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This article aims to provide an overview of what is occurring within two large District Health Boards in New Zealand: Counties Manukau DHB, ranking number three in relative population size, and Canterbury DHB, number two. The conclusions provide a comparison of these approaches and draw on some of the new developments which are being driven by and through these District Health Boards.

Canterbury DHB have embraced a capability/competency framework while Counties Manukau DHB have chosen an alternative approach, enacting “leadership as a practice approach”. CMDHB have developed a range of development intervention across management and leadership levels while CDHB have chosen a path of HR practices aligned to a capability framework.

The approaches taken by Counties Manukau DHB and Canterbury DHB, while different, are driven by many of the same elements both internally and externally, indeed they might even be considered complementary. A focus on quality and patient safety, the changing dynamics of clinicians and managers, the integration of primary and secondary care and the increasing move to multi‐disciplinary teams who focus on care systems in an environment of increased demand alongside proportionally decreasing resources feature in both and require an adaptation of leadership in a health context.

The approaches taken by the two DHBs are unique to their organisations and the sector, yet provide exemplars of practice for other large health providers. The outcomes will reflect their differences in approach and the specific workforce challenges each faces.