In many developed-world countries, attempts to enhance healthcare quality, effectiveness, and
efficiency have shifted away from top-down techniques and toward measures that rely more on
frontline employee participation and empowerment. Various clinician-led, network-based
initiatives in Europe and elsewhere (Addicott et al., 2007; Van Wijngaarden et al., 2006)
represent attempts to delegate responsibility for improving health-service provision to staff at
the 'coal face,' who are better positioned than senior managers and policymakers to transform
services in a sustainable way.
This trend has sparked debates in medical sociology and related fields about the changing
nature of healthcare work, including professional boundary reconfiguration (Nancarrow and
Borthwick, 2005), professional identity management (Waring, 2011), and shifts in authority and
accountability in changing organizational forms (Martin, 2009a). In this environment, attempts
to empower frontline personnel with the capacity, skills, and legitimacy to drive changes in
healthcare organization are particularly noteworthy. In particular, there have been significant
initiatives to improve clinical staff's 'leadership ability' (Koteyko and Carte 2008). A variety of
programs to encourage and support leadership in healthcare have been established in the
United States, the United Kingdom, and internationally, similar to other public services.
Leadership is increasingly viewed as a skill that should not be limited to senior executives at the
top of companies, but should be embraced by employees at all levels (Hartley and Allison,
2000). Managers, clinicians, and even patients are encouraged to be 'leaders' by demonstrating
good practice and influencing their peers in order to accomplish change that is accepted by all
(Martin a Learmonth, 2012). However, people charged with exercising leadership encounter
practical challenges, particularly in public service environments such as healthcare, where
policy imperatives, professional divisions, and bureaucratic systems can obstruct staff's capacity
to lead across boundaries and up hierarchies (Coope et al., 2012; Martin, 2009a). As a result,
the concept of 'distributed leadership,' as espoused in management literature and
operationalized by managers and policymakers, has received a lot of flak (Currie et al., 2011;
Martin and Learmont 2012; O'Reilly and Reed, 2010).
Policymakers are increasingly emphasizing the need for leaders at every level of service
delivery, driving change across organizational and professional boundaries, to address 361
social issues that are not amenable to improvement through the actions of a single profession,
organization, or even sector. Martin and Learmonth (2012) studied the evolution of leadership
rhetoric in important government policy documents in the United Kingdom, identifying both an
increasing emphasis on leadership in general and a shift in focus towards the role of frontline,
clinical leaders throughout the health professions. Recent policy documents, such as the NHS
Next Stage Review (Secretary of State for Health, 2008), call for all clinicians (explicitly include
non-medical as well as medical professionals) to be "practitioners, partners, and leaders" (2008:
14; see also ch. 5 passim). Despite being the product of a different government and heralding
significant changes in NHS organization (in England), the recent white paper Equity and
Excellence maintains this emphasis on clinicians' front-line leadership, promising to 'liberate
professionals and providers from top-down control' (Secretary of State for Health, 2010: 27):
'clinicians will be in the driving seat and 'clinicians will be in the driving seat and 'clinicians will
be in the driving seat and 'clin (2010: 51).