Nicholas Timmins: Is there a leadership crisis in the NHS?

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  • Posted:Wednesday 11 May 2016

Speaking at our breakfast event on 11 May 2016, Nicholas Timmins introduces our report, The chief executive's tale, and discusses common themes and challenges raised by the twelve departing NHS leaders who were interviewed for the report.


Welcome to the Chief Executive’s tale. Chief executives in both the singular and plural – the views of a dozen of them! And the main thing I do is to urge you to read them, not to listen to me, because I’m merely the amanuensis in all this, and I may be alone in this judgement but I found them riveting, stimulating, comforting, frightening, warming, full of warnings and in a number of cases, very frank!

But very briefly, what comes out? Well given the immense financial and operational strains on the NHS at the moment, plus the desire for transformation – whatever that may precisely mean – they are, unsurprisingly perhaps, a very happy bunch of bunnies. At very fact, at one level, they are. These accounts tell of both the dark side and the bright side of being an NHS Chief Executive, all of them said – often quite literally in these words – they had no regrets – even as they worried about whether there is a pipeline of successors available to follow them, given the pressures involved in the job, and that incidentally applied even to those whose tenure ended in a way that they would not have wished but who were brave enough to join in this exercise, and to all of them, we’re immensely grateful to them for finding the time to do this.

Even so, the job clearly is not easy right now, and over the years I sometimes had only limited sympathy for NHS Chief Executives who have, on occasion, complained about the impossible conflicts in the job; after all, many people in both the public and private sectors have to handle incompatible objectives. On my first day at the Press Association, the National News Agency, part of whose job is to try to break the news both accurately and faster than anyone else, I remember the then News Editor, Noel Richley, taking me aside – I was 23, he was I don't know what but looked to this young kid somewhat old.

Wonderfully gaunt aquiline features, a shock of entirely white hair, beautifully tailored striped flannel suits, looked as though he had been made on Saville Row before he inherited them, but with the trousers always held up – heaven knows why – not by a belt, but by a length of bale twine crudely knotted at the front – a wonderful affectation – and his words to me were, “Nicholas, this job is terribly simple. There are only two things you have to do: you have to be fast and you have to be right. the most important of these is that you are right, but God help you if you're second.” And those twin and essentially incompatible goals were what I tried to live by over the next 30 years but that to be fair was only two impossible things before breakfast. 

Now the NHS triumvirate of finances, access and quality has always been there, and we did in these interviews genuinely try to guard against memory playing tricks so that all people remembered was a better yesterday that never really quite existed, but right now that triangle does feel pretty hard to square. As Sir Jonathan Michael put it, “Most of the levers that we used to use to balance them have gone.” You could increase weights to help manage the finance, or slightly alter things on quality, but each of them has been nailed to the floor by regulation or legislation so the job is inherently more difficult. There are a number of Chief Execs who have left on grounds of ill health and so on and so forth which says quite a lot, and I think that is worrying.

And that sums up as briefly as could be a lot of what is in here. It’s not just the money. From where they sit, Chief Executives feel overregulated and over-inspected, and in some cases, inspected on the wrong things, and once again the subjects of excessive and sometimes conflicting demands for information to the point where it’s getting in the way of the day job and positively hampering the search for transformation. It is not, as Angela Pedder who is about to speak, put it – the Chief Executives say, “Go away and leave us alone.” Accountability matters, but when accountability gets in the way of action, it’s being overdone.

There were a few kinds words here at the 2013 reorganisation that flowed form Andrew Lansley’s act, but not many. Disastrous and catastrophic were the most common adjectives, and that judgement included the way the regulators feel required to follow their statutory obligations, even when that stops good things happening, and they kind of know that it’s stopping good things happening, and the loss of an intermediate tier also kind of came through – an interesting loss given that strategic health authorities well far from universally loved. But several said there is now no one to hold the ring when significant reorganisations of services are needed, and someone needs to settle conflicting interests between organisations – some of which are statutory. All that, these CEO’s felt was getting in the way of innovation.

It’s important to stress a couple of other things here; first that these were the Chief Executive’s views and second that by no means did they all agree about everything, which is another reason why they’re all worth reading. They’re not – as Chris said – a scientifically selected sample, and this is not a piece of bounced reporting because this was an exercise to elicit the Chief Executive’s tales, and there has been no attempt to go back and give the regulators and inspectors a change to tell their side of the story. But reading Keith McNeil’s fury on what it was like to be on the wrong end of a CQC Inspection or Mark Newbold on how he felt tied to a tree by the demands of assorted regulators and purchasers and with the separation of those roles at times confused should at the least provide food for thought.

Other aspects of the current job include how it now feels much more publicly exposed thanks to social media. Complaints remain about a bullying culture – expressed either in those words or in terms of unacceptable behaviour. With the disappearance of the old style tiered management of regions and areas and SHA’s, there’s a widespread perception that there is much less managed career development available, and then where it does still exist, it’s narrower in scope than it was and something has got lost there by – so to speak – mistake. These elements and others, including the fact that second and third level posts are better paid these days, and that people are more interested in a work/life balance, leave these Chief Executive’s worrying about how many people would be prepared to step up into their shoes given the greater exposure, and that view was true whether these Chief Executives came from either a purely managerial or a clinical background.

And it was notable that one or two of those we approached to take part in this declined on the grounds that their recent experience of the job still felt too raw to talk about – back again to that Jonathan Michael quote – all of which makes this sound like a rather depressing read, and in fact it’s anything but. Much of it is uplifting. I was particularly struck by how many of the CEO’s, when asked to whom they felt accountable, instantly replied, “The patients.” Ahead of more formal accountability to their boards or regulators or purchasers, or even heaven for fend, the Secretary of State or the Public Accounts Committee.

There was a palpable sense that this is a job that can make a real difference to the lives of many, many patients – hundreds and indeed many, many thousands of them over the years. That when it went right, it was hugely rewarding. Point also made by those who came to the NHS from the private sector and often from a non-health private sector background; that for all the difficulties, this was – on the good days – the best job in the world, as one interviewee put it.

So it’s not all doom and gloom, but there’s also a fair amount about the job and the supplier successes to do it, that unquestionably needs addressing. Thank you very much.


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