Chief executives are running scared
The NHS needs leaders who are curious and ready to take risks − not motivated by fear of failure, argue Douglas Board and Robert Warwick
Was the HSJ survey of 81 NHS chief executives which highlighted a “climate of fear” an example of the NHS having a mild panic attack, convincing itself too easily of the specially difficult nature of the challenges which it faces? If not, what can be done about it?
‘The relevant political pressures included not only changes of minister, local authority or party, but the senior managerial politics of becoming “toast”’
The same week that HSJ released the survey results, we shared some of our own research findings with NHS audiences, adding substance and shape to the survey’s concern. The first was an open seminar conducted by the Centre for Health Enterprise, Cass Business School and the second was a private dinner for chief executives hosted by headhunters Saxton Bampfylde.
Ann Bourne, head of the health practice at Saxton Bampfylde, said the firm was working on double the usual number of NHS chief executive vacancies. Good news commercially, but when combined with the reservations which good potential candidates were expressing to her about stepping forward, one which gave her a systemic concern.
An acceleration in the already high number of major chief executive vacancies, combined with a culture of fear (making candidates wary of coming forward) and boards wary of appointing new people would all make things worse.
Great expectations
A psychologist at Saxton Bampfylde experienced in assessing senior executives across sectors had found the bar of expectations now being set in the NHS extraordinarily high.
Unfortunately, according to the King’s Fund paper Leadership of Whole Systems a short-term, task-focused, risk-averse focus is precisely the opposite of what is needed. Reviewing available research on the leadership of increasingly complex systems, of which the NHS is a prime example, the paper places centre stage the need to surrender fantasies of control.
‘NHS senior leadership jobs may be becoming unacceptably hard’
Complex systems can’t be controlled, even if you shout at them loudly. Instead, the research emphasises the need for leaders – and by implication those who appoint them – to be open and curious, embracing uncertainty and being positive about change, and investing as much energy into relationships and behaviours as into delivering tasks.
This complements research into the selection of people at or near board level. Choosing Leaders breaks new ground in exploring why recognised HR good practices such as competencies and structured interviews, which have transformed most junior and middle level selection in the past 40 years, have – across all sectors – left boardrooms and senior executive positions largely untouched.
It makes the case that senior selection, and other senior executive activity, can be better understood by seeing in it the constant jostling of three impulses: science, politics and intuition. In this context “science” refers not only to lab coat science but to the whole impulse to treat management as an objective, measurable and targetable activity.
Unacceptably hard
Having worked for 18 years on senior search assignments across a wide range of sectors, it seemed to the author likely that the NHS was putting exceptionally high voltages through all three sets of cables – more targetry, more politics and more clinical and other experts (with fiercely held but not easily expressed intuitive expertise).
If so, this would corroborate the psychologist’s observation: NHS senior leadership jobs may be becoming unacceptably hard. The relevant political pressures included not only changes of minister, local authority or party, but the senior managerial politics of becoming “toast”. Becoming de facto blacklisted because of an association with failure in the minds of a few pivotally connected senior individuals, with no curiosity about the individual’s actual contribution, keeps fantasies of control well supplied with sacrificial victims but does nothing to overcome fear or increase the system’s human capital.
‘We think it likely worrying about fear and NHS leadership is more than a fleeting panic attack, reflecting genuinely exceptional structural challenges’
However, rather than writing leadership in the NHS off as a horror story, we might find inspiration, oddly enough, in a story told by a master of the macabre Edgar Allan Poe which has been picked up by scholars such as Norbert Elias. Some fishermen in a boat are being dragged down into a whirlpool, wreckage swirling around them. All were lost bar one who, despite fear, was curious enough to notice the different extents to which differently shaped objects were sucked down into the maelstrom, and so threw himself overboard lashed to a cask.
We think it likely that worrying about fear and NHS leadership is more than a fleeting panic attack, and may reflect genuinely exceptional structural challenges. However, curiosity and courage, with each of us helping the other to name the security blanket of control for the fallacy that it is, may make a new beginning.
Dr Douglas Board and Dr Robert Warwick are senior visiting fellows at Cass Business School
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Readers' comments (8)
harry.longman@patient-access.org.uk | 17-Jan-2013 11:47 am
Profound, thought provoking and deeply worrying at the same time. If the climate of fear and the resulting selection of just the wrong kind of candidate prevails throughout the NHS, let me ask one question: where does responsibility lie?
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Anonymous | 17-Jan-2013 1:09 pm
Sir David says, elsewhere in the HSJ is that the problem is simply that we're not 'top drawer'. I could weep.
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Blair Mcpherson | 17-Jan-2013 2:40 pm
Chief Executives in the NHS have spoken of a climate of fear (Health Service Journal). I assume they are expressing anxiety about the pressure they feel under. The pressure of increased demands, the struggle to hit efficiency targets, the stress of maintaining care standards whilst cutting back posts and the challenge of delivering the governments reforms. It’s tough at the top. But here is another way of looking at it. If your team is stressed it’s your fault. You control the work, you provide the support and you manage the priorities. Likewise if there is a climate of fear then it is your job as a leader not to transmit that fear unless of course this is your preferred management style in which case you really can’t expect any sympathy.
As a leader you should have the courage to speak out, to make clear the implications of budget cuts and changes to the way the NHS operates especially if this impacts on patient care. Chief executives may well be only too aware of the risks of speaking out, if they lose the confidence of the board or our considered not on message by politicians/the ministry of health, then it may adversely affect their career but you can’t claim to be a leader if you don’t have the courage of your convictions.
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roger kline | 17-Jan-2013 4:35 pm
Blair is right.
But,just imagine what it is like for staff if that's how the Chief execs feel
Even wose, just imagine what it is like to staff or managers who question or challenge their chief exec
Worst of all just imagine what it is like if you raise a concern which imlicitly raises questions about how the Trust is run eg as a whistleblower
Step forward, Sir David "partnership" Nicholson?
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Anonymous | 18-Jan-2013 4:05 pm
Blair - I agree in principle but the approach taken by the SHA's to date has ranged from cack-handed to machiavellian in supporting, removing or anointing CEO's / CEO candidates.
Many of the current crop of non-FT candidates - especially in London - are beholden to the SHA leadership and, whilst fearful, simply won't push back in the way you describe. Cynically I would suggest they wouldn't have been appointed / put forward if there was a chance that they might make waves.
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Umesh Prabhu | 19-Jan-2013 1:13 pm
NHS has too many masters, fragmented management streams and structures like Primary care, Acute Trust, Community Trust, Mental Health Trust and Social Care which is completely under different management, confusion around co-operation and competition, too many reforms, poor fragmented IT systems, leaders with personal agendas and too many political interference! Current financial challenges and economic pressure should act as a catalyst for everyone to work together, putting patients at the heart of everything we do and we need strong leadership with integrated management structure with clear line of accountability providing service for 500, 000 population with excellent primary and community care, community based 7 days, 365 days elderly care service and the most important single point of contact for triaging for any out of hours service. We also need single paperless medical record.
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Mark Newbold | 19-Jan-2013 1:27 pm
Fascinating article, thanks, with many points worthy of detailed discussion. For instance, the phrase 'fear of failure' is an interesting one to reflect on.
What is 'failure'? Officially, 'failure' means not achieving obligatory targets, and I have argued elsewhere that this feels like a very narrow and arbitrary definition of failure, and one that doesn't any longer chime with the views the public would have on the matter. One can hit 4hrs, or 2 weeks, or 18 weeks, but still provide disrespectful care to the elderly, or oversee poor clinical outcomes or high mortality rates - I think that is failure but it would not be defined as such currently.
I'm not sure that 'fear' is the right noun either. A CEO knows for certain that they must achieve the targets, or certain regulatory consequences will follow. The Board is similarly aware. There are few choices to be made, they are 'must do's' and so it is pragmatism rather than fear which drives CEO's and Boards to prioritise these I think?
I believe that ceasing the 'shouting loudly' approach will lead to more local innovation and more adventurous attempts by Boards to genuinely prioritise what is important in the communities they serve. We would see some real successes in important areas, but we would also see lesser performance in some current priorities too. Wouldn't this be a price worth paying?
We are defining success and failure wrongly - access is not the priority now, care quality is. Lets change this, and recognise too that in fact it is fear of failure centrally that is holding us back. Allow local to trump national, and then we will see how innovative we can all be?
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Robert Warwick | 20-Jan-2013 7:18 pm
Thank you for the comments, both Douglas and I feel that these are important issues. I am doing some research in the social care field at the moment on similar issues (which will be published later in the year). Strip away all of the structures and ways of working there are related (but admittedly not exactly the same) pressures. Is there similar dread, fear and anxiety of leadership – no! At least not when it comes to looking over the shoulder. Any fear, dread and anxiety (as well as paradoxical feelings of and hope, drive and optimism) are directed towards the task in hand of delivering real improvements for members of society.
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