System Leadership in Healthcare: Leading Across Boundaries

In April, the Royal College of Paediatrics and Child Health (RCPCH) and Talent for Care hosted the third and final session in their Being Leader webinar series: System Leadership — Leading Across Boundaries. Led by Dr Megan Peng (Associate Director of Workforce & Professional Development at RCPCH), with speakers Arran Daly (Senior Facilitator & Programme Manager at Talent for Care) and Dr Daljit Hothi (Consultant Paediatric Nephrologist & Clinical Lead for HD at GOSH), the conversation explored what it means to lead when the system itself is the challenge.

Below are the core insights from a rich, wide-ranging discussion — relevant for anyone navigating leadership in complex healthcare environments.

1. 🌐 Systems are messy ~ and that's the point

Daljit opened by mapping the characteristics of healthcare systems: the stakeholders nested within ICSs and neighbourhoods, the environments that shape culture, and the dynamics — visible and invisible — that drive how systems actually behave. Systems include influences we can see (the parents in front of us) and influences we can't (the doctor-aunt in Australia who's shaping a family's decisions).

The key takeaway: systems aren't problems to be solved. They're environments to be navigated.

"Systems are really complex and really messy and it's hard. But you have to engage with that messiness if you're a system leader." Dr Daljit Hothi

2. 🧭 Three Dimensions of System Leadership: Doing, Being, Thinking

Arran built on the Being a Leader framework that has run across the whole series, applying it specifically to the scale of system leadership.

• Doing at system scale means scaling up the action — clarity of vision and purpose, understanding what matters and why.

• Being at system scale means recognising the ripple effect. As a system leader, people who have never met you will form judgements about you. Your presence — how you show up — travels further than you can see.

• Thinking at system scale demands greater cognitive complexity: holding more information, integrating more perspectives, and moving from linear cause-and-effect thinking to non-linear sense-making.

"You're moving from a linear process where you can talk about cause and effect to non-linear, which is really messy. You can't predict it. You have to experiment and see, and then constantly reassess where you're going." Arran Daly

3. 🤲 What System Leadership Actually Requires: Acceptance, Grace, and Self-Awareness

When asked directly what's needed to lead within a system, Arran's answer was immediate and unambiguous.

"The words that come to mind are acceptance, grace, and self-awareness. We need to accept that we can't predict the outcome. And we need to be okay with: that didn't work, what do we do now? — not get bogged down in the fact that it didn't work." Arran Daly

He was equally clear that these qualities are not just for those at the top. Leadership, in Arran's framing, is a human skill — and the more it's embedded at every level of the NHS, the more movable and workable the whole system becomes.

"The more we can bring leadership skills from the second someone starts within the NHS — giving them some leadership development of some description and encouraging them to continuously grow and learn — that, for me, makes the difference." Arran Daly

4. 🔍 Practical Behaviours That Signal Effective System Leadership

The conversation turned practical when an audience member asked what day-to-day behaviours signal genuine system leadership. Both speakers offered grounded, actionable responses.

• Reflective practice — before, during, and after. Arran recommended a three-stage reflection habit: reflect on who you're being before you go into a meeting, notice what's happening during it, and debrief after. This single practice, done consistently, builds awareness and creates growth.

• Hold your expertise lightly. Daljit's principle: everyone is right, but only partially. Rigid expertise contracts your perspective. Openness expands it.

• Ask questions rather than stating views. In complex systems, no single person holds the complete picture. The system leader's role is to join the dots — and you can't do that if you're doing all the talking.

• Curiosity as a leadership habit. Arran brought this directly back to Talent for Care's MDT programs: 'Invite them into curiosity. Even with your rightness — go and ask that person over there, just see what they say.' Curiosity is what allows fluidity. Rigidity is what creates friction.

5. 🌱 Can You Lead a System Without a Senior Title?

One of the most direct questions from the audience: can you be a system leader without formal authority or a senior title?

Both speakers answered yes — emphatically.

"You can lead your own internal system. You don't need any permission to do that. If you're constantly trying to learn about yourself, reflecting on your actions and behaviours, celebrating the good stuff — you don't need permission from anyone for that." Dr Daljit Hothi

Arran offered a practical example: a team he'd worked with the day before had decided, as a collective action, to hold themselves accountable in every meeting for ensuring everyone's voice was heard. No title required. That, he said, is system leadership.

6. ⚡Leading Teams in Low Morale: Possibility over Performance

A particularly resonant question came from the audience: how do you lead a team to a more positive place when there are constant pressures on outcomes and morale is low?

Arran's response centred on the concept of relatedness — Talent for Care's framing for the relational foundation that makes growth possible — and on the leader's role as a buffer for the team.

"We speak a lot on our leadership programmes about creating growth, and the underpinning piece to creating growth is relatedness. In a team that's really struggling, that relatedness has often dropped or is lacking. What can you do as a leader to guide that, bring that back, and create the conditions for a bit more growth?" Arran Daly

Daljit added that the first step is acknowledgement — not ignoring the reality of where the team is — before gradually helping people reframe from a space of negativity towards possibility. She drew on the distinction between performance (deficit-focused, backwards-looking) and learning (future-oriented, possibility-led).

"The NHS is currently obsessed with performance. But we have a choice as individuals to say: I need to balance that with growth — and actually, maybe even foreground growth over performance." Dr Daljit Hothi

7. 🚧 Boundaries Are Made Up — and That's Liberating

One of the most striking threads of the conversation was about boundaries: the artificial divisions between systems, teams, trusts, and tiers of care that people treat as fixed — but which are entirely human-made.

"The boundaries we create — 'this system versus that system' — are man-made. We created those boundaries. The NHS is part of a worldwide healthcare system. Where do we want to stop the boundaries?" Dr Daljit Hothi

Arran extended this into a direct challenge for system leaders: when you treat differences across teams or trusts as barriers, you close off learning. When you reframe them as opportunities — curiosity about how they do it differently, and what you could take back — you open up the system.

He gave a concrete example from Talent for Care's programs for Healthcare Assistants in the Midlands: putting participants from different trusts in a breakout room together and asking them to just talk about their jobs. What they come back with — the recognition that some things are similar, some completely different, and that there's something to take home — is itself a form of system leadership.

8. 🤖 AI and System Leadership

The final question from the audience touched on AI. Will it factor into system leadership in the future?

Both speakers approached it with the same nuance they'd applied to everything else: neither dismissive nor uncritically enthusiastic.

"AI is part of our systems. As a leader, to ignore the fact that AI is here would be very silly. But as a system leader, you've almost got to take an objective view — this is not your possession of an AI tool. It's about the whole team, the whole system. What's their readiness? What are their vulnerabilities?" Dr Daljit Hothi

Arran agreed, framing AI as a tool — one that can relieve workload rather than replace people. His view: keep the purpose central. If the purpose is healing people, use AI in service of that, not in service of cost-saving.

Closing reflection

Megan closed the series with a personal reflection on how far leadership conversations in medicine have come. When she was in medical school in the 2010s, leadership wasn't on the curriculum. Now it's part of training, embedded in curricula, and being discussed — as in this series — as a human skill that operates at every level of every system.

The Being Leader series has explored presence, practice, and now boundaries. Taken together, the three sessions make a compelling case: effective system leadership is not about having all the answers. It's about holding complexity with acceptance and grace, staying curious, and building the conditions — the relatedness — that allow teams, and systems, to move.

Joining us at RCPCH Conference 2026?

Talent for Care will be at the RCPCH Annual Conference in Birmingham, 11–13 May 2026.

Join Arran Daly and the TfC team on Tuesday 12 May for workshops and sessions on leadership in the RCPCH Learning Mini Theatre (main exhibition hall). Professor Turner, President of RCPCH, will join for a special afternoon session on systems leadership and working across boundaries.

To find out more about Talent for Care's leadership development programs for NHS and social care organisations, visit talentforcare.uk or get in touch with Alessandro or Nik directly.