How to survive as an NHS chief executive

There has been a recent spike in the numbers of very experienced NHS CEOs departing from some of the biggest and most complex healthcare trusts in England.

This is concerning because of the growing evidence about the positive effect of stable leadership on the performance of healthcare organisations. It is estimated that the average CEO lasts only around three years.  

More hearteningly, we have also identified that there is a higher than expected number who have more than 10 years under their belt. Their stories are worth hearing.

In the first phase, undertaken in early summer 2019, of an ongoing research study, emerging findings from semi-structured interviews with 10 currently serving chief executives reveal some interesting themes.

These five women and five men have an average tenure of around 17 years each, either staying in one organisation, or moving across several in the course of that time. They come from a cross-section of different types of trusts and geographies.

There has been a recent spike in the numbers of very experienced NHS CEOs departing… This is concerning because of the growing evidence about the positive effect of stable leadership on the performance of healthcare organisations

We asked what steered them to join in the NHS, and why they think they’ve lasted so long. We also sought insights about how they tackled setbacks and failures, how they considered the job has changed, and how they themselves have changed and developed.

A further line of enquiry was the significance of their relationships with their chair and board, their senior leadership team and their peer networks. Finally, we asked what advice they would give to newly appointed first time chief executives.

The analysis, which is currently under way, will seek to identify how very senior leaders in the NHS develop and maintain personal resilience, and the suite of attitudes and behaviours that are associated with professional longevity.

Five themes

So far we have identified five main themes.

First, the declared personal motivations of these CEOs to work for the benefit of patients, staff and local communities are very strong, sometimes explicitly ideologically driven, and often expressed in quite emotional terms. They describe the NHS as intoxicating, and although the job is tough, and can be brutal, the payback is huge. And they have been able to maintain their sense of commitment and vocation over the long-term.

Second, they have an array of leadership strategies that often include high visibility inside the organisation combined with focus on a few long term goals, an attention to building great relationships with local partners, and understanding the external environment in which their organisation is operating. They have often developed political astuteness by one or more experiences of working at the national level, although their primary loyalty to their own organisation and community is very apparent.

Third, there are some common patterns in how they have overcome setbacks, criticisms and failures, which all had experienced at some point. Some honestly attribute their longevity to sheer good luck, for example pointing to being in the right place at the right time.

They also have a tenaciously positive outlook to failure – rather than ruminating over unfair treatment, they seem to have an ability to move on quickly to recover from personal disappointment, to see the event as an opportunity to learn, draw support from family and close friends, and recognise and manage their emotional reactions. They are also careful to be respectful and understanding of the work of national NHS bodies.

Fourth, even the most experienced of these long serving chief executives speak of the vital importance of the senior leadership team, their chair and board, signalling the value of collective leadership in running these complex organisations. In relation to recruitment of executive talent, technical competence, rigour, creativity and having the right values and behaviours were all emphasised. The perceived significance of the quality and length of relations with their executive team was particularly striking.

They have an array of leadership strategies that often include high visibility inside the organisation combined with focus on a few long term goals

Fifth, nearly all had either coaches, mentors, or trusted individuals whom they went to for ongoing support, and many had a combination of all of these. Most were very active members of NHS CEO networks which were highly valued, both as a forum for intellectual challenge and fresh thinking, and as a safe space for comrades in adversity. Some placed a high premium on setting time aside for personal learning and intellectual growth, which was pursued in various ways, either via academic study, or seeking out individuals to test ideas out with, or searching out new experiences from within the healthcare sector and beyond.

Finally, drawing from these five themes, here is a selection of pieces of advice, from this group, for newly appointed CEOs in their first role:

• Always focus on patients, staff and communities

• Make staff happy and treat with them with kindness and dignity

• Secure the right senior leadership team

• Avoid the cult of personality: longevity is important only if you’re the right person to do the job

• Don’t be afraid of seeking help

• Get a coach or mentor or other form of personal support

Full analysis is under way and a report will be available in the autumn, following validation with all those who took part. We envisage lessons for policy and practice in recruitment and retention, training and personal development for aspiring chief executives, and insights into the impacts of NHS system culture on senior leadership (rather than the other way round).

Following the publication of the Interim People Plan, with its strong emphasis on improving the NHS leadership culture, the findings will also be timely as the final version of the NHS People Plan takes shape later in the year.