Being an NHS chief executive: the best of times and the worst of times

Our new report, published in partnership with NHS Providers, shows that being a chief executive in the NHS today is both ‘the best of times and the worst of times’, to borrow from Charles Dickens.

As Nick Timmins’ interviews testify, it is the best of times because of the ability to make a real difference to people and patients, offering a sense of achievement and fulfilment that is difficult to realise in other roles.

It is the worst of times in the face of growing pressures from regulators and others that, at the extreme, are expressed as bullying. In some cases, bullying results in chief executives leaving the NHS, either by choice or more often because they are asked to do so.

The high personal cost to these individuals is hard to exaggerate. The cost to the NHS of the loss of experienced leaders is in some ways even higher at a time of growing concern about vacancies in top leadership positions.

With the NHS in England facing financial and performance challenges greater than at any time in its history, there is an urgent need to find better ways of supporting leaders who get into difficulty rather than replacing them pour encourager les autres. Many of the support systems that used to exist are no longer available, and today’s chief executives operate in a more isolated and sometimes hostile environment than in the past.

This matters for a number of reasons, most obviously in deterring the next generation of top leaders from putting themselves forward for chief executive roles. It also matters because continuity of leadership is directly associated with organisational performance. Constant chopping and changing of leaders – on a scale approaching that of football clubs – creates a weak foundation on which to build success.

Ed Smith, chair of NHS Improvement, spoke at a recent seminar at the Fund of the pernicious impact of the ‘firing squads’ who sack chief executives when things go wrong. His view, shared by the Fund, is that ‘regulated trust’ is much less effective than ‘real trust’ as a basis for improving NHS performance. Real trust is not fostered through a reliance on rules but rather through positive organisational cultures that encourage calculated risk taking and avoid blame.

These cultures support people to act in a way that is trustworthy and to do the right thing. They encourage behaviours and instincts that enable people to behave with integrity at all times. As our Director of Leadership and Organisational Development, Marcus Powell, argues in his commentary on the report, positive cultures take time to develop and require sustained effort by leaders and staff at all levels.

Rules and regulations designed to increase trust all too often have the opposite effect, resulting in over-reliance on compliance rather than the nurturing of commitment. Real trust cannot be mandated and emerges through the actions of leaders who create the conditions in which people are supported to be effective.

Change has to start at the very top through the actions of ministers and the leaders of national bodies. The culture of fear in the NHS, described by Don Berwick in his report on patient safety in 2013, needs to be replaced, and rapidly, if the NHS and its leaders are to rise to meet the challenges with which they are faced.

Rediscovering real trust is essential if current and future chief executives are to experience the best of times and to find support during the worst of times.

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Comments

#547604 Dave Stutchbury
Head of Commercial and Business Development
Nottingham University Hospital NHS Trust

The view of these departing CEO's is interesting and shows how difficult the role is however I think they have missed the core point. The NHS will need to be bold and allow Leaders from both outside and inside the NHS who have a different approach to get into these top posts. Currently a lot of Boards/Head Hunters are looking for Leaders who have gone through a 'traditional' route to mitigate risk however they are not going to get the transformational change required if they keep replacing like with like. Time to be bold.

#547607 Rita.symons

As a recently departed nhs leader - this feels v pertinent . 4 weeks out of the NHS feeling v positive about the future but v sad that after 25 years in the NHS i felt the need to leave. I remain an optimist!

#547609 Richard Spicer
Retired consultant surgeon
University

The real problem for CEO s is that they have to implement government policies however idiotic they are. This creates big problems between front line staff and management, however much the managers may feel on the side of staff they are not able to express this for fear of being sacked. How is that system ever going to work?

#547633 Kathy Torpie

I don't know which group of healthcare CEOs are worse off - those who have to follow government policy motivated by politics or those who have to follow the financially motivated policy of the third party insurance industry. In either case, physician and patient are the meat in the sandwich between the directives of external forces and the CEOs who have to implement those directives.

#548186 kevin riley
Retired Public Sector Solicitor and User and active Supporter of Doctors and Nurses working in the NHS
Self Empoyed

THE OVERRIDING NEED IS FOR MORE "FRONT LINE" SERVICE DELIVERY STAFF IF ANY IMPROVEMENT IN PATIENT CARE IS TO BE ACHIEVED AND THE RESPONSIBILITY FOR PROVIDING CARE ONCE PATIENTS HAVE LEFT HOSPITAL TO BE REMOVED FROM LOCAL AUTHORITIES AND TRANSFERRED TO THE NHS - WITH ADDITIONAL FUNDING OF COURSE..
OVER 50% OF TOTAL TAXPAYERS MONEY SPENT ON STAFF IN THE NHS GOES TO ONLY 2.35% OF THE TOTAL NUMBERS OF STAFF EMPLOYED - NAMELY CHIEF EXECUTIVES AND OTHER SENIOR MANAGERS - NONE OF WHOM ARE INVOLVED IN FRONT LINE SERVICE DELIVERY.

-Chief Executives and senior managers accounted for only 2.35 per cent of the 1.318 million staff employed by HCHS and GP services across the NHS in 2015" (Source http://www.nhsconfed.org/resources/key-statistics-on-the-nhs * HCHS = Hospital and Community Healthcare Services.

Therefore 50% of the total amount spent by the NHS on employing staff is being spent on only 2.35% of the individuals employed – by the NHS namely the 165+ Chief Executive and other senior “managers “in each of the now “free from democratic control” NHS Foundation Trusts. (Source National Audit Office).

A gross disparity between operational and non-operational “service delivery” staff, that would never be tolerated in any other “service” industry - let alone one dealing with (literally) life or death situations on a daily basis.

Regards,

Kevin S. Riley Solicitor (Ret.)

#548260 george anderson...
teacher
retired

The biggest problem with the NHS is that it is controlled by left wing fascists. They decided who will be treated and maintain their jobs through intimidation and bullying.

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