Leadership is what we turn to in times of change, yet many of our systems are built to resist it.

Last month, I sat in a room filled with some of the most thoughtful, committed leaders in Australian and New Zealand healthcare. We gathered for RACMA’s 2025 Strategic Planning Day, not only to chart a course for the College but to consider the kind of leadership the future will require.

It’s easy to forget how rapidly the world is shifting. Artificial intelligence, telehealth, and predictive analytics are no longer emerging ideas. They are reshaping healthcare today. Models of care are moving beyond hospitals and into communities. Systems designed for acute episodes must now respond to prevention, population health, and supported self-care, as Kidd has described. Meanwhile, our workforce is under strain – stretched, ageing, and in urgent need of renewal, as highlighted by Duckett and Stobart.

In this context, leadership must be both principled and practical – anchored in values while able to respond to complexity and change. But here lies a tension. While we rely on leadership to guide transformation, many of our systems continue to default to preserving the status quo.

That’s why our discussions at the Planning Day were so important. We reflected on RACMA’s identity and the relevance of the term ‘Medical Administrator’. We considered the kind of leadership our sector needs to navigate the challenges ahead, and the role the College must play in shaping it.

One key message emerged: leadership must evolve. Traditional, centralised models are becoming less effective in addressing today’s health system challenges. The future calls for leadership that is collaborative, responsive and multidisciplinary. It must be grounded in clinical insight and systems awareness and able to navigate disruption in real time.

We’ve seen this need in action. During the COVID-19 pandemic, systems that empowered local teams were often more agile and effective than those constrained by rigid, top-down models, as noted by Fraser et al. in the Medical Journal of Australia. Countries investing in community-led care, such as New Zealand’s locality networks, are achieving better outcomes and greater value, as also noted by Duckett and Stobart.

But the discussion doesn’t end with leadership capability. System settings play a powerful role in shaping what’s possible. Governance structures, workforce planning, and funding mechanisms can support or limit innovation. Persistent barriers like siloed operations and outdated incentives remain, even when leaders are willing to change.

The interaction between leadership and system design is critical. Strong leadership can drive reform, but sustainable change also requires systems that make leadership more effective. Flexibility, trust, and shared accountability must be built into the way we structure and govern health services.

At RACMA, we continue to believe that doctors bring unique strengths to leadership – clinical expertise, a deep understanding of risk and systems thinking. But those strengths matter most when applied in ways that respond to the evolving needs of the sector, and when backed by systems that encourage responsiveness rather than rigidity.

That’s why we are reimagining our role as a College that fosters and champions exceptional leadership. Leadership that draws on medical knowledge while also engaging with partners across sectors, embracing new ideas and adapting to change.

This is not a matter of positioning. It is a necessary strategic response to the realities of demographic pressure, financial constraint and digital disruption. Our systems are under strain, and those leading them must be prepared to guide thoughtful, long-term transformation.

This work takes courage – the courage to challenge outdated structures and embedded resistance, and to lead with purpose rather than position. As David points out, structural unkindness remains embedded in parts of our system – and must be addressed.

Change at this scale cannot be achieved alone. Leadership is collective. It requires collaboration across jurisdictions, professions, and sectors as well as engagement with consumers and communities. We need to influence public discourse, shape reform agendas and redefine what effective leadership looks like in practice.

We also need to invest in people. Leadership must be supported at every level – from the ward to the boardroom, from policy to practice. It’s not limited to those in senior roles. Change comes from those willing to step up wherever they are. Clinical governance must also evolve. As Dwyer has argued, we need enabling environments where innovation and accountability can coexist.

This is about more than vision. It’s about designing systems that enable better care, building capability across the workforce and aligning leadership development with the realities of a changing world. And it starts with us.

As the day concluded, I felt something rare and valuable: clarity. Clarity about our purpose, our direction and the role RACMA must play in supporting the leadership our future health systems will need.

The future is not predetermined. It is something we must actively shape.

It’s time to lead boldly.

Author

Professor Erwin Loh

Prof. Loh is President of the Royal Australasian College of Medical Administrators and National Director of Medical Services for Calvary Health Care. He was previously Group Chief Medical Officer at St Vincent’s Health Australia, Chief Medical Officer at Goulburn Valley Health and Chief Medical Officer of Monash Health. He has qualifications in medicine, law and management. He has adjunct professorial appointments at Monash University, University of Melbourne and Macquarie University. He has been an invited speaker at local and international conferences, and has published books, book chapters and journal articles on leadership, governance, AI and health technology. He is a member of the Association of Professional Futurists. He received the Distinguished Fellow Award from RACMA in 2017 for “commitment to governance, research and publication”.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: President of RACMA; Associate Editor for BMJ Leader

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