Leadership in today's NHS: delivering the impossible

This content relates to the following topics:

Key messages

  • In 2014, work by The King’s Fund assessed the level of leadership vacancies in NHS provider organisations. As pressures on services have increased and NHS organisations are called on to work more collaboratively, levels of leadership vacancies and leadership churn continue to pose problems.

  • This 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.

  • The survey showed that leadership vacancies are widespread, with director of operations, finance and strategy roles having particularly high vacancy rate and short tenures. 

  • A culture of blaming individuals for failure is making leadership roles less attractive. Organisations with the most significant performance challenges experience higher levels of leadership churn. National bodies need to do more to support leaders to take on and stay in these roles. 

  • To tackle high leadership churn, national programmes should target professional roles where concerns over the pipeline of future leaders is greatest. Regional talent management functions – largely absent since the abolition of strategic health authorities – should be rebuilt in the new joint NHS England and NHS Improvement regional teams. 

  • More attention should be given to addressing the environment NHS leaders operate in. To help ensure these roles are attractive in future, national bodies should better model the behaviours they expect in local leaders, the expectations of ‘what good looks like’ should be more clearly articulated, and NHS leaders themselves should be treated more humanely. 

Why look at leadership challenges?

In the past 18 months to two years, the acute chief operating officer has been the toughest post to fill. It vies for top spot with finance directors. This isn’t surprising as finance and operations are the areas of greatest angst and pressure in the system.
National stakeholder

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 nature of the challenges facing leaders of NHS trusts has also changed, with greater emphasis placed on working collaboratively as part of more integrated health and care systems. The task of being a leader in the NHS is not getting any easier or any less complex. 

Over the past three years, several reviews of NHS leadership have attempted to better understand and address the impact of these pressures. These reviews have identified the churn of senior leadership teams – characterised by short tenures and high vacancy rates – as a particular problem. But there is relatively little information on current vacancies and tenure in the NHS, and the factors that are influencing them. 

For this reason, The King’s Fund has worked with NHS Providers to review the current level of vacancies and tenure of executive directors in NHS provider trusts. Our report draws on NHS Providers’ annual quantitative survey of leadership vacancies and on qualitative interviews and a roundtable The King’s Fund conducted with NHS trust directors and national stakeholders. The purpose of our research was to better understand the pressures on NHS trust leaders and identify ways to address these pressures. 

What is the current state of leadership churn in NHS trusts?

Leadership vacancies in NHS trusts remain widespread with 37 per cent of all surveyed trusts having at least one vacant post for a board-level executive. The highest vacancy rates were for director of operations and director of strategy roles. 

Low tenures mean investment in relationship-building doesn’t get done, and if it does get done there is no return on it and the next time round people think ‘why bother?’ It creates a bit of a ‘why bother?’ culture for both the interim [director] and the organisation.
NHS trust chair

Turning to tenure, 54 per cent of substantive executive directors were appointed in the past three years (2015 to 2017) and the average (median) tenure was only two years. Directors of operations and directors of finance were most likely to have been appointed in the past three years. 

Higher vacancy rates and shorter tenures were found in trusts experiencing the most challenged levels of performance. Trusts rated as ‘inadequate’ by the Care Quality Commission had 14 per cent of posts vacant, compared to only 3 per cent in trusts rated as ‘outstanding’. Our interviews and roundtable event highlighted the impact leadership churn can have on organisations. Short tenures can lead to too much focus on day-to-day priorities at the expense of longer-term strategy. A ‘revolving door’ approach to leadership also undermines the credibility leaders have with staff in their own organisations and with external stakeholders. The churn of leaders can stall organisational progress, which can be especially costly as trusts try to work collaboratively in local health and care systems to develop more integrated models of care. 

What factors influence the attractiveness of NHS trust leadership positions?

I’m still amazed people are prepared to put themselves forward for these roles. The level of exposure is higher than it's ever been and the knee-jerk response from ‘the centre’ is one of ‘decapitation’ as the first option… You’re just a quarter away from financial failure and performance failure before you get sacked.
NHS trust chief executive

Several different factors contribute to high leadership churn. These include a high level of regulatory burden and a lack of autonomy. The constant pressure to report ‘upwards’ to national bodies has left directors feeling disempowered and with less time to focus on their day-to-day jobs. Several interviewees mentioned how recent regulatory or political interventions to remove leaders for failing financial or performance targets suggested that individual leaders are sometimes held to account for system-wide problems. The increasing personalisation of organisational performance by national bodies was making director roles less attractive. 

A reduced appetite for risk was mentioned as a factor in the appointment process by both applicants and decision-makers for director-level posts. This risk aversion manifests as a desire to appoint people who have ‘done the job before’, and less willingness to find candidates from outside the NHS or from elsewhere in the health and care system. This reduces the available talent pool and is exacerbating the difficulty of finding NHS leaders of the future. 

If you look at the top tables of the NHS you will see people of the same gender, same ethnicity, same age and even same school profile. That can’t be good for bringing new ideas to the table when you are facing new challenges. We need more diverse leadership.
NHS trust chief executive

National data painted a sobering picture of how ethnically diverse NHS leaders are. Only 7 per cent of very senior managers were from a black and minority ethnic background, which is far lower than representation in the NHS workforce and local communities. There was some evidence that leaders were taking more action to pursue greater equality and diversity. These included ensuring recruitment panels have black and minority ethnic representation and developing in-house mentoring and reverse-mentoring programmes. 

There was little evidence that there is a coherent national strategy for supporting the most challenged trusts, which often have the highest levels of leadership churn. Holding a leadership post in these organisations was seen as an isolating experience, with incoming leaders facing a high chance of failure (in meeting performance or financial targets), but little forgiveness or understanding from national bodies of the difficulty of these leadership positions. Enhanced buddying arrangements between high- and low-performing trusts and more protection for leaders taking on these challenging organisations are needed. 

What can be done to make NHS trust leadership roles more attractive?

There are already effective national programmes that support aspiring chief executives. But more could be done to extend these leadership and development offers to the other professional roles experiencing high churn and where there are concerns about the pipeline of future leaders. The recent launch of a national support programme for aspiring directors of operations is a welcome step and could be built on with similar offers for directors of strategy, for example. 

We need to make these roles more attractive. We need leadership roles that are demanding but doable. We need the autonomy, not regulatory control, to do them. We need national support and air cover for difficult tasks if we are going to have a chance of turning things around.
NHS trust director

But the most common suggestion for improving the development of future leaders focused on the need for better regional talent management, similar to that previously provided by strategic health authorities. Closer working arrangements between NHS England and NHS Improvement will provide an opportunity to rebuild this important talent management function. Local NHS trusts should also invest in seeking out and developing future leaders. This could include refreshing directors’ portfolios at regular intervals and exploring opportunities for less experienced members of staff to participate in projects that would develop their board-level skills. 

Ultimately though, interviewees cautioned against placing too much focus on formal talent management or development programmes, and several noted a more effective talent pipeline alone will not reduce vacancies as long as the current operating environment and treatment of leaders is unchanged. Interviewees noted that changing this culture would require national bodies to better model the behaviours they expect of local leaders, a clearer articulation of ‘what good looks like’, and for NHS leaders to be treated more humanely. 

Even if much of the discussion about leadership vacancies and tenure was framed as a problem to address, the leaders we spoke to viewed their jobs as a vocation and a privilege. Current NHS leaders were self-described ‘cautious optimists’ who believed that the route through the challenges of NHS leadership involved them, as senior leaders, promoting and demonstrating the behaviours that would make these roles attractive for subsequent generations of leaders. 

Related content


Pearl Baker

Carer/Independent Mental Health Advocate and Adviser,
Comment date
25 February 2019

I no longer feel the necessity to read the same old rhetoric anymore, the only thing that has changed under this TORY Government is the LA have insufficient money 2 DELIVER anything, cannot recruit staff, those Leaders! that remain are of the 'old guard' who's only objective is to self 'motivate' others into their way of thinking' enabling others 2 join their 'group' of 'self preservation at all costs, 'integration' is not really understood or indeed mentioned in this REPORT.

Hi I am a CARER, ignored, by ALL, just like many others, we feel 'undervalued, but acknowledged as SAVING the NHS Billions. Carers are the NHS best 'asset' we learn how to cope, we learn how to survive, but it no thanks to the NHS or indeed like the Kings Fund who 'follow' the same 'pathway' without even 'giving' us a second 'glance' we follow the 'light' and reach our 'objectives' from others 'sympathetic' to our cause to make a difference. I am speaking of those within the SYSTEM who see our plight. These are the TRUE LEADERS.

Dr Umesh Prabhu

Was Medical Director of Bury and Wrightington, Wigan and Leigh FT,
Comment date
28 July 2018

NHS doesn't have leadership culture but has management culture. This is the fundamental problem of NHS, Since the labour government pumped more and more money, waiting times have come down, survival for many diseases have improved and things have improved dramatically and with that culture has changed. NHS has management culture of bullying, intimidation and target driven culture NHS leadership is dominated by Nurses or Finance Directors and it has become more and more finance focused and target focused. There is acute shortage of doctors and nurses and rota gap is huge. Front line staff are fed up and even BMA and others have colluded with bad system, bad process or bad leaders and have been ineffective in any of their fights including junior doctors contract negotiation, Many whistelbolwers lives have been ruined by bullying culture and not even one CEO has been held to account. Some have lost the jobs but many have been re-circulated including CEOs who were removed for culture of bullying in the organisation. CQC test for Fit and proper person is not fit for the purpose for which it was introduced. Leaders with authority but with no accountability is the most dangerous form of leadership in the World. NHS leadership is insular and turn over is high. Culture of bullying, racism discrimination at the top of many organisation is shocking. I was the main speaker at 7 conferences recently and met nearly 400 doctors and sad to hear none of them want to be leaders! NHS leadership is insular.

Transformation needs transformational leaders with courage to hold everyone to account. NHS has culture of bullying, racism, discrimination and sadly has a culture of rewarding those who collude with the system than those who challenge the system or leaders.

It is the job of good leaders to hold bad bullying leaders to account and NHS is also works in silos and there are many middle men and women who make lot of money out of NHS like head hunters, private investigators, private consultancy firms, agency and many other staff. As long was there is a system of lack of governance and poor accountability, patients, staff and NHS will suffer.

Leadership is all about honesty, sincerity, kindness, compassion and clear accountability and courage. Until we move away from culture of management and bring back culture of leadership and honesty and hold leaders to account patient, staff and NHS will continue to suffer. We must appoint value based doctors and nurses and train them in leadership and must transform NHS and social care putting patient safety and quality of care at the heart. Happy staff - happy patients.

Rishi Das-Gupta

Director of Innovation,
Comment date
23 July 2018

The report highlights a lot of progress made towards a stable leadership. I'd be interested to know how many industries can boast an increase in CEO tenure of a year delivered in just over 3 years (presumably if there was no movement it could only have increased 3 years!).
I think that the commentary about what it means for the profiles of candidates is really important (p36). If we have less churn, the number of candidates applying for a job, who have done the same position at another organisation will be lower (or career progression slower). It is no use a challenged Trust looking for an "experienced" COO/Director of Finance as there is little incentive for a high-performing COO/DoF to leave a stable Trust to take over at a smaller / challenged Trust. I think this lays down the gauntlet to leadership programmes and recruiters to understand what "de-risks" the appointment of candidates with a shorter track record to deliver a director portfolio.
In my opinion, this feeds into the ongoing diversity issues (and under-representation of non-white people) at senior levels in the NHS. In the absence of a way to de-risk this appointment of candidates with a varied backgrounds, appointing someone who is well networked in the current establishment (or has a similar background) seems the course of action for which a board will be least open to criticism. There is a comment from a Chief Exec who outlines "I always appoint the best candidate" and notes that none have been non-white. I think the challenge is for each of us to understand what evidence we use to judge who is the best candidate and what level of risk we are willing to accept around an appointment.

Add your comment