Leadership and management in the NHS have become the focus of much attention over recent years, and the recently published report by the King’s Fund is an excellent primer.1 The report helpfully tackles the two subjects separately, but their distinction is worth exploring further; management is perhaps the more generic term, and an understanding of how this has changed may offer insights into the role and manner of leadership.

The overarching task of the NHS is not that complicated; it provides healthcare to the population in a fair manner (with perhaps a nod towards health improvement). It only becomes complex when the number of variables that influence this aim are considered: a politically accountable system with a tax based budget that accounts for a 10th of the entire gross domestic product; delivery of care to a diverse population largely by professionals trained to be autonomous and self directed, using interventions whose effectiveness varies enormously; and a workforce of nearly 1.5 million people spread across several hundred separate organisations.

In organisational terms delivering these objectives requires management, leadership, administration, and bureaucracy. Recent reforms have emphasised transactional tasks (for …