Insights March 2017
Open Letters

Leadership “inaction” or Leadership “in Action”—The Change Dilemma

Dr. Graham Dickson

This letter is part of series of Open Letters from Canadian leaders in Healthcare. To see the complete series please click here   

The old adage that everyone wants change but no one wants to change is alive and well in Canadian healthcare. Governments call for transformation, yet are not willing to transform their own behaviour. Everyone wants collective efforts to be patient centred, but don’t want to partner with each other or patients because they are afraid of losing control of the agenda.  Everyone wants a well-honed, integrated system of patient care but wants to retain independence and autonomy from that system. We all want collaboration, shared visions, and collective action to achieve change, but when pressed to deliver, we often revert to demands of ego, turf, and combativeness. It seems that we intellectually “buy” the notion of transformation, but aren’t ready to accept the personal demands associated with its success.  Instead of leadership in action—championing and orchestrating change—we have leadership inaction; lots of talk and no action.

In healthcare we throw words around--reform, transformation, leadership, and change—as if by saying them, we will bring them about.  Many of us are all arm-chair voyeurs of leadership and change, rather than players of it. And of course, as we indulge in our “fantasy” health system change games (endless meetings, symposia and conferences) it sometimes feels like we are trying to convince ourselves that we are really doing it, rather than playing at it. 

The scope and breadth of behaviour change, time required, and sophisticated leadership needed to transform healthcare is vast. Healthcare exists in a volatile, uncertain, complex, and ambiguous world;a world that demands strategic, distributed, innovation, authentic, adaptive, and complexity leadership approaches. 1 This skill set is very different from the skill set that created the health system we now wish to change.

Given this challenge, let’s review what some recent documents say with respect to the leadership of change in the Canadian healthcare.

  • A recent Saskatchewan Advisory Panel report on health system structure recommends one provincial regional authority to replace the existing 12.2 It describes the job of leadership is to align action behind patient-centred care—province-wide. The current model with 12 boards, 12 Chief Executive Officers (CEOs) and their associated senior leadership teams, who have had a similar charge for the past seven years, were apparently unable to accomplish this. The report suggests that structural overburden- the infrastructure serving 12 different regions—is the problem. The report does acknowledge that different leadership skills—and potentially a redistribution of those skills (e.g., more medical leadership)—is necessary. But it doesn’t explore these issues in any depth.3  So really it is “in the dark” when it comes to knowing whether or not the leadership capacity exists in Saskatchewan to (1) make a one-region system work which is itself a major change task; and (2) actually make patient-centred care work.
  • A recent Manitoba government report—although not proposing a one-region province—analyzes the changes needed to truly create a patient-centred provincial delivery system. 4 It uses the term leadership 66 times. It emphasizes the power of provincial, regional, and community leadership teams (e.g., indigenous health, palliative health, mental health) to steward change. It suggests strong clinical leadership is necessary. However, it appears to assume that the people in current positions of leadership can take on these challenges, and have the skills to do so. Is that a reasonable assumption, without a comprehensive look at the kind of skills required to implement a system vastly different from the one those leaders are stewarding today?

Now let’s put these two examples into a broader national context.

  • Do we know the quantity of leaders/managers in a health system required to enable its transformation?   No. Do they have the skills to do so? A CHLNet Benchmarking study5   and a Canadian Institutes of Health Research (CIHR) study6 suggest not.
  • Healthcare is the most complex industry in society. Yet in other “less complex” industries they depend on their leaders/managers to create change. But in healthcare we cut administration when budgets get tight and demands for change increase.
  • We continue to rely on government to lead transformation. This is somewhat ironic, given government and its agents, the public service, are on the lowest rungs of a “trusted profession” scale; whereas doctors and nurses are high on that scale. So why aren’t doctors and nurses asked to help shape the transformation? Is that because our leadership style and approach—starting with government, but extending into the public administration of health—does not know how to do so, using their current leadership practices?
  • There is no national plan or strategy—and rarely provincial ones -- to provide a comprehensive developmental opportunity to all health leaders (formal managers, doctors, nurses, and patients) who want to participate in reform, and develop the capabilities needed to be successful at it.
  • Even if we asked doctors and nurses to exercise leadership in healthcare, many are on the verge of exhaustion and burnout. Statistics show this has been the situation for years.7, 8 Yet somehow there is an ongoing myth that these tired and hard working people will step up to the patient-centred change challenge if we “just get it right.” Yet low engagement, and high turnover and absenteeism numbers tell us that we are struggling just to keep operations on track.
  • A basic function of leadership is to articulate a clear vision of the future, align the work with it, develop and implement a transition plan, and measure progress.  Yet it is acknowledged across the country that these conditions are lacking.  Why?

Such is the change dilemma. Without the kind of leadership that is needed, the message to doctors, employees, citizens and others is:  abandon the healthcare system you have now “on faith” and trust us, the leaders who have made this mess, to sort it out. This is a hollow promise. Our collective valuing of leadership “in action” only plays out in rhetoric: “inaction”. How long will we tolerate this change dilemma? How long can we?



  1. Nunez, M. (2017). Bridging the 21st-century leadership gap:  Emerging development practices. Accessed on February 23, 2017 @
  2. Abrametz, B., Bragg, T, & Kendel, D. (2016). Optimizing and Integrating Patient-Centred Care: Saskatchewan Advisory Panel on Health System Structure. (December). Accessed on February 25, 2017 @ file:///C:/Users/gdickson/Downloads/Saskatchewan%20Advisory%20Panel%20on%20Health%20System%20Structure%20Report.pdf Pp. 1-33.
  3. It does reference an attempt in 2009 to identify such leadership needs: Deloitte (2009). The Need for Transformation in Health Care Administration: Report on the administrative component of the Saskatchewan Patient First Review. Accessed online on February 25, 2017 @ Pp. 2—40.
  4. Healthintelligenceinc. & Associates (2017). Provincial Clinical and Preventative Services Planning for Manitoba. Doing Things Differently and Better. Final Report Submitted to Deputy Minister, Ministry of Health, Seniors and Active Living. Accessed on February 26, 2017 @
  5. Canadian Health Leadership Network (2014). Canadian Health Leadership Benchmarking Survey Report: CHL-Bench. Accessed on February 26, 2017 @
  6. Dickson G, Tholl B, Baker GR, Blais R, Clavel N, Gorley C et al. (2014). Partnerships for health system improvement, leadership and health system redesign: cross-case analysis. Ottawa: Royal Roads University, Canadian Health Leadership Network, Canadian Institutes of Health Research, Michael Smith Foundation for Health Research. Available:
  7. Provincial Health Services Authority (2006). Creating Healthy Health Care Workplaces in British Columbia: Evidence for Action. A Discussion Paper. Accessed on February 25, 2017 @  pp.1—69.
  8. Fralick M, Flegel K. Physician burnout: who will protect us from ourselves? (editorial). CMAJ2014;186(10):731. Available:

About the Author(s)

Dr. Graham Dickson, Ph.D. Professor Emeritus, Royal Roads University


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