Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by deputy editor Dave West.

Despite the well-known lack of ethnic diversity among NHS trust directors, HSJ’s finding earlier in the summer that, across all chairs and executive leads of all sustainability and transformation partnerships and integrated care systems, there is only one person with a black or minority ethnic background was a little surprising. 

There are plenty of projects under the auspices of STPs and ICSs working hard on inclusion, inequalities and linking better with communities; but the absence of ethnic diversity at the top does rather call into question how deeply the commitment here runs. 

Some have explained it away quite lightly as a function of the pool systems are fishing in – ie. existing NHS chief executives – so there will be fewer black or minority ethnic leaders. 

Lena Samuels, who is the one exception as chair of Hampshire and the Isle of Wight STP, agreed one reason was the current mix of the more senior and experienced NHS leaders – though she also said it can and should be addressed rapidly. 

More concerningly, though, could it also be a result of the informal approach to things like governance and recruitment at the top levels of STPs and ICSs? Where process and rules are weaker it may be easier for good intentions to be forgotten and built-in bias to return. 

It reflects – as do the other features of the leadership landscape – the very varying, ad hoc and often vexed work of filling these kinds of roles over the past three years. 

There has been high turnover among STP exec leads since they were first recruited in 2016 – higher even than the notoriously perilous status of trust chiefs. That’s little surprise to those who understand the nature of these fledgling set-ups. 

There’s no one reason for the scale of change. Some have given up their roles because the ask on them changed too much; disillusionment; realisation they were not up to the task; or it proved too onerous to do as a job share – especially for some provider chiefs. Elsewhere, people have been moved on, and the role of STP leader used as an intervention device – a way to parachute people in to try to deal with serious problems or rows.

One trend is the fall in STPs and ICSs being led by current acute trust chief executives since 2016.

Initially the default for STPs was to appoint a part-time leader from within the patch. From then onwards, regulators put a lot of effort into persuading trust bosses to do the roles: they wanted to stop STPs becoming enlarged commissioning groups, to have the ownership of providers, and to move beyond commissioner/provider divides. So some will think it’s a failure that has reversed.

But they are not often being replaced by incumbent CCG leaders – instead growth has largely been in dedicated STP/ICS leaders, ie. those who aren’t splitting it with any other NHS role, where newcomers split into two groups. The first is those like Sir Andrew Cash in South Yorkshire and Alan Foster in the North East who have since 2016 retired from the trust leadership role they previously held but kept their ICS hat.

The second is where leaders have been brought in in a dedicated capacity – effectively parachuted in by regulators – to try to sort things out. On its own terms this has gone fairly well so far, with examples including Sussex – which has got on a better track since Bob Alexander joined in 2017 – and Buckinghamshire, Oxfordshire and Berkshire West which is now an ICS, Fiona Wise having joined in the same year.

In all these cases, we are talking about renowned managers getting towards the end of their own careers; and therefore willing and able to take on these highly uncertain, unstable and tricky positions. 

As well as being part of the reason for the lack of diversity (it is less among very senior managers with long experience than newer ones), this confirms another nagging and serious concern for those who want system working to become a fixed and stable feature of the service.

These kind of leaders may be doing well, but are often effectively in their systems on an interim basis – they are not really in it for the long haul.

It remains very difficult to get the best NHS managers at an earlier stage of their career to take on these roles, especially in difficult patches, and especially in a dedicated and permanent capacity.

The confusion and complexity of STPs and ICS, combined with the career uncertainty and risk of failure, is – for many, although not all – unappealing; this may also be contributing to the absence of diversity at the top.

HSJ’s Integrated Care Summit 2019 will discuss ICS and much more, on 19-20 September in Manchester. It is open to senior leaders in relevant roles and sectors.