Healthcare leadership has always been complex, but in recent years a new reality seems to be emerging: the rise of factional leadership. Across health systems, aged care, and hospitals, leaders are operating in environments where factions are no longer the background noise of organisational life, they are becoming a defining feature of leadership itself.
What Do We Mean by Factional Leadership?
Factional leadership occurs when groups within an organisation stop looking to central authority for direction and instead rally around their own priorities and champions. Sometimes these factions form along familiar lines — clinical teams versus executives, departments with different visions, or service streams competing for resources. At other times, they are subtler, emerging as loyalty networks, shadow hierarchies, or “in-groups” with disproportionately greater influence.
At its heart, factional leadership is an adaptive response. When people lose faith that the leadership centre can hold, they create their own centres of gravity.
Why Healthcare Is Particularly Vulnerable
While no sector is immune to factions, healthcare is especially fertile ground for them to grow. Frequent restructures and leadership turnover create vacuums that informal leaders are quick to fill. Conflicting accountabilities such as quality versus cost, efficiency versus safety, equity versus access, pull leaders in opposite directions, creating space for factions to argue their corner.
Meanwhile, trust in top-down decision-making markedly weakens. Frontline staff often feel that executive strategies are detached from day-to-day realities, and they gravitate toward leaders who “actually get it.” When voices feel unheard, culture silos deepen, and organisations begin to look less like unified systems and more like loose federations of factions.
The Double Edge of Factions
It’s important to note that factional leadership is not always harmful. At its best, it represents healthy dissent, diverse expertise, and distributed leadership —all of which are essential in complex systems. Many healthcare innovations have been driven by groups who challenged conventional thinking and disrupted the status quo.
But when factions emerge from unmet needs and persistent disconnection, they can become costly. Decision-making slows to a crawl. Whisper networks and shadow hierarchies begin to carry more weight than formal governance. Consultation processes risk being weaponised to delay or obstruct. Most damaging of all, frontline engagement declines when staff perceive that internal politics matter more than patient outcomes.
The Subtler Risk: Competing Realities
One of the deeper challenges with factional leadership is that it creates competing versions of reality inside the same organisation. Executives may be working from one narrative, often shaped by financial imperatives and performance dashboards, while clinicians experience a very different reality on the ground. When such multiple “truths” coexist without them being reconciled, leaders lose their ability to align strategy with frontline experience. The result is confusion, mistrust, and an erosion of credibility at every level.
Why Factions Are Appealing
Factions also thrive because they meet very human needs. They offer belonging, clarity, and a sense of agency in systems that often feel overwhelming or grossly unfair. For individuals working in environments where change is constant and uncertainty is high, the certainty of a faction can feel reassuring. This makes factions ‘sticky’ and people are reluctant to leave them behind, even when they know collaboration would serve the greater good. Leaders who fail to understand the psychological appeal of factions risk underestimating their staying power.
The Leadership Challenge
For today’s healthcare executives, the real test is not whether factions exist —because they always will— but what they represent. Factions are rarely just the work of “difficult personalities”; they are usually symptoms of structural misalignment, cultural fracture, or a leadership gap.
Leaders must ask themselves: Am I cultivating a cohesive leadership team or presiding over competing tribes? Do I reward loyalty to the mission or loyalty to individuals? And where might I be unintentionally reinforcing silos I claim to dismantle?
Factional leadership thrives in the absence of shared purpose. And shared purpose does not appear on its own, it must be designed, protected, and continually reinforced.
The Path Forward
The boom in factional leadership tells us something important about the state of healthcare today: people are searching for clarity, belonging, and credibility, and they will create it for themselves if and when the system does not provide it. That energy can be channelled productively —or it can fracture an already strained sector.
This is why the most urgent leadership task is not simply to cast a vision, but to integrate. Leaders who can build coalitions across divides, bridge professional and organisational silos, and hold competing priorities in balance will create the conditions for progress. Those who cannot risk presiding over systems where the loudest factions set the agenda.
Healthcare does not need fewer voices. It needs leaders who can bring those voices into harmony. The future will belong not to the strongest faction, but to the leaders capable of weaving the different factions into a cohesive whole.
At the core of effective leadership, is the ability to make sound, accountable decisions across complex systems. For health leaders and directors who want to strengthen this capability, the AICD – AIHE Foundations of Directorship Health Variant program provides a practical grounding in governance — a skillset that is critical for ensuring your organisation leads, rather than lags, in the face of system stress. Register for our inaugural intake in October.
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