How do NHS leaders remain resilient in the face of mind-bending stress? Psychiatrist Raj Persaud talks with four top chief executives about the secrets behind their success

Robert Creighton: two-star turnaround

A former Department of Health senior civil servant and acute trust chief executive, Robert Creighton has been chief executive of Ealing primary care trust since 2002

Dr Raj Persaud says: Robert turned round the local healthcare system in Ealing, going from zero stars to two and from a significant financial deficit to an underlying recurrent balance. He says a key element in his success is always being clear about goals and maintaining focus despite the often chaotic and changing agenda thrown at NHS chiefs. He also persuades those around him to understand and share this focus - being encircled by the right people is key to effective leadership, he argues.

Central to the situation in Ealing was how to turn its financial predicament around. He only discovered there was a black hole in the finances after being selected for the job - he says he had been given a completely different understanding of the fiscal situation before his appointment.

Importantly, he was given time to turn things around. In many NHS organisations he sees around him, leaders are not given enough breathing space to make the necessary impact. This tends to mean that short-term thinking comes to dominate the service. Key to this is relationships, believes Robert, with non-executive board members and in particular trust chairs being vital in benevolently allowing chief executives time and space.

Strangely enough for someone who scored such success in the financial arena, he also believes NHS leadership can become preoccupied with budgets, which he says are there to exert some financial discipline but are not actually the bottom line - in his view that is service to patients.

He vividly recalls being interviewed for one chief executive position where the finance director asked him what he would do in a tough position of having to exceed his budget or risk levels of patient care. He admitted he would sacrifice the budget on the altar of patient care. He was offered the job - that particular finance director agreed with his priorities. But Robert also thinks a recent tendency for finance directors to be popular appointments to top NHS positions reflects an obsessive belief that the be-all and end-all of leadership is to balance the books. In his view this does not generate the inspirational leadership a people-intensive organisation needs.

Intriguingly, Robert gained his deepest insight into who he could work with best after a particularly difficult time. He reluctantly parted ways with Great Ormond Street Hospital for Children after a thorny period with a senior colleague led to the realisation they could not work together. It was possibly the lowest point in his life - he says his whole sense of identity was tied up with his career success and the prospect of unemployment hit him hard. He admits the complications he had encountered at that trust temporarily undermined his confidence in his leadership abilities.

Yet in the long run the experience contributed to his resilience and he argues that he is now a much more confident leader. When presented with the sudden unexpected black hole in Ealing's finances he did not panic. Being a strong central source of stability and a calming influence in the face of catastrophe is, he now believes, a key role of a leader. He contrasts this style with some former health ministers he has worked with.

The complexity of the NHS can mean people are not clear about their goals and one big problem is whether the chief executive is merely a conduit for the will of politicians or brings their own vision to the organisation.

Robert observes that it was only relatively late in his career (he has also worked as a teacher) that he understood the value of emotional support from senior colleagues and friends. He is intrigued by the vogue for mentoring among chief executives, given that he strongly believes leadership is about knowing who you are in order to surround yourself with the right people. But he also feels the quality of support for senior managers, and in particular the preparation the NHS delivers to those about to take on the role of chief executive, is often woefully inadequate.

Edna Robinson: contrary perspective

Until October Edna Robinson is leading the recovery of Trafford Healthcare trust as chief executive. She is also a professional adviser to the chief medical officer's team on service design for chronic obstructive pulmonary disease, national lead for NHS Networks and a leadership adviser to the Home Office

Dr Persaud says: Edna's position on leadership in the NHS starts from what many might consider a most contrary perspective; she is not sure the NHS is always the answer to the UK's healthcare problems.

One of the acts she is proudest of in her career was actually contracting out some services normally provided by the NHS to a local social enterprise. Although a deeply unpopular and contested decision within the local NHS at the time, only a few years later that particular move came to be seen as an exemplar of best practice.

Edna recalls that the night before she made that decision she came under intense phone lobbying by local NHS leaders, who seemed to see the service as having a natural right to certain bits of work. It was a view she did not share.

Her analysis is that much NHS leadership is a club that fails to celebrate fundamental creative vision, making short-term pragmatism the order of the day. She prefers to stay outside that club and believes doing so allows her to see problems more clearly and to pursue more radical or imaginative solutions.

She has never been hamstrung by the need for peer regard; she feels this can be a weakness in NHS leadership. She concedes, however, that largely working outside the 'network' means she is often not party to inside intelligence or gossip - but this does not appear to have harmed her career.

Her background - she started work for the NHS as a midwife - gives her roots as a clinician, unlike many chief executives. As she also started her career by fighting for healthcare for pregnant homeless women she has long had a deep interest in socially marginalised people and has always felt most comfortable with the role of advocacy for the consumer.

She is clearly driven by deep political convictions in the role of the NHS in assisting the disadvantaged.

Her core philosophy means she is relentlessly driven to provide a service. This often requires taking on vested interest groups. She is clearly fearless in this, as exemplified by her successful campaign for pharmacies to provide emergency contraception to teenagers.

The problem with leadership in the health service, she contends, is that visionary thinking 'outside the box' is not encouraged because everyone falls into the trap of taking similar outlooks.

Instead she describes herself as 'manipulative'. She means that she will often use a government-imposed target or initiative to get her own way by harnessing the money or energy brought by the new initiative and diverting it in a direction that ticks the official box while serving her own agenda.

Edna does this because she is sceptical about many health service givens - such as an 'office model' for delivery of healthcare permeating the whole organisation. An example of this is the envisaging of primary care as a smaller version of hospitals.

She believes that a lot of discontent among health service staff happens because what they are being asked to do no longer engages with what they were passionate about when they joined the NHS. Truly great leadership recognises this basic overlooked reality and engages with it, she says.

She cites the fact that GPs are now better paid than ever before but 'remain miserable' because in practice they are being asked to provide daily solutions to patients' problems, which the medical model is not actually good at. Her view is that medicine may not always be the only answer, although it is the only answer the NHS appears designed to deliver.

She says that the danger of not engaging with demotivation is that staff then manifest their stress in other diversionary places, by fighting battles that are about preserving their status while the fundamental issue over job satisfaction remains unaddressed. She believes this is a key but neglected issue for leaders.

While Edna is concerned about how to help health service staff do what they do best, she is not above summarily getting rid of those who are not pulling their weight or worse. She says that she once moved rapidly to purge staff who were abusing patients at a psychiatric hospital she worked in.

She recalls vividly how some psychiatrists she worked with at that time simply walked out of the room when, thanks to her, it was made that clear to them that patients were now going to be invited to take part in the planning process of the local service.

This did not faze her; she did not want entry to the NHS club then either.

David Astley: living a dream

David Astley has held senior management positions in Norwich, Greenwich, Cambridge and East Kent before becoming chief executive of St George's Healthcare trust in London in 2006

Dr Persaud says: The blackest day in David Astley's long NHS career NHS was when he had to attend a meeting of 400 local people who were baying for his blood because of the closure of a local accident and emergency department. Just hours before, he had attended a meeting with the NHS Executive that placed the performance of his trust under severe scrutiny. On top of all that he had just been tipped off that undercover reporters from ITV news programme Tonight with Trevor McDonald were vehemently probing his organisation.

Yet David remains surprisingly sanguine about the enduringly thankless task of an NHS chief. It was while he was working as a hospital porter to support himself as a student that he first envisaged becoming one and since achieving this in the early 1990s he feels he is living a dream.

While he agrees that a similar position with an equivalent-sized private sector organisation would be more remunerative, less complex and more recognised and rewarded, he says there is nowhere he would rather work than the NHS because of the importance of the role, the positive impact on the community and the unique quality of staff.

It is this relationship with staff that he feels is most distinctively demanding for chief executives because of the emotive standing a hospital has in the local community. Staff come from that community and so the emotions generated by changes in local healthcare provision are especially strong.

David has been at the centre of many changes which generated unfavourable press coverage but has escaped personal attack. He believes this is down to his personal leadership philosophy which makes integrity a fundamental building block in his relationships. He contends that as a leader his relationships must be founded on others understanding that things he is trying to do arise out of honest core values. So even if colleagues do not agree with his mission, they can understand that he is struggling to do his best in difficult circumstances.

David is interested in the psychology of leadership and regularly attends a learning set of other chief executives, convened by a facilitator with a psychotherapeutic background, where senior NHS leaders can share problems and provide support for each other. Leaders, he says, are in a unique position to shape their own organisations but must be sensitive to the fact that the NHS is actually a set of organisations, often with very different internal cultures. Having worked across a wide spread of NHS bodies he is acutely aware of the need to adapt styles.

He likens the recent difficulties of the NHS to buying furniture at IKEA - we see nice things we think would look great in our homes but having purchased a flat pack off the shelf, we get it home and scratch our heads trying to make head or tail of small print in the instructions. Similarly the government and others have grabbed at good ideas and wanted to introduce them into the NHS without adequate consideration of how to manage transition or change.

He points out that in the private sector major changes such as those the NHS grapples with would attract substantial contingency planning and funding, with businesses writing off profits for a few years. In the NHS change is often not well planned or managed because not enough allowance is given to the demands of the change.

There is something about David which draws people in to help and support. He recalls how at stressful times other senior leaders in parts of the system geographically very remote from him would call him up out of the blue just to check how he was doing. It is this kind of support, plus the fact that leaders in other healthcare systems keep telling him what an exceptional bequest the NHS is to our society, that keeps him motivated to make his trust an outstanding place to work. And not just the best in the UK - he has his sights set on world class.

Peter Homa: catapulting ahead

Peter Homa was the first chief inspector of the Commission for Healthcare Audit and Inspection and chief executive of St George's Healthcare trust before becoming chief executive of the newly merged Nottingham University Hospitals trust

Dr Persaud says: For Peter inspirational leadership in the NHS is about a culture of exceptional performance rather than one set by the current target regime. He views targets as often setting a ceiling on managers' ambitions - they focus on hitting the mark - when instead they should be aiming to use the target as a platform for catapulting the organisation towards ever more superior feats.

Peter says an NHS leader should start by describing a 'plausible, challenging future' which inspires and engages staff. He believes this is the hallmark of great leadership and is particularly interested in how to garner that extra discretionary effort from staff, arguing that the pursuit of inspiring goals motivates staff to greater efforts, gaining greater job satisfaction and returning exceptional performance.

Peter's ambition is to make his the best acute teaching trust in the country by 2016. This is no idle grandiose declaration - it goes to the core of what leadership is for him. He believes that at the heart of all leadership is a proposition that a leader explicitly or implicitly puts to the staff before engaging them with assembling a route map of where they are today and where want to be in the future.

Having set out an agenda which looks remarkably like the kind reflected by the 'singular visionary' type of leaders who pull followers along in their wake, Peter stresses the enormous amount of time needed at the beginning of a leadership term to get to know staff and listen to their concerns. In particular he sees the chief executive role as facilitating clinical staff to deliver. He says theirs is the centrally difficult role in the NHS and that means their frustrations need to be addressed.

Peter says has noticed that a lot of chief executives came from one-child families, as he did. He wonders whether this partly accounts for the requisite self-reliance of leadership that can also feel isolating.

But for him, dialogue and building team spirit require a sense of a shared future: he is very future-focused, seeing every 'today' as a stepping stone towards a possible 'tomorrow'. It is vital to get that vision of the future clear and firmly steer the organisation towards it.

Psychological research on future-focused individuals confirms that they are often highly motivated and tend to achieve their goals compared with those who are more present- or past-oriented.

But they also tend to be chronic worriers with lower well-being. Laughing at this, Peter says he does not accept he is a worrier. He says leaders must look after themselves, so they can in turn look after the organisation. He can put work into the correct perspective and he places great importance on leisure interests and family time. He doesn't worry about work while away from it.

A turning point in his career may have been the difficulty he encountered at the Healthcare Commission, which he left after a relatively short period.

Very disappointed by the outcome of the job, and under enormous strain, he formulated a plan for the conduct of his professional life: always behave with the kind of dignity towards others - no matter the inner emotional turmoil - that later you can look back on with pride and respect.