Leadership vacancies in the NHS: What can be done about them?

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There is a growing awareness that NHS provider organisations are experiencing a high number of vacancies at senior levels, are reliant on interims and are experiencing a greater ‘churn’ of senior leaders. This situation could have a negative impact on staff morale and engagement, on costs and on performance.

The King’s Fund, in collaboration with the HSJ Future of NHS Leadership Inquiry, undertook a freedom of information (FOI) request to obtain an accurate picture of board-level vacancies, supplementing the data gathered with in-depth interviews and a literature review. This report details the level of vacancies and their impact and suggests reasons for this.

Key messages

  • A third of NHS providers have at least one board-level position not permanently filled. This is especially true for NHS trusts with poor performance/quality care, like those in special measures. This loss of leadership could be creating strategic instability, wasting financial resources, reducing staff morale and affecting quality of care.
  • Factors contributing to this are a perceived blame culture in the NHS where executives feel exposed if anything goes wrong (even for things outside their control), excessive regulation and unrealistic expectations of what can be achieved in short timeframes.
  • Every NHS organisation should have a leadership strategy and leadership development plan. National organisations have a key role in removing excessive regulation and modelling the kinds of leadership behaviours needed for the future.

Policy implications

  • National bodies such as Monitor, the NHS Trust Development Authority and the Care Quality Commission have a key role to play in creating a culture that removes the barriers to recruiting and retaining board-level leaders. This means reducing the regulatory burden on NHS organisations and offering support and time to organisations facing challenges.
  • There is a need to develop individuals who have the requisite skills and experience to lead organisations in difficulty and potentially to lead multiple organisations.
  • Reforming the NHS needs to rely more on change from within organisations and systems and less on performance management and regulation.

More on leadership vacancies in the NHS


Jeremy Lewis

Head of Consulting,
The Beech Centre for People, Performance & Organisational Development
Comment date
16 January 2015
The King’s Fund report on Leadership Vacancies in the NHS rightly points to three factors that all link to the need for stronger leadership capacity and capability:
1. Loss of leadership capability leads to instability, which can be costly, reduce morale and affect care quality. Our evidence suggests this loss is costly, and does reduce morale.
2. Two of the three contributing factors in the report relate to leadership behaviour (blame culture and setting unrealistic expectations). In our opinion at least 70% of the operating climate in NHS organisations is due to poor leadership behaviour.
3. The report suggests that regulation should be reduced, and also recommends NHS organisations need leadership strategy and a leadership development plan.

Our evidence points to an additional factor
The Beech Centre suggests an additional factor – a lack of clarity in roles, responsibilities and accountabilities at board level (both executives and non-executives) is setting the tone for a frustrating operating climate that reduces clarity in the messages staff receive about strategic direction. This negatively impacts staff engagement and leads to a weakened culture at a time when NHS organisations need everyone to be pulling in the same direction. The situation is exacerbated when leaders give contradictory messages and do not demonstrably “walk the talk”.

We are currently undertaking a programme of diagnosis work with our clients not only in the NHS, but also across other sectors including Police and Local Government, that engages directly with leadership teams to explore the whole interconnected system (strategy – structure – process – people – culture) that in turn informs the organisational development strategy needed to shift performance.

Across the public sector there is clear evidence of investment of time and resources in strategy, structure and process but under-investment in people and culture. Investment in these more ‘tangible’ areas however will be influenced by and have an effect on how people engage with the changes brought about. Often these changes lead to a culture developing unhelpfully which in turn impacts on performance.

The emerging evidence is clear: individual leaders and boards need help to become clearer about their roles, responsibilities and accountabilities across all aspects of people and culture, not just strategy, structure and process.

What can be done?
The Beech Centre agrees with the King’s Fund report that change must come from within each organisation, so the question to NHS organisations is:
“How best to create a leadership strategy and development plan that demonstrates sustainably improved performance as measured by costs and care quality?”

Recommended approach
We believe three steps are needed:
1. Undertake a diagnosis of the whole system. Our experience suggests enough evidence can be obtained in as little as a half day workshop with the senior leadership team.
2. Informed by the diagnosis, invest in culture change through a world class leadership development programme including coaching and a live 360 degree feedback process which, by focusing on the behaviours and mindset shift, in turn shifts performance
3. Recruit the right leaders
You can then measure the impact your organisational development strategy is having by regularly undertaking a health check on the impact of the developmental actions taken on the whole interconnected system.

To find out more about The Beech Centre’s world class approach to organisational development diagnosis contact Jeremy Lewis, Head of Consulting, The Beech Centre for People, Performance and Organisational Development. jeremy.lewis@thebeechcentre.co.uk

David Greenwood

Former industrial manager (retired). Now a Healthwatch volunteer.,
(was) Metals & Chemical industries
Comment date
22 December 2014
This might be a good time for the DH to re-consider how it should manage the Health Service. Mimicking corporations with their 'executives' and 'boards', short term employment contracts and golden salaries has clearly failed.
What is really needed is good management.
Furthermore this management should comprise a large proportion of medics who have practiced. The current divide between medics and boards has created an "us and them" culture. A natural progression from practising to managing would create a better way of running things.
The "blame culture" can be mitigated only from the top (i.e. the Secretary of State). If the upper echelons habitually throw their underlings to the wolves it is no surprise if no one wants these jobs.
Finally, first and foremost, the needs of the patient should be given top priority. The present arramgements put the bureaucratic system first.

Shera Chok

Director of Primary Care,
Barts Health
Comment date
15 December 2014
It would have been useful if leadership in primary care had been included in this report, given the emphasis on new models of care and integrated care in the 5 Year Forward View.

There are some really strong models of leadership development in primary care emerging e.g. in East London.

Nasir Hannan

The Practice Heart of Hounslow
Comment date
12 December 2014
would be good within the infographic to look at the proportion of the NHS that are BME and then what proportion they have on boards.

I bet the figure would be startling.

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