This report draws on the experiences of ten senior leaders to look in depth at the skills needed to be a system leader. The ten individuals are from different backgrounds and work in different contexts, and give some very candid reflections on their successes and failures. There was consensus among those interviewed that much more needs to be done to develop system leaders. This could include ‘buddying’ younger, less experienced managers and clinical leaders with more experienced counterparts, and doing more to protect whistle-blowers. But there was some debate as to whether system leadership can be taught, or needs to be learnt the hard (and long) way.