Marcus is the recently appointed Director of Leadership and Organisational Development at The King’s Fund. This article is his response to the views expressed by 12 departed or soon-to-be-departed NHS leaders in The chief executive's tale.
I’m reading these chief executive stories as a newcomer to the world of the NHS, having spent my entire career outside the public sector in executive positions at Marks & Spencer, as a change consultant at Ashridge Business School and more recently on the board of Nuffield Health. I’m hearing the warning from Nicholas Timmins that they represent the views of the departed or soon to be departed, perhaps with some reminiscing about the past and grumblings that the role of chief executive is difficult and lonely. I understand that it’s never been an easy job, resources are tight and managing the complexity of the duality of legislation and regulation has always required skill and judgement.
If I think about the work I’ve done with boards and senior leaders in the private sector it would perhaps also reflect the same views, so nothing new so far. However, the underlying issues that these stories point to, feel, even to me, to be signals of a system that’s buckling under a heady cocktail of factors that we ignore at our peril. If this was a report that was presented to the leaders of a company in the private sector, it would create the basis for fundamental change and action.
Much has been written about the difficulty of attracting talented leaders into health, but health is no different from any other sector in that respect. All the best organisations are fighting for the best talent – and there is a shortage. Good people can pick and choose and they are better informed than at any other time in history about what it’s like to work in a particular sector. It doesn’t even work any more to simply broadcast the rhetoric that health can offer the most satisfying and rewarding career. The advent of social media, the constant news about lack of funding and over-regulation can very quickly provide access to a different truth.
I am struck by the consistency of the commentary that the levers to do the job have been nailed to the floor; that the system micro-manages; and that, at times, regulation seems to favour process rather than outcome. This is a toxic combination and one that no talented leader, whether clinical, financial or administrative, would want to endure for long. So something needs to change.
If this report was presented to the leaders of a company in the private sector, it would create the basis for fundamental change and action.
Vibrant and healthy organisations must constantly adapt and change if they are to be able to respond to a shifting context and environment and there has never been a time when change is more needed in health than now. An ageing demographic, increased life expectancy and a better-informed and demanding population all increase the pressure on a system that has not received sufficient funding in recent years to keep pace. In change parlance, first-order change is now not enough. A complete paradigm shift is around the corner and, hearing the views of these chief executives, we don’t seem prepared for it.
This shift will need leaders who are confident, competent and have the energy to innovate. They have to be able to take risks to try out the new and experiment with novel ways of providing a service. The environment in which they lead needs to be responsible, responsive and above all supportive to seek out new ways of working that go beyond the current paradigm. Such an environment is exciting and rewarding and will attract the best talent, who will create the change that is needed. It becomes a virtuous circle that the best will attract the best and the negative contagion that we are currently experiencing will be replaced by one that is positive and innovative.
This report suggests that we have a long way to go.
The experience of high-performing health systems and the work done in understanding the nature of innovation in the private sector perhaps provide some of the clues to what systemically we now need to pay attention to:
1. The role of the regulator
The burden of regulation and related loss of autonomy were a theme in the chief executives’ interviews. We know that innovation appears in the most unexpected places and that regulation is the killer of innovation. It’s not unusual for organisations that operate in a regulated environment to cease to be able to adapt because they are strangled by regulation that goes way beyond aspects of the operation that properly need to be regulated. A regulatory environment that is focused on consistency and order goes in the opposite direction to one that values and encourages innovation – it values staying the same rather than changing. In the private sector these organisations simply become irrelevant and are replaced by new ones that provide a new and innovative service. In the context of a national health service this isn’t possible. So if innovation and change are essential and over-regulation kills that, then now is the time to stand back and consider what the purpose of regulation is and where it is going too far and exceeding its remit.
2. Innovation and the leadership culture
When change is needed, leaders need to be at their most confident. They have to relish trying out new things and experimenting, amplifying the best and discarding what doesn’t work. The bullying and fear of failure that many health sector leaders experience and that are recounted in this report does the exact opposite. Leaders retreat into what they know and behave in a way that does more of the same and the change never materialises. In the context of this report, bullying is systemic; it comes from all directions externally, not the least of which are the politics of health, the media, regulation and financial constraints. Not only that, the bullying is contagious and soon the bullied themselves become the bullies. So it’s not surprising that patient care quickly becomes affected. At some point the system has to collectively address this and recognise that all aspects of the system are contributing to and colluding with this. This is not a utopian dream; it’s becoming a necessity.
Shifting this culture starts locally, and much is being done. Most local leaders know that a positive, engaged workforce will deliver higher-quality care. However, this local endeavour has to sit in an environment that fosters and encourages it. So the challenge is for the national bodies, regulators and legislators, the media and the local communities to work together to fundamentally shift their attitude. If we want a vibrant, innovative health sector then the systemic bullying has to stop.
3. Nurturing talent
The best leaders can lead in many contexts. They adapt their style according to the challenges they face because they can draw on experience – experience that the system nurtures and values. This experience gives them the confidence to innovate; they know the boundaries of what is possible and what is unacceptably risky. The responsibility for individual progression should be with the individual. But when talent is scarce and leadership is the valuable currency, more needs to be done to secure talent, nurture it and provide a leg‑up in an increasingly complex and fragmented environment. Resources need to be secured to provide development, establish career pathways and define the ownership of extraordinary talent for those individuals and talent groups that deliver disproportionate value. It is striking how many testimonies in this report lament a lack of support for leaders on their way up.
The role of NHS Improvement here is clear and urgent. While local trusts have a responsibility to develop and nurture their own, we need a national talent strategy that aims to take a broader, longer-term approach. This means that assistance can be properly given to help manage careers and create opportunities so that we have bench strength to serve us well for the future. Funding constraints on developing talent must be addressed to allow The King’s Fund and other organisations that have a long history of leadership development to support this area.
4. Can the real experts please stand up
The mix of issues that face leaders in today’s health economy seems more complex than at any time in recent years. Reading between the lines of the interviews, there is a sense that the leadership challenge is almost impossible or at best progressively exhausting, with few accolades when things go well. When things don’t go well, however, ‘experts’ line up to dispense seemingly endless advice.
There needs to be a fundamental reassessment of the attitude in the system and of how we can create an environment where improvement and innovation are the norm. First we need to acknowledge that the expertise to navigate the complexity of the issues lies first and foremost with those people who face the challenges. If we want leaders to lead then we have to appoint the right ones and let them get on with it. Then those national bodies that aim to intervene should reframe their ‘help’ as working in partnership.
That’s not to say that targets shouldn’t be set along with the expectation that they are met. But an environment of co-operation and support that acknowledges what’s working as well as what’s not is a far more generative culture than the one described by the chief executives in this report. My experience is that the private sector learnt this lesson long ago.
The forces at work to keep any system the same are stronger than people acknowledge.
I acknowledge that these four reflections in themselves are simplistic. However, as someone who is looking at this situation fresh, I believe that the consistency of the commentary should be deeply worrying to anyone who has an interest in health. And we all do.
The creation of NHS Improvement gives us a real opportunity for change but the forces at work to keep any system the same are stronger than people acknowledge. Why wouldn’t they be since it’s the same people doing slightly different roles? The task is to support and encourage them to adopt the paradigm change that’s now needed and not just reinvent the past. Government must take its part seriously, attempting to step beyond the short term and be the guiding force for change.