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.