Why aren’t there more women leaders in the NHS?

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How likely do we think it is that David Nicholson’s replacement as chief executive of NHS England will be a woman? Although women make up three-quarters of the NHS workforce, they still remain under-represented in senior leadership roles. For example, only 37 per cent of foundation trust directors are women, and a minority of them are in chair or chief executive roles. Similar disparities are found in medical leadership across primary and secondary care.

Why is this and why does it matter? To answer these questions we need to know more about women’s leadership styles and the barriers that prevent women achieving their full potential. A survey run by the Health Service Journal and The King’s Fund has elicited some interesting insights which resonate with much of what we hear when working with public sector leaders. They particularly echo the experiences and views of the participants on our executive women’s leadership development programme, Athena.

When asked whether men and women lead differently, respondents most commonly highlighted that women had a more collaborative, inclusive, empathetic and/or understanding style than men. Such qualities are well aligned with the open and honest culture advocated in the Francis Report. But are they the sole territory of women? Don’t men exhibit these characteristics too?

And do all women behave in this way? A minority of respondents suggested that women are more aggressive than men. Some linked this to a belief that, to succeed, women need to take on the characteristics more commonly associated with male leaders. But is that hypothesis too loaded with gender stereotypes?

Research published in the Harvard Business Review in 2012 used 360-degree evaluations to rate the effectiveness of more than 7,000 leaders. Women scored higher than men in 12 of the 16 leadership competencies, including taking the initiative and driving for results, as well as in more nurturing categories. At every level, more women were rated as better overall leaders than their male counterparts. While setting up male and female leaders in direct competition may be rather divisive, the survey shows that women have huge amounts to contribute to leadership.

So why are women so under-represented in NHS leadership roles? At first glance, many of the barriers experienced by our survey respondents appear to be those inherent to leading a complex, changing NHS rather than being directly gender related. Look closer, however, and a number of more gender-specific barriers are revealed. The most commonly identified were a culture of old boys’ networks, nepotism and prejudice and a macho, pace setting environment, along with unhelpful attitudes towards women leaders. Almost a third of respondents highlighted difficulties in juggling child care and work commitments and many added that family responsibilities limited how much they can join in work-related social events, making it even more difficult to break into male-dominated networks.

Factors such as ethnicity and age appear to exacerbate gender barriers, while a significant number of respondents said that their main challenge is their own lack of confidence. Respondents identified numerous factors that could help them overcome these barriers from good managers of either sex, an enabling organisational culture, peer support, female role models and mentors, flexible working opportunities and access to leadership development opportunities. 
There are lots of fantastic leaders helping to support and drive improvements in the NHS at the moment. Some of those are women. Who knows whether the next chief executive of NHS England will be a woman, but aren’t we missing a trick if we don’t try to create the right conditions for more women to lead the NHS, alongside their male counterparts?

This blog was co-authored by Nicola Hartley, Director of Leadership at The King's Fund.


john smith

interim commissioning manager,
self employed
Comment date
19 July 2013
I think that such articles are unhelpful and fail to strike the right balance about discrimination in the NHS.

The last 5 CCG commissioning teams I have worked with have been led by female directors and each circa 20 strong team has been female only - not a single man in sight in over 100 staff.

If you think this is bad (and I suspect that many wont), the number of disabled staff in these teams was also zero; yet disabled staff make up circa 12% of the workforce in the private sector.

Why does the Kings Fund bring some balance into this debate?


Clinical a Director, Radiology,
The Royal Wolverhampton Ahospitals a NHS Trust
Comment date
22 September 2013
I find this emphasis on recruiting women to leadership roles worrying. Men are taking on an increasing role in family responsibilities and I find I have the same limitations in taking up leadership roles. I also find that in many committees the women heavily dominate in terms of numbers. There is no clear impact from this on the decision making process. These committees tend to be marginalised because they are seen as ineffective, although some gender bias may come into this.
One should aim at getting good leaders rather than worrying about whether they are men or women. Fairness is important not numbers.

susan oliver

Chair of European League Against Rheumatism Health Professionals,
Eular (European League Against Rheumatism)
Comment date
01 November 2013
My comment on this topic relates to the sad fact that nurses form the largest NHS workforce and as such the largest proportion of these are women. Yet the structures, frameworks and opportunities to develop lead nurses (and not only women) is frankly sadly lacking. NHS managers would do well to actively encourage a strong voice for their nurses and as such will show respect and encourage leadership for those with a small voice within the NHS power systems which currently maintain a steady focus on the views of the consultant body perhaps more than they should do !

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