CHIEF EXECUTIVES: Can today's chief executive survive the raging currents of NHS change? Peter Spurgeon and colleagues find out what it takes to stay at the top, and look at ways of reducing casualty rates

Chief executives in healthcare organisations represent a pool of highly experienced and talented individuals. By the time they are appointed, they will typically have had a number of posts both inside and outside the health service and have benefited from a range of training and development activities.

The loss of such individuals is expensive to the service in financial, personal and performance terms.

1,2 Often, this loss is unavoidable in a health service operating in a turbulent environment, involving mergers, reconfigurations and change. But there is a sense that some chief executive losses are preventable and that better mechanisms for selecting, supporting and managing this group of staff might avoid some of the talent drain.

This situation is not peculiar to the UK health system. Research has shown around 100 senior managers are forced to leave the Dutch healthcare sector each year.

3Typical reasons include a lack of mutual respect and trust among senior colleagues, conflict with senior medical staff or a clash of management styles.

This study concluded that premature dismissal was usually associated with the relationship aspects of management, rather than any deficiency in performance of business or technical skills.

A UK study found the relationship between the chief executive and the chair to be critical to successful management of health organisations.

4The complexities of partnership working in conjunction with a demand for a more positive focus on staff management will place even greater pressures on the socio-emotional aspects of leadership.

Concerned to prevent the loss of chief executives, Stephen Day, director of West Midlands regional office, commissioned a study into possible prevention strategies.

It was also recognised that the exit process might be handled better so that the health service could keep the skills and talent of the particular chief executive.

Though the West Midlands region, like others, had seen chief executive departures, it was not the intention of the study to produce a set of specific case-study descriptions.

The aim was to derive a set of generic principles for an intervention strategy.

A series of semi-structured interviews was held with 12 chief executives from different types of health organisations in the West Midlands. The interviews covered the following broad areas:

impressions of internal staff relationship(s) - for example, what works well, what causes anxiety;

indicators of the relationship developing;

confidence in aspects of the chief executive's performance - internal and external relationships;

identification of the critical issues affecting effective working;

approaches to avoidance of conflict and relationship breakdown;

identification of the crucial skills of a chief executive.

As with most qualitative, interview-based studies, a very large descriptive data set resulted. The information obtained was grouped into broad themes covering critical indicators of effective management of the organisation and behavioural characteristics relating to positive management of interpersonal relationships. The table (above) of critical indicators summarises the comments by respondents. The information relates specifically to those who took part in the study, but the general nature of the concepts perhaps offers useful guidance to many of the emerging leadership development programmes.

The proposals below offer a number of recommendations for personal development and relationship management.

Personal development Provide a mechanism for learning support such as a 'buddy' chief executive or external mentor.

Provide opportunities for prospective chief executives to 'shadow' and 'act up' in their own and other organisations.

Secondments for chief executives and prospective chief executives to other NHS organisations - as well as other public and private sector organisations.

Greater involvement of regional directors in the development of chief executives.

Setting aside time for proper regulation of personal goals, with a stronger sense of balance between performance indication and staff management.

Framework for managing relationships More active involvement of the regional director in managing the personal development of chief executives, especially those relatively new in post.

Many executive directors expressed a desire to have a regional director 'drop in' for informal conversation so that concerns or misgivings might be identified.

The need for a 'code of conduct' to be developed in the context of relationship management. This might take the form of 15-20 items for self and stakeholder use. This could be part of the 360-degree appraisal process. The regional director could use this to deal with 'fear' and 'bullying' cultures and to encourage proper management of relationships as opposed to domineering hard performance.

Offer an independent counselling and support option where issues emerge. Interviewees emphasised the importance of independence to ensure uptake and to avoid any overlap with regional monitoring processes.Within this independent role there might also be assessment and development work relating to the concept of emotional intelligence within leaders.

More work to establish the compatibility of chair and chief executive.

Succession planning work needs to incorporate identification of potential chief executives and personal support to ensure they acquire the necessary range of skills.

The results of the study have been shared by the regional director with the chief executive community in the West Midlands and will be used to shape further work on succession planning, building further on the 360-degree and development planning process for potential chief executives already in place.

Since the study was undertaken in 2000, the NHS Leadership Centre has commissioned a number of development programmes for chief executives and directors with potential to reach chief executive positions. This must be applauded. But it is also important that personal development is balanced with mechanisms for on-going review of both business and relationship management.

Key points A study of chief executives identified the ability to prioritise, clear vision, resilience, and willingness to take decisions as key factors in success.

Some wanted more active involvement from the regional director.

Chief executives could be subject to 360degree assessment.

More work is needed to establish the compatibility of chief executives and chairs.

Effective management of performance Critical indicators clear vision and direction ability to prioritise focus on key issues on top of financial performance delivering the key performance indicators such as waiting lists understanding of the political agenda implementation of agreed plans willingness to take decisions capable of strategic thinking ability to analyse complex issues Got what it takes?

Keys to management relationships

Positive

appropriate involvement of chair consistency, integrity and openness supportive behaviour avoiding blame and scapegoating willingness to be seen, to be visible good links with clinical staff resilience clarity about role boundaries ability to synthesise critical issues involvement of whole team, no cliques resilient, positive, enthusiastic willing to cope with dissent and criticism loyal encouragement of 'team'focus recognises political imperatives develops strong networks keeps chair and non-executives fully informed shares information openly

Negative

poor relationship with chair or other members of team over-reliance on one or two executives disharmony in views of team autocratic in dealing with dissent frequent cancellation of meetings lacks emotional intelligence to assess mood of team verbal agreement not enacted or denied lack of transparency in decision making bullying and emergence of culture of fear demanding but unsupportive undisciplined meetings dysfunctional behaviour of board members (body language) clandestine meetings poor external links (health authority, regional office) corridor gossip lack of respect for other team members inconsistent strategy disloyal comments from team members