I have been lucky enough in my career to work with a range of cabinet ministers, FTSE 100 company chairs and chief executives and Whitehall permanent secretaries. I believe that being an NHS trust chief executive is just as difficult as any of these roles, if not more so.

It’s a view I know is shared by David Bennett at Monitor, the health sector regulator. Why?

Consider the following factors involved in being a trust chief executive. For a start, you’re running a safety critical organisation − getting it wrong can mean the difference between life and death on a systematic basis and there aren’t many organisational leaders who directly bear that responsibility.

‘It can sometimes feel like you are managing what one chief executive described as a “set of warring tribes”’

Your role is usually subject to the full glare of local and sometimes national media attention. Service failures and service changes are all headline news and there’s often a level of personal vilification involved in the coverage.

Health issues understandably generate strong emotions in local communities and this is often reflected in the way the local debate about healthcare is conducted.

Lack of support

It’s a business model over which you have startlingly little control. You effectively have a compulsory universal service obligation: you must treat whatever comes through the door, to stringent and demanding national standards and targets, such as waiting times and clinical and quality standards.

If someone turns up at your A&E department, for example, because everyone else (eg: all the local GP surgeries) is shut, you can’t do anything about it. Failure to deliver the targets, sometimes due to factors beyond your control, can result in finger pointing rather than constructive support designed to help you improve.

Prices are often centrally fixed and may not reflect the true cost of what’s being provided. Your ability to deliver your service is constrained by the need to operate in a highly complex interdependent system with little or no control over the other system players.

For example, the person who buys your services changes, just after you’d got used to working with them, and you now have to form a completely different set of relationships.

Tribal loyalties

You’re currently required to improve the quality of the service you offer while reducing the cost of your service by 5 per cent every year − right on the edge of what international experience says is sustainably deliverable.

But 65-70% of your costs come from your workforce, with these costs driven by a highly inflexible national pay agreement that can ratchet up annual pay increases, even when there is supposed to be a national pay freeze.  

‘Complex leadership challenges like running a trust live or die by their ability to attract, retain and develop the best talent in senior roles’

At the moment, in particular, you’re trying to cope with the consequences of displaced demand that is coming from the rest of the health and the social care system, with the latter under particular strain in some places as local government spending cuts begin to bite.

While you are formally in charge of your organisation, you have to contend, such as if you are an acute hospital chief executive, with the fact that over 100 different bodies ranging from the royal colleges and regulators to health and safety inspectors and local authorities, have the right to come in and demand that you start or stop a particular activity.

Although you may have great and highly motivated staff, it can sometimes feel like you are managing what one chief executive described as a “set of warring tribes”. Some consultants, for example, may have stronger loyalties to their profession and other sources of income than the trust you lead.

Cause for concern

So why does this matter? There is lots of evidence to show that systems with complex leadership challenges like running an NHS trust live or die by their ability to attract, retain and develop the best talent in the most senior leadership roles. I hope everyone would be as concerned as I was when a leading sector headhunter told me the following four facts last month:

  • they had struggled to find even one appointable candidate in their last 10 NHS trust chief executive appointment processes;
  • over the summer, four trusts had asked them to approach what collectively turned out to be 10 former chief executives to see if they would return to the role. All 10, still working but not in the NHS, many in the voluntary sector, refused. They all cited the pressures outlined above;
  • the average length of tenure for an NHS chief executive these days is 20 months and leadership turnover in some of the more challenging trusts is clearly a significant factor in poor performance;
  • there were 20 trust chief executive vacancies at one point last summer.

This is clearly a major problem.

What can we do about it? Why don’t we start with everyone in the NHS recognising just how difficult these roles are and offering all the support − moral and practical − they can to those who are sitting in the hottest seats around?