The HSJ Future of NHS Leadership inquiry and a King’s Fund paper highlight the causes of the ongoing crisis in leadership of the health service. Richard Lewis explains how

The King’s Fund paper on board vacancies, which was produced in collaboration with the HSJ Future of NHS Leadership inquiry, confirms what has long been suspected: senior roles within the NHS have become less attractive than they were and churn of board members is significant.

Richard Lewis

Richard Lewis

The paper shows around a third of acute, mental health and community trusts report at least one vacancy or interim executive board member, and 9 per cent of all vacancies overall relate to the role of finance director. Moreover, the tenure of the chief executive is short – on average just more than two and a half years – and half of those responding to the research have been in post less than a year.

Multiple causes

The paper highlights several causes. Some relate to the structural challenges the NHS faces - for example, uncertainty created by impending trust mergers or market competition that affects community trusts makes board level posts less attractive.

‘Unstable or poorly performing trusts are associated with the highest senior turnover and a reliance on interims’

Other causes are more pernicious. The intense scrutiny placed on individual leaders means that the risk/reward ratio has been negatively skewed.

As one respondent claimed, criticisms can be highly personal and public, and leaders may find their “head on a pole”.

The King’s Fund also highlighted a bullying culture within individual organisations and across the NHS as a whole. So it is perhaps not surprising that gaps in the top ranks appear and there is no ready supply of assistant directors prepared to make the step up.

Inverse leadership

Arguably the most worrying finding was the “inverse leadership law”. This refers to the growing polarity between the strongest and the weakest trusts.

Unstable or poorly performing providers are associated with the highest senior turnover and a reliance on interims. By contrast, the top, stable trusts were comparatively attractive to the best candidates.

‘If those trusts in special measures – arguably in the most need of strong leadership – 28 per cent were without a substantive chief’

Of those trusts in special measures – and therefore arguably in the most need of strong leadership – 28 per cent were without a substantive chief executive. This compared with 7 per cent of trusts overall.

These results are cause for concern and suggest a profession in trouble. They mirror what we have been told at meetings of the Future of NHS Leadership inquiry: that recruitment and retention of senior executives is a serious problem.

Suggested solutions

We have heard many possible solutions. The King’s Fund suggests changing the composition of senior management itself. This would ensure greater diversity and more female, and black and minority ethnic managers. It would also remove obstacles to doctors taking on leadership roles and encourage entry to those currently outside the NHS altogether. How to do that is a key theme of the inquiry.

In addition, the King’s Fund paper suggests a leadership development plan should be created by all local organisations and collaborators that set out how future management capability will be developed and secured.

‘NHS leaders need to be authors of their own recovery, rather than waiting for rescue from outside’

Finally, the paper argues that national organisations such as Monitor, the NHS Trust Development Authority and Care Quality Commission need to create a culture that is supportive of good leadership and, in particular, to tackle the culture of blame that deters existing and would-be NHS senior managers.

The King’s Fund paper is a timely reminder that NHS leadership urgently needs a fillip. The years of casual public and political blame have taken their toll.

Keepers of their own destiny

However, NHS leaders need to be authors of their own recovery, rather than waiting for rescue from outside. The creation of a strong professional ethos, supported by tangible developmental support for individuals is a priority.

The NHS and the public are rightly demanding of its senior leaders. But at the same time, those leaders must be treated fairly and should be confidently proud of their many impressive achievements.

‘The NHS is facing perhaps its greatest challenges and its need for strong leadership is unquestionable’

The time to address this leadership crisis is now, and we firmly believe our inquiry will be part of that work.

The NHS is facing perhaps its greatest challenges and its need for strong leadership is unquestionable. Simon Stevens’ NHS Five Year Forward View sets out a credible path to recovery and the chancellor has latterly pulled a financial rabbit – albeit it modestly sized – out of his hat.

However, all this will be for nought unless the right leadership is in place to drive the NHS forward.

Richard Lewis is partner and health consulting practice leader at EY, and a member of the HSJ Future of NHS Leadership inquiry

One in three trusts have board level vacancies