NHS leadership and culture: our position

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Part of The King's Fund position

Collaborative, inclusive and compassionate leadership is essential to deliver the highest quality care for patients and tackle deep-seated cultural issues in the NHS, including unacceptable levels of work-related stress, bullying and discrimination.

What we think

The quality of care that patients receive depends first and foremost on the skill, compassion and dedication of staff. The more engaged staff are, the better the outcomes for patients and the organisation generally; a comparison of engagement scores in the NHS staff survey with a wide range of outcome data suggests that strong staff engagement is associated with improved patient experience, higher inspection scores and lower infection and mortality rates. 

However, data from the NHS staff survey shows a workforce facing major cultural challenges. NHS staff are continuing to report worrying levels of stress, bullying, harassment and discrimination in the workplace. Staff are also under immense strain as a result of severe workforce pressures as services struggle to recruit, train and retain enough staff.

40 per cent of NHS staff reported feeling unwell as a result of work-related stress in the past 12 months.
Source: NHS England 2019

Leadership plays a key role in shaping the culture of organisations, but NHS leaders are facing considerable challenges, including significant financial and operational pressures and excessive regulatory demands. In addition, some report that they themselves are on the receiving end of poor leadership behaviours, often from national bodies, that are the opposite of the compassionate and inclusive leadership they seek to practise. This is reflected in high vacancy rates and short tenures among senior leaders that risk undermining organisational culture and performance.

To support staff and improve care, leadership at all levels needs to be collective, compassionate and inclusive. The emergence of sustainability and transformation partnerships and integrated care systems means that leaders also increasingly need the relational skills to lead across systems rather than just individual institutions. The lack of diversity among senior NHS leaders is unacceptable, and there is a pressing need to ensure that, at all levels, leadership of health and care systems reflect the diversity of the communities they serve. More clinicians should be supported to move into leadership roles and develop their management skills, with evidence suggesting that clinical leadership is associated with higher productivity and better organisational performance. 

High-quality leadership will be essential if the NHS is to deliver on the many ambitions set out in the NHS long-term plan. This needs to start at the centre, with national bodies more visibly modelling the behaviours needed from leaders across the system. The forthcoming NHS people plan presents an opportunity to set out what more will be done to develop and embed cultures of compassion, inclusion and collaboration across the NHS.

The context

Culture is often described as ‘the way we do things around here’ and is influenced by a number of factors, including the organisation’s founding values, the early experience of joiners and the behaviour of leaders. Leadership and culture are fundamentally intertwined, and leaders play a crucial role in successfully applying the principles of culture to achieve their organisational goals.1

Staff are the NHS’s greatest asset, but a number of challenges are taking a significant toll on the workforce. In addition to severe workforce pressures, including large numbers of staff vacancies, surveys have shown that staff experiences of working in the NHS can be very negative. In the 2018 NHS staff survey, 40 per cent of NHS staff reported feeling unwell as a result of work-related stress in the previous 12 months, 13 per cent said they had experienced bullying or harassment from managers and 19 per cent experienced it from other colleagues. These experiences shape and are directly affected by the culture in which staff work. Leaders at all levels play an important role in improving the culture of the organisations they work in.

Leaders in today’s NHS operate in a climate of extreme pressure, which is exacerbated by high levels of leadership vacancies and leadership churn. Our research suggests that the attractiveness of leadership roles has been heavily affected by, among other factors, financial and operational pressures and greater ‘personalisation’ of performance and attribution of blame by regulators, other national bodies and politicians.  

The task of leading in health and care is also evolving. For example, health and care leaders are increasingly expected to lead beyond their individual institutions, working as part of local systems to transform how services are delivered. This places a stronger emphasis on relational skills and shared leadership across the many organisations they need to engage with in order to improve the health and wellbeing of their populations. 

Only 7 per cent of very senior managers in the NHS are from a black or minority ethnic background.
Source: NHS England Workforce Race Equality Implementation Team 2019

Collective, inclusive and compassionate leadership is now increasingly recognised as essential for delivering high-quality care and cultural change throughout the NHS. In practice, this means shifting from traditional command-and-control structures and ‘heroic’ leadership towards a model that distributes leadership to wherever expertise, capability and motivation sits within organisations. It also means leaders listening to staff and arriving at a shared understanding of the challenges they face, empathising with and supporting them, rather than always imposing decisions from the top down.

One area where the NHS is failing its staff is in relation to equality and diversity; this includes the way staff are treated at work and their employment and career opportunities. This includes inequalities between black and minority ethnic (BME) and white staff working in the NHS. Since April 2015 the Workforce Race Equality Standard has been mandated through the NHS standard contract, and providers and commissioners are expected to show progress against nine indicators. A number of organisations have made progress and are providing visible and high-impact leadership on these issues, but across the NHS as a whole progress is not as rapid as it needs to be and there is considerable variation.

Clinical leadership has been established as a critical factor for improving the performance of health care organisations. Studies have suggested that higher representation of clinicians on the governing boards of NHS hospital trusts is associated with better performance, patient satisfaction and morbidity rates.2

The NHS long-term plan has committed to developing and embedding cultures of compassion, inclusion, collaboration and greater diversity across the NHS. This has since been developed and expanded on by the Interim NHS people plan with further actions to come in the full NHS people plan expected later in 2019. To be credible and have impact, these actions will need to be specific, timebound and clear about how they will be monitored and followed up. This must include the behaviours of staff in the national bodies. 

  • 1.Schein E H (2010). Organizational culture and leadership. The Jossey-Bass Business & Management Series. 4th edition. Vol. 2. San Francisco, Ca : Jossey-Bass: John Wiley & Sons.2.Veronesi G, Kirkpatrick I, Vallascas F (2012). Clinicians in management: does it make a difference?

Key spokespeople on NHS leadership and culture

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Suzie Bailey

Director of Leadership and Organisational Development

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Jo Vigor

Assistant Director, Leadership and Organisational Development

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Nicola Walsh

Assistant Director, Leadership and Organisational Development

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Lisa Weaks

Assistant Director, Leadership and Organisational Development