transformation is ultimately to improve services and outcomes for patients, avoiding those conversations can carry consequences of its own.
Culture shapes an organisation’s appetite for change
The ability to have honest conversations is closely connected to the culture in which change is taking place. Sam hears clients describe change fatigue and a lack of trust that this programme will deliver what it promises. Understanding that starting point is important, because organisations, and individual teams within them, will not necessarily respond to change in the same way.
For Sam, assessing the existing culture and an organisation’s “appetite for change” can help leaders understand those differences and tailor their approach accordingly. A team that has experienced repeated initiatives without seeing lasting results may approach another programme with greater scepticism than one with stronger confidence in its leadership. Recognising those conditions early can help shape how change is communicated, introduced and led alongside existing operational pressures. Who is the right cheerleader for the change? Often, it is someone who has previously been resistant.
Culture is also reinforced through everyday leadership behaviours. Sam draws on the work of Megan Reitz, who describes how leaders can create practical signals that speaking up is genuinely encouraged. There is a difference, for example, between telling people “my door is always open” and deliberately creating the time and space for those conversations to happen: “I’ve booked out 2–4 pm every Thursday, so please do let me know what’s on your mind and pop in.”
These may appear to be small behaviours, but they help demonstrate what is expected and accepted within an organisation. Creating regular opportunities for concerns to surface can allow issues to be addressed earlier, rather than waiting until they have become more difficult to resolve.
Better leadership can mean doing less
NHS organisations are rarely managing one change programme in isolation. Service redesign, financial recovery, capital investment, workforce pressures and day-to-day operational demands can all compete for attention, often alongside new initiatives and expectations. In that environment, effective leadership is not only about deciding what an organisation should do, but also what it should stop doing.
Sam recently attended the launch of the Health Foundation’s Productivity Commission report, Breaking the Cycle, which reinforced a point that runs through her own experience of transformation: improving performance is not necessarily about adding more.
Technology provides a practical example. Sam notes a presenter of the Productivity Commission who said that “Technology can be a distraction and reduce value unless the foundations are in place.” New digital systems, equipment or infrastructure need the right skills, processes and interoperability around them if they are to deliver value, a topic explored by several contributors in this FORTIS article on turning digital data into real operational value. “We must liberate people’s skills at work,” another panel member commented, by doing less, empowerment and training.
That brings the argument back to alignment. When leaders have a shared understanding of the outcome they are trying to achieve, they have a clearer basis for testing new demands and competing priorities against it. Sam puts the question simply: “Does doing XYZ help get us to our final destination? If not, why are we doing it?”
Having the confidence to ask that question can be particularly important when organisations are under pressure. Reactive initiatives and restructures may create additional activity without necessarily addressing the underlying issue. Saying no is therefore not about resisting change; it is about protecting the capacity, investment and attention needed to deliver the change that matters.
A message from the Productivity Commission launch captured this for Sam: “Let’s be confident to be boring.” Transformation sometimes comes from staying the course rather than constantly introducing something new. It requires leaders to maintain a clear direction, address difficult issues and remain focused on the priorities they have already agreed on. For Sam, it ultimately comes down to this:
Know where you are going, be bold and speak up. If not you, who?
