NHS trusts face worryingly high levels of senior vacancies

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A near-toxic mix of pressures facing NHS organisations, coupled with a culture of blaming individual leaders for failures beyond their control, means NHS trusts are facing significant difficulties in recruiting and retaining senior leaders, according to a new report from The King's Fund and NHS Providers

New survey data from 145 trusts shows that executive director vacancies in NHS providers are widespread. 

Key findings include: 

  • 8 per cent of executive director posts are vacant [1]  
  • more than a third (37 per cent) of trusts have at least one vacant executive director role, with director of operations, finance and strategy roles having particularly high vacancy rates or short tenures 
  • more than half (54 per cent) of directors have been appointed in the past three years and the median tenure of a chief executive is just three years 
  • short tenure was a concern for all executive director roles, but a particular problem for chief operating officer roles
  • trusts rated 'inadequate' by the Care Quality Commission (CQC) experience higher levels of vacancies and turnover rates – these trusts had 14 per cent of posts vacant and 72 per cent of their executives had been appointed in 2017.

Research shows that a high level of churn in leadership roles has a significant negative impact on the culture and performance of trusts. Leaders interviewed for the report also suggested it results in short-term decision-making, which can paralyse organisations at a time when they should be moving forward to develop new ways of delivering care. 

The report highlights an ‘inverse leadership law’, where high levels of vacancies and turnover rates disproportionally affect the organisations with the most significant performance challenges. In trusts rated as 'outstanding' by the CQC, only 3 per cent of posts were vacant and 20 per cent of executives had been appointed within the past year (2017), while trusts rated 'inadequate' had 14 per cent of posts vacant and 72 per cent of executives had been appointed in 2017.  

NHS leaders interviewed for the report viewed their jobs as both a vocation and a privilege. However, they highlighted an increased risk of regulatory 'decapitation', suggesting that consequences of poor performance or failure are perceived to be increasingly 'personalised' and laid at the door of individual leaders by some national bodies, politicians and the media. This can lead to a greater unwillingness to take on these challenging roles and can discourage bold leadership once in a role. 

The authors also warn that the leadership of NHS trusts is not diverse and does not reflect the wider NHS workforce or local communities, for example, only 7 per cent of very senior managers in the NHS are from a BAME background. While there are signs that publishing data on leadership diversity within trusts is beginning to have a positive impact, pressures on the NHS are exacerbating this problem by causing recruiting organisations to be more risk-averse when considering less-experienced candidates, further narrowing the diversity and experience of NHS leaders.  

The report calls on the national bodies to take action to address leadership vacancies and cultures that deter experienced staff from taking on these roles. It says responsibility for leadership has to be spread across the system, and that an overly centralist approach will not work. It suggests that rebuilding the regional talent management functions previously performed by strategic health authorities should be a priority for the new joint NHS England and NHS Improvement regional teams. National leadership development programmes should also expand their focus to include those board roles that are particularly difficult to recruit to. 

Additionally, there has been a 'changing of the guard' over the past few years, with a large number of the longest serving hospital chief executives having retired and a new generation of talented leaders coming through. With organisations being asked to work together collaboratively in local systems of care greater recognition of the importance of system leadership is needed in appointing future leaders, the report argues. 

Suzie Bailey, Director of Leadership and Organisational Development at The King's Fund said:

'Leaders in today’s NHS operate in a climate of extreme pressure: staffing vacancies are rife, there are widespread challenges in meeting financial and performance targets and demands on services continue to increase. The leadership task facing leaders of NHS trusts has also changed, with greater emphasis placed on working collaboratively as part of more integrated health and care systems. Leaders tell us the job of being a leader in the NHS is still rewarding but is not getting any easier or any less complex, and at present there is not enough support or respect for the people in these incredibly difficult roles. 

'Responsibility for NHS leadership is everyone's business – attracting and supporting the right kind of future NHS leaders should be central to the NHS 10-year plan and the work of the national bodies.'

Saffron Cordery, Director of Policy and Strategy and Deputy Chief Executive at NHS Providers said:

‘We know that high turnover among chief executive and other board-level roles has a negative impact on the culture and performance of NHS trusts. It is no great surprise that the best-performing trusts often have stable leadership in place over many years. It therefore can’t be right that our most challenged organisations continue to experience the biggest difficulties in recruiting and retaining leaders. We need a new approach to supporting the most challenged trusts and systems to develop their leaders rather than continuing with a revolving door approach. This includes finding ways of enticing high-performing leaders into struggling trusts but that isn’t easy to do when a culture of blaming individuals for perceived failures exists. These are complex roles in complex organisations and we need to recognise and appreciate the significant leadership challenges involved.
‘One of the solutions to our leadership challenge is to bring through a new generation of leaders that is more diverse and reflective of the communities the NHS serves. While there has been some progress in recent years, there is still a huge amount to do on this front. The data we now publish on leadership diversity within trusts is having a positive impact, but these are small steps and we need to create an environment in which NHS organisations are able to take on less experienced candidates with confidence. Nurturing talent and embracing diversity must go hand in hand.’

Notes to editors

  1. An NHS trust board typically includes the following executive director roles: chief executive, finance director, medical director and nursing director. Other executive roles include: deputy chief executive, director of strategy and transformation, director of workforce/human resources and director of operations/chief operating officer.  
  2. Leadership in today's NHS: delivering the impossible, is published by The King's Fund and NHS Providers on Wednesday 18 July 2018. 
  3. The report is based on a survey of NHS trusts and foundation trusts carried out by NHS Providers in late 2017, qualitative interviews and a roundtable event with frontline leaders and national stakeholders. 
  4. For more information or to request an interview please contact: 
    Gemma Umali, Press and Public Affairs Manager, The King's Fund: 0207 307 2583, g.umali@kingsfund.org.uk 
    Emma Sharpe, Communications Officer, NHS Providers: 020 7304 6841, emma.sharpe@nhsproviders.org 

The King’s Fund is an independent charity working to improve health and care in England. We help to shape policy and practice through research and analysis; develop individuals, teams and organisations; promote understanding of the health and social care system; and bring people together to learn, share knowledge and debate. Our vision is that the best possible health and care is available to all.

NHS Providers is the membership organisation and trade association for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS foundation trusts and trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate. NHS Providers has all trusts in membership, collectively accounting for £84 billion of annual expenditure and employing more than one million staff.