Getting the right leadership in place

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‘Your most important job will be replacing me’ said my chief executive when I started as Chair at University Hospitals Birmingham NHS Foundation Trust four and a half years ago.  There have been a few other challenges along the way, but fundamentally she’s right.  Getting the right leadership team in place for the trust and keeping them there is the single biggest contributor to our success and the wellbeing of our patients and staff.  It’s a job that is becoming more and more difficult as The King’s Fund and NHS Providers’ research into NHS leadership demonstrates.

We recently appointed a new chief executive – our excellent medical director.  We had a strong internal candidate, which was just as well because there were precious few candidates willing and able to step up from the rest of the system.  We do have particular challenges – a recent merger making a big and complex organisation and big shoes to fill in following Dame Julie Moore, our retiring chief executive.  We have a stable and experienced senior executive team; we’re lucky that people want to stay with us, but we have also put a strong focus on succession planning at all levels of the senior team. 

The report poses the question of whether NHS boards should be less risk averse in seeking out talented leaders. The truth is that my trust thought it would be a big risk to look at, for example, candidates from other sectors – a candidate would need to be exceptional and to demonstrate an understanding of the particular challenges of running a high-profile, tertiary centre with a large number of excellent, but opinionated clinicians.  That’s why we take our responsibility to grow our own so seriously. However, we have also recently appointed a chief nurse from a smaller, more community-facing trust. 

Our new chief executive is in a small minority of only 9 per cent of chief executives who are medically qualified.  Why, despite the exhortations from the centre, do so few clinicians want to step up into leadership?  What is at the heart of the leadership shortage?

First, the risk:reward ratio is wrong.  I was keen for the stable leadership team we’ve developed at UHB to take on the challenge of supporting our neighbouring trust, Heart of England, when they got into financial and performance trouble.  I felt that this was a good way to provide fresh challenge while keeping the highly sought-after executive directors in the trust.  When the two boards decided that an acquisition should be explored, it took nearly a year to get some basic assurances providing minimal financial and regulatory protection to UHB.  Our leaders felt that all the risk sat with them despite having been asked to double their workload during the period of intervention.

Looking around, we may nevertheless have escaped the worst.  Too many chief executives – and chairs – have lost their jobs while they endeavour to take on some of the toughest challenges in the NHS. 

Second, leadership within the NHS is becoming more complex.  Quite rightly, we now expect our chief executive to run an excellent organisation and to work across the system building relationships and challenging the way that we offer care to our population, not just in our trust. Our existing chief executive is also the STP lead. This requires strong local autonomy and the ability to find local solutions.  Instead, as the report identifies, the constant pressure to report upwards has left directors overburdened and disempowered.

Where you are a successful and stable leadership team, you may be able to resist the worst ‘interference’.  However, where you are already under pressure, you risk a regulatory ‘pile-in.’  Sixty-seven per cent of respondents to the annual NHS Providers regulation survey reported an increase in regulatory burden over the previous 12 months (NHS Providers 2018b). 

While there are some good leadership initiatives out there, there is no point in developing a pipeline of leaders if they peer over the final hurdle only to be discouraged by an environment that limits their freedom to lead and puts their hard-won reputations and careers at risk.  Ministers and regulators need to be brave – free up the best leaders and stick by those doing the toughest jobs.  You can’t regulate and inspect quality and safety into the system, but you can support the NHS leaders who will deliver it for you. 


George Coxon

Various across H&SC,
Comment date
24 August 2018

When is see a title mentioning leadership my eyes prick up! My fingers tingle perhaps a more apt image I’ve a well rehearsed oft repeated set of words about leadership that I do modify a little bit from time to time but essentially they include - offering direction, making decisions (sometimes tough ones), enabling, empowering, providing excitement & containment, instilling values/ethos/ belief, role modelling & culture shaping - saying sorry at times, saying ‘I don’t know what do you think? too. But 4 critical factors above all others apply to my leader role with staff - I do in fact prefer the term our staff rather than mine in truth 1) humility & humour must be carefully weaved into the manner of ones leading 2) credibility is core - if you’re no longer doing the thing you’re leading this diminishes day by day. Talking the talk at a safe distance is all too common amongst leaders 3) personal insight & awareness of ones blind spots is vital and finally 4) wisdom & good judgement in balancing priorities as well delivering outcomes if you will with a diverse team ( not cloning a set of common speaker procrastinators ) is the test of true leading by innovative can do leadership

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