Mind the gap: women and leadership in the NHS

This content relates to the following topics:

Article information

  • Posted:Thursday 14 June 2018

A podcast about big ideas in health and care. We talk with experts from The King’s Fund and beyond about the NHS, social care, and all things health policy and leadership. New episodes monthly.

Subscribe on iTunes

Is there a glass ceiling for women in health and care? What should be done about it?

Following the recent gender pay gap debate, and as part of our wider work on diversity, Helen McKenna talks about leadership and gender in the NHS with Jane Dacre, President of the Royal College of Physicians, Anne-Marie Archard, Director of the London Leadership Academy, Sam Jones, former Director of the New Care Models programme at NHS England, and Deborah Ward, Senior Analyst at The King's Fund.

Further reading

Content not displaying properly? The episode is also available for download here .


  • HM:     Helen McKenna
  • AA:      Anne-Marie Archard
  • JD:       Jane Dacre
  • SJ:        Sam Jones
  • DW:     Deborah Ward

HM:       Hello, and welcome back to the third episode of The King's Fund podcast where we talk about the big issues and ideas in health and care.  I'm Helen McKenna, I'm a senior policy advisor here at the Fund and I am your host for this episode.  The theme today is women in leadership in the NHS.  First we're going to look at the gender pay gap and then we're going to look more broadly at what can be done to support more women to progress into senior roles across health and care and I'm joined by four incredible guests today.  Rather than me introduce them and potentially get it wrong, I will let each of you introduce yourselves.  So Samantha, Ann-Marie, Jane and Deborah, could you briefly introduce yourselves and also, just to throw a curve ball into the mix, could you tell us when you were a child what did you want to be when you grew up?  Let's start with you Anne-Marie. 

AA:        Hi, I'm Anne-Marie Archard and I'm the director of the London Leadership Academy.  So that's one of ten academies that we have that work across the NHS doing all sorts of exciting things around leadership development, organisational development, but in particular I think for today what's really relevant is that in London we're doing an awful lot of work around women in leadership and we've got a fantastic women's network that is up and running with over 500 members and we're working with a range of other organisations who are also doing the same.  When I was a child, when I was really young, I really wanted to go and be in space.  I won't say be an astronaut but I was born in … I won't tell you when but the first man on the moon, so that gives you a big clue, and I thought by the time I was 25 that we'd be living on the moon.  So that was my ambition and then a little bit later, when I became slightly more realistic, I actually wanted to be an arts administrator and director and I think actually being a leadership director has a lot of the same sort of skills and qualities.

HM:       Fantastic, thank you.  Jane...

JD:         Hello, I'm Jane Dacre, I'm the President of the Royal College of Physicians.  Relevant to today I'm the third president that's a woman in 500 years so we're not terribly progressive in that department in my college but, hey, all of that is about to change.  How did I get here?  I'm a physician, I'm a rheumatologist, I'm passionate about medical education and so have spent a lot of my career designing and developing ways that doctors can learn better.  When I was about six I wanted to be a policeman.  I had three brothers so, to a certain extent, I think that's the secret of my career because I always had to do what the boys were doing and so I spent a lot of my time throughout my life really wanting to be in the thick of it with what the boys were dong and, here I am, nearing the end of my career and I'm still doing it, which is probably a bit sad.

HM:       And do you ever look back and think, what if I had become a policeman?

JD:         Well at the age of twelve I changed my mind to become a doctor and the reason for that was that I didn't really know how to become a policeman and the main benefit seemed to be that you were less likely to go to prison and then I discovered that wasn't true (laughter).  So I thought that … my father said to me, he used to call me a fast talking ratbag, and I was quite good at science, so he said that if I was a fast talking ratbag and quite good at science maybe a doctor would be a good career for me.  So I thought well okay, I'll do that instead.

HM:       Inspiring words from your father (laughter).

JD:         Absolutely.

HM:       Okay, thank you.  Sam.

SJ:          Hello, my name is Sam Jones, I'm currently working independently but previous to this I was the National Director for the New Care Models programme and before that I had been a provider … hospital provider Chief Executive and a long time ago I was a paediatric and a general nurse.  I was trying to think about what I did want to be when I grew up because I didn't have a plan, I just … I still don't have a plan, I still don't really know, I just wanted to wear a suit, but I was just struck by something that Jane said.  So I have quite a few brothers and it was very clear the way that we were brought up is that there was no difference between me and my brothers and therefore it didn't even cross my mind or anyone else's mind that I wouldn't do anything that they could do or beat them clearly.  So I was just wondering how much of that plays out as we move forward.

HM:       And Deborah?

DW:       Hi, my name is Deborah Ward, I'm a senior analyst here at the King's Fund and before that I used to work for NHS providers as an analyst there as well.  When I was growing up my ambition was to be an archaeologist, I think this was the rise of Time Team in the 1990s and actually I did do that very briefly but it's not quite as glamorous as Time Team would have you believe.

HM:       Well thank you for the introductions.  Okay, so given it was all over the news so recently let's start with the gender pay gap.  So all organisations with more than 250 employees across all sectors, not just health and social care, had to publish their gender pay gap by April this year.  Deborah, you're our resident expert on all things gender pay gap related, can you first of all tell us what the gender pay gap is as a concept?

DW:       Yes, so gender pay gap is the difference in average hourly pay between men and women.  We normally talk about it as a median pay gap which is the middle value rather than the mean which is the average.  I mean it's normally expressed as a percentage.  So if it's a positive percentage, that shows that men are earning more than women, if it's a negative percentage, that shows women are paid more than men.  So we looked at the data that was reported as part of the reporting process for all NHS organisations, so for Trusts and Foundation Trusts, for Clinical Commissioning Groups that reported … that were large enough to report and for the national bodies and we found a gap of 9.5% in favour of men.  We also looked at a sample of social care providers which was a little bit trickier but they have an even better pay gap that comes out at 3.2% in favour of men.

HM:       Okay, so even better is smaller pay gap, yes?

DW:       Even better is smaller.

HM:       Yes.

DW:       Zero is optimum.

HM:       Yes, okay and so just thinking about some of the factors behind the pay gap, I mean Jane I'll come on to you in a second because you're actually leading a review of the pay gap, but Deborah in terms of your analysis what have you seen?

DW:       So we looked at some of the research that's been going on about the factors for the remaining gender pay gap.  We pulled out four things.  One is that men and women tend to do different types of jobs.  The NHS - about 77% of the workforce is female but then if you look at, say, engineering you have the opposite balance.  We also found that there's some evidence that jobs done by women are undervalued.  There's a great quote in an article I read which was in the US saying that men who watch cars are paid more than women who watch children.  So car park attendants have a higher average wage than childcare assistants.  There's quite a lot of conversation happening at the moment around something called the motherhood penalty, so the time women take out for child caring responsibilities and for other caring responsibilities is known to have a significant impact on earnings.  There's also some evidence which shows that the time at which you have your children also has a bigger impact.  So if you have children between the ages of 25 and 35 you're less likely to recover your earning potential to the same level as a man and I think the other factor that we've talked about is the fact that men tend to hold more of the senior roles, so women in leadership is a definite factor in the gender pay gap. 

HM:       Okay, thank you.  That's really, really helpful and so, Jane, the Secretary of State Jeremy Hunt has asked you to lead a review looking at the gender pay gap in the medical workforce.  I know it's incredibly early days, I think it was only announced a few days ago, but can you tell us a little bit about what you're planning? 

JD:         The preliminary evidence from the NHS actually suggests that there's a 15% gender pay gap for doctors and as a within-career within-profession gender pay gap that's big.  Preliminary work suggests that whilst some of that can be explained by the things that we've been talking about, there's a significant proportion of it that is unexplained.  So what we've done for the purposes of the study is to set up a steering group and a stakeholder group, that's what we're doing now, to make sure that we have as wide an input and as wide a reach as we can, but we have commissioned a research team to provide both quantitative and qualitative data analysis.  So the quantitative stuff to get pay scales and proper evidence from how people are remunerated in the NHS and for the qualitative stuff we're gathering together groups of men and women to have qualitative interviews which we are going to put together and then alongside that we've embarked on a very broad literature review of issues around women, women's progression and gender pay gaps.  So it's all very new but we've started actually with quite an extraordinary amount of publicity, much more than I expected.  So off we go.

HM:       I think this is a good moment to bring in our other contributors to think about what's going on more broadly in terms of why there are fewer women than men at the top of the health and care system.  So just thinking about the stats, 77% of the NHS workforce are women and yet they only hold 37% of the senior jobs.  So I'll just be interested in hearing your views about what's going on there.  Do you think that there is a glass ceiling?  Let's start with you Sam.

SJ:          So I have to declare that I'm quite uncomfortable with it being focused on women.  So I'm not a table thumping this is about women and just women, I am absolutely obsessed with equality and what we can do to address some of the inequality that we have.  I don't think there is a glass ceiling just to be right up front about it, I've never experienced a glass ceiling.  I think that we have a job to do at some of the national arm's length bodies, I think it will be good to have more senior women in those positions not for women's sake but because of the different type of leadership that people can bring and I think that goes back to the point about having the more diverse type of leadership the better it is for what we're trying to achieve.

JD:         One of the things that I've observed which is probably just a generalisation, is that where there are elections in medical role colleges women get elected, where there are appointments men get appointed.

HM:       That's really interesting, yes.

JD:         I don’t really need to say anything more about that but to say with the demographics of the population the medical population are changing and more and more women are coming in and are reaching consultant level across the board.  In the last five years or so there's been a huge increase in the number of women elected to lead the medical royal colleges which is fantastic.  The number is going down a bit.  I think there is slightly a view, well, we've done that then we don’t need any more.  In fact one senior colleague - when I was lamenting the lack of a female name on a ballot paper  - said to me, "Haven't there been enough of you already?" 

HM:       Wow!

JD:         So there is still a bit of a way to go but we've done it once for the majority of the medical royal colleges to be led by women so I think we can do it again.

HM:       So Anne-Marie, what do you think about this issue of a glass ceiling and whether there are particular barriers to women progressing?

AA:        I think it's difficult to say whether there's a glass ceiling or not.  I mean the data would indicate that there is an issue rather than a glass ceiling in particular.  I mean my personal experience is I've worked for very senior women pretty much all the way through my career in the NHS.  I was extremely lucky to work for a female director job share, which I think is actually slightly exceptional rather than the norm, and I think there's something about how we actually provide more role models and actually talk about the different opportunities there are in the ways that we can work that actually make the roles more attractive.

HM:       Okay, and so what about other barriers?  Jane, what are you thinking in the review?

JD:         I am a believer in unconscious bias and I think that some of the barriers certainly that I've faced are because people find it difficult to envisage a woman doing that particular job.  Once they start to do it then people forget about it and it's all fine, but there are unconscious biases.  There are also societal and cultural reasons.  So the expectation on us as women is that we probably ought to be doing the majority of the caring responsibilities both of children and of the elderly, and so until the culture in our society changes to accept that both men and women are capable of caring for children and elderly people effectively it will be difficult to change the way that men and women are perceived and I think that's quite a big thing.

HM:       So just on the caring responsibilities, my understanding is that the NHS has fairly well developed flexible working policies.  I don’t know if they're fully implemented and available to people when they want them, but the NHS is far better than other sectors and yet, for example on paternity leave, the uptake is much lower.  Anne-Marie, how is the NHS in terms of flexible working policies?

AA:        So on the whole we have very good flexible working policies and I think part of the challenge is that whilst they exist, people obviously have the right to apply to work flexibly, that the employer has to listen to that right, they have to actually look at whether that actually meets their business need and if it doesn't they can turn it down. And I think in reality and the experience we're hearing certainly from the women in our women's network is that they aren't able necessarily to universally access flexible working policies because employers are quite risk averse and so it needs a few brave employers to really look at how they can do that more effectively.  We need to look at taking up more flexible ways of working as well.  So we know things like job shares in particular are underutilised in the NHS, that's a great way of bringing two people together to fill a particular role.  It has its challenges as well but it has lots of benefits.  We also know that people want to work much more flexibly and as we've talked about, not just for caring responsibilities.  We're entering into now a new psychological contract with our younger generations coming through into work they want a better work life balance. 

JD:         Just on flexibility one of the things we've been doing in the College of Physicians is something called the chief registrar programme and during that programme we suggest that people work in their normal NHS day job for three days a week doing acute medicine or whatever, and then they have two days a week when they do something for the wider benefit of the NHS, so they learn about leadership or they learn about quality improvement or whatever.  So in the chief registrar programme they do leadership and quality improvement for two days, NHS stuff for three days and it seems to me that the way forward for medical careers, if we could do it, would be to let everybody do that because then everybody is part time, the part time stigma goes away, the presentism goes away, you can deliver your seven day service and you have people who don't get so burnt out because they've got more variety in their jobs and the problem with the implementation of that at the moment is that there just aren't enough of us to be able to do it.

HM:       Workforce shortages.

JD:         Yes.  There are rota gaps and that's what stops it, but there are certainly great plans to change things to redefine the working week and what people do in it.

HM:       Increasingly people that's what they want from their careers, isn't it?  It's much -

JD:         Absolutely.

HM:       - more of a portfolio approach.

JD:         There are more and more people in training who are saying, "Do you know what, I want to get off the hamster wheel, I want to be able to do something different," and the more we accept that I think the richer the workforce will be for it.

HM:       So what about cultural barriers?  What about the feeling of the culture at the top of organisations?  Sam, I know you … so you've been a Chief Executive of a hospital trust and you've worked at the very top of NHS England, what's your experience of cultures at the top of organisations?

SJ:          I've been a provider Chief Executive for about eight years in different organisations and I think we set the tone.  I had absolutely no problem going to sports day, picking up the children occasionally and balancing it from that perspective.  So I feel very strongly that we set the tone, we … whoever leads an organisation it's okay to go and do those things.  Working at NHS England I didn't experience anything different.  I was reflecting, so certainly Simon Stevens is extremely supportive and champions equality at the highest level.  I think what I probably experienced was some of the processes and systems translating that into us doing things in practice weren't there and also, more importantly, it was my own pressure and my own expectations.  So I'm reflecting listening to the conversation, I think I'm probably my own worst enemy when it comes to it.  So when I decided last year to take a break and step down from the national programme I said one of my reasons, main reasons, was because I wanted to spend a bit more time with my family and people thought I'd been sacked.  People actually phoned me and said, "That's a lie," and actually our Comms Director said, "You can't say that, you sound like you've been sacked, you're going to spend more time with your family."  It's like, "No, it's not actually, it's really what I want to do, I just want to get a little bit more balance," and I reflected I'd worked for 28 years without a break.  I'd gone from entering into nursing and then all the way through being very lucky.  So experiencing the top of the shop, so to speak, is we set the tone and we should make it as easy as we can for people to work in a different way.

HM:       Yes, Jane did you have something?

JD:         Just to say, I absolutely agree.  I think at the top of the shop there isn't a problem, but there are behaviours and I think subliminally along the way there are behaviours that are off putting to women.  There are issues even in my own college the boys will go off for a golf day during which quite a lot of business will happen and I don't play golf. There are people who say, "Let's meet for a pint," and I don't drink pints and there are different parts of the profession where those male stereotypical behaviours are more common and those tend to be the parts of the profession that are hostile to women and once that boy gang mentality comes in that's when women start to have a hard time.  So having been the head of a medical school some of the things that are said to the young women coming through are completely inappropriate.  All sorts of things are said quietly behind the radar and although there are no structural barriers and although the people at the top tend to be enlightened, the groups on the way through are not always and do sometimes say things that are inappropriate.

SJ:          So therefore we have to call it out when it happens and it is often now, isn't it, calling it out?  Somebody asked me if I was sleeping with somebody because we were getting a lot of good publicity, this is just not an acceptable thing to say.  It's not an acceptable thing to say to anybody and you call it out.

HM:       I think that's right, there's quite a lot of softer stuff even that's quite subtle around going to the pub for a pint that can be quite exclusive.

SJ:          And we do it also.

HM:       Yes.

SJ:          We women do it also, we may not go to the pub to have a pint but we have our version of different types of social norms.  So I think it's recognising the differences and also recognising not to be exclusive is what we need to do.

HM:       Sam you touched on this earlier but obviously there is a much wider issue around the lack of diversity at the top of the NHS that goes far beyond women, there's an even bigger problem in terms of the lack of people of colour in senior roles and also representation of different ages and sexual orientation.  I think it would be helpful for listeners just to kind of … although it might seem like an obvious thing to articulate, what we think the benefits of having a diverse leadership in the NHS are, in particular for patients and outcomes and experiences.

SJ:         Well we should be reflecting the population that we serve and the population that we serve doesn't look the same, doesn’t behave the same and has different challenges.  It's almost a no brainer from that perspective.  I think Jane's point there about unconscious bias is absolutely right and hats off to Sarah-Jane Marsh for being very public, the Chief Executive of Birmingham Women's and Children's for very publically stating she would not sit on an interview panel where there wasn't appropriate BME representation.

HM:       And Jane anything to add on that?

JD:         Well just to say that if we learn from the boards in industry there is evidence that their performance is better if they have a more diverse group of people and I personally think that the quality of the conversation is so much richer if you get people who come from a diverse set of backgrounds who are able to give you views that maybe you wouldn't have thought of yourself.  I think that's hugely empowering.  As a college president it's empowered me when I have to go and speak truth to power to know that I'm taking the aligned view of a diverse group of people, that's a very, very powerful message.

HM:       And Anne-Marie you run a lot of programmes at the NHS Leadership Academy, what's your view on this kind of articulating the benefits?

AA:        So I think absolutely what we need is diversity because it's not just about being representative of a population, it's actually about having diverse thought.  We know that group think actually undermines some of our risk taking and decision making processes.  We can see that from other industries as well.  So what we want is constructive challenge from a diverse range of people with a diverse range of backgrounds and who bring different thinking into our spaces. 

HM:       Sam, you touched on it being a responsibility of people at the top of organisations to set the culture, and that that's what you did and continue to do, can I hear from each of you around sort of what are the individual actions that you have taken?

SJ:          Well I have been incredibly lucky throughout my career that people have given me time and space and cups of tea to go and blether at them irrespective of seniority.  So I learnt that from a very early age when I first started nursing is that that's exactly what I aim to do and try to do, which is give people space and time to talk about some of the issues that they face, people that are coming through shadowing opportunities.  I talk a lot in 140 characters normally about some of the work life balance things that I personally experience and also continuing to talk so hopefully positively about the honour and privilege of doing the jobs that we do.

HM:       And Jane, what about you?

JD:         I found that having a framework in which you operate is really important.  So having a structure that has some rules about every job needs to be advertised strangely enough, and that when you advertise the job you need to have a gender balance on the appointments committee or during the appointments process, that when you get a job it's for a finite time in a medical royal college so you don't sit in your job for the next 30 years doing whatever you like, everybody has to have an annual appraisal.  So just normal structural things.  So just quietly implementing those and then I suppose the final thing is zero tolerance for any nonsense or bad behaviour, just say, "I'm sorry, no, that's not the way that we do things round here," and gradually, I don’t know whether it's all just around me, but it stops.

HM:       Do you think that there is a place for female only leadership programmes?  So there's one … so we run the Athena programme here at the King's Fund and I know that you Anne-Marie, the NHS Leadership Academy also run some female only leadership development programs, do you think those are a helpful way of supporting women or do you think that actually they … people fall into many different categories and really we need to be bringing people together?

AA:        I think it's a both and, because I think some of the things that we need to do, it's quite easy to fall into a deficit model when we're talking about any underrepresented group and in that if we have a deficit model then we're saying, "You need to do … we need to improve you to actually move into a more senior level role," but I think also society is structured that there is inequality so actually doing something that actually proactively helps groups to actually develop and giving them safe spaces to actually do that development together is important. But if it just remains exclusively to whether it's women or whether it's BME or whether it's LGBTQ then actually that's not going to be helpful overall.  So, for example, our women's network is by women for women with men - we are not exclusive.

HM:       Yes, and what about other things that the national bodies can do?  There's the 50/50 target I think across the NHS to have 50% women by 2020, are there other … is that going to do it or what are the other measures that we need to see from the national bodies?

SJ:          So the national bodies are in a significant position of influence and using that to positive effect.  So whether it be Simon championing Windrush or the national boards talking openly about what they're doing to give people opportunities, shadowing, certainly from a personal experience David Behan from the Care Quality Commission was always very good in terms of giving time and space to come and talk to him.  So I know the policies and procedures they're all there but it's actually using the positions to be able to talk about what they're doing to support this in practice.

HM:       Okay, and Anne-Marie, just given your position at NHS Leadership Academy?

AA:        I think there's a real challenge about whether we do something about positive action and I know that people rail against it when we talk about positive action but actually if our data very clearly shows us that there are real issues for women, people of colour, other groups, then should we be thinking about something that addresses that and how might we do that?  We've got some positive action programmes that we actually support particularly around BME staff, but is there more that we could do?  Are we going to make some significant choices about choosing candidates based on different criteria?  If you have two candidates that have the same level of meritocracy would you choose a black candidate over a white candidate?  That could be really challenging to have a conversation about that, but I think we should open those conversations up because I don't think we'll see things change if we don't do that.

HM:       Jane, positive action, what do you think?

JD:         I think that we run the risk of only looking forward and thinking about all of the things that we haven't done so far and I think that some of the time we need to go to the back of the boat to look at the wake and see how far we've come, and so I think that there may be a time when positive action is necessary but I think that the change is happening.  So we need data, going back to the gender pay gap review, we need a trajectory to see whether there is actually a time when we will get equality but … and if we can show through data that there isn't then that's when we need to start using positive action.

HM:       So just to close our very interesting discussion today, you're all women who have got right to the most senior levels of the health sector, what advice would you give to people just starting out and who potentially are struggling and are looking for support in order to progress?  Sam.

SJ:          Don't suffer in silence if you're not sure what to do.  There is so much out there that we collectively can support with and don't be afraid to ask.  So it took me about 20 years to work out that I could ask and it was okay to do so and many of us are there cheering you on and we'll do anything that we can do to support people coming through.

HM:       Jane.

JD:         I think you have to be yourself.  So if something … if you're very happy about something show it, if you're not very happy about something call it out.  Then the other thing is use practical things that are all around you like internet shopping, make sure that you make the best use of your time and don't take any nonsense.

HM:       And Anne-Marie.

AA:        So I think there's something about being really clear about what you need and what you want to actually make you most effective at work and that includes the stuff you need outside of work.  If you've worked that out and you can go in and have a conversation you know what you need, you're in a much stronger position than if you're just thinking I'm not sure whether I could do this role or not and I think alongside that don't be afraid to say no.  One of the things that I've been complimented on my career actually is that I say no quite a lot and that actually means that people know what my boundaries are and they actually respect you for it.  You can't say no all the time but if you have a line and you're clear when you don't want to cross it.

HM:       Fantastic.  Well thank you all so much for your reflections and for an incredibly wide-ranging discussion.  Well that's it from us.  Thanks for listening.  Please subscribe, rate and review us on iTunes and tell your friends about it and tell them to subscribe and if you have feedback or ideas or topics you'd like to hear covered in any future episodes then please get in touch either on Twitter, via @thekingsfund or my account @helenamacarena or you can leave feedback on our website which is www.kingsfund.org.uk.  Bye for now and hope you can join us next time.


Catherine Turner

Comment date
07 July 2018

This was a very interesting podcast, particularly when you discussed why we should bother with equality as I think sometimes that gets lost. It was disappointing that you didn't think about disability when you were talking about the various types of equality-concerned groups.

Add your comment