NHS management: time for transparency at the top

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Another month, another resignation. The departure of the Mid Staffordshire Foundation Trust Chief Executive, following a Healthcare Commission investigation over mortality rates, has sparked much debate within the service. While the circumstances surrounding Martin Yeates' leaving may have been unique, or at least unusual, comparisons have been made in the national and trade press with the recent departure of other high-profile chief executives – for example in London and Yorkshire and Humber SHAs.

There is little new in this. Turnover is high – the average tenure of a chief executive is said to be around two and a half years. And therein lies the problem.

We need to recruit the brightest and best into these roles, yet it is rare to have a pool of good candidates, and recruiting to these senior posts remains challenging. There are good reasons for this not being the most popular career choice. Becoming a chief executive is a risky business – some fall victim to restructuring, others are moved on amid thinly veiled, but rarely backed up, hints of wrongdoing.

This is a hidden world, but for those within the system an all too familiar process. A chief executive may receive a call or a visit from the Department of Health, a strategic health authority, or a regulator pointing to a 'lack of confidence' in their performance, and a resignation may be 'encouraged'. Pressure may be brought to bear on a chair or a board to make a swift decision on the basis that short-term pain may alleviate long-term problems. There will be few in senior NHS management who cannot point to an example of this approach with which they are personally familiar.

But this is a covert business which lacks process and transparency. More often than not no-one outside the decision makers knows what has happened, what the real issues are or even whether or how far the chief executive is culpable. The result is usually that the chief executive is paid off – lack of process may be quicker but in the short term at least is much more expensive. The disappearing boss can also reappear elsewhere in the system – sometimes in another chief executive role, sometimes undertaking a discrete piece of work at the Department of Health or employed in some form of consultancy activity. Nor is there any reason why they should not be able to pursue their careers in this way as no fault has been proved or, in many cases, even suggested.

In reality though this means that – except in the most extreme cases – departing chief executives tend to be treated the same, whether they are leaving because of a lack of performance or for circumstantial reasons. We have a system therefore that lacks transparency, fails to identify where performance is the issue and is profligate with scarce talent. 

As the chief executive of NHS London Ruth Carnell pointed out recently, no-one should be trying to protect those not up to the job. But those heading complex organisations need  time to bring about significant change. They may also need support through development or other interventions, and at times senior level cover when the unpredictable and unmanageable 'events' occur and the pressure is on for a politically expedient outcome.

Compare the treatment of chief executives to the treatment of a senior clinician accused of poor performance. This process can be long and expensive, but it is more transparent, and the outcome is more clear cut – for example a doctor who is shown to be incompetent is likely to be suspended from the medical register or struck off and unable to practice elsewhere. In such cases, the system may seem unforgiving, but it is unequivocal.

Both approaches have their flaws. However, is it not possible that some elements of the approach to clinicians could usefully be adopted for chief executives? For example, the proceedings and treatment could be transparent and follow due process even if this takes longer and may be more expensive. Could there not also be a commitment to consistency of approach, outcome, reward and resolution?

If we want to encourage our chief executives to look out and not up, we must also protect them from having to look over their shoulder. They should know that they will be rewarded for success, supported when they genuinely need help and managed appropriately when they demonstrate lack of competence or trust. We cannot assure them of that until the process for dealing with failure is more open, transparent and honest. This may mean that when things do go wrong, resolving the future of each individual will take longer and ultimately be more final and potentially more painful, but it may be better for the system as a whole and more equitable for those involved.

This article was originally published in The King's Fund monthly Update, March 2009


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