A range of problems and events all broadly linked to the quality and, particularly, availability of leadership are rapidly converging.
If they remain unresolved, 2013 may see the NHS significantly under-prepared to maintain, let alone improve, service quality while delivering the redesign which will keep the system affordable.
The first problem is the sheer scale of senior posts which are unfilled or occupied by an interim. An incomplete list of acute and mental health trusts without permanent chief executives takes in: Avon and Wiltshire Partnership; Berkshire healthcare; Brighton and Sussex; Cambridge University; Countess of Chester; Croydon; Great Ormond Street; Ipswich; Isle of Wight; University Hospitals of Leicester; Milton Keynes; Morecambe Bay; North Bristol; North Middlesex; Peterborough and Stamford; Plymouth; Royal Liverpool and Broadgreen; South London and Maudsley; South Tees; and Weston Area Health.
This list does not include the currently leaderless South London Healthcare. It is one of 16 trusts which this week received an “escalation letter” from the Department of Health signalling heightened monitoring of their progress through the foundation trust pipeline. Further vacancies will appear as a result of this scrutiny.
Of course, top-level vacancies mean gaps appear further down the leadership hierarchy as people act up and management is de-layered in efficiency drives.
There is a similar struggle within the organisations being created to run the new system. Last week, NHS Commissioning Board director of commissioning development Dame Barbara Hakin complained of the difficulty in filling top jobs at commissioning support services. The board is also having to sell its own local area director jobs as “ambassadors” to give the positions a sense of importance that many potential candidates believe they lack.
At the same time as the NHS battles to fill these key positions it is experiencing a talent drain which is shocking even experienced observers. The fact the NHS will lose the skills and experience of strategic health authority chief executives Sir Ian Carruthers, Sir Neil McKay and Dame Ruth Carnall at the same time is just the tip of a spectacularly large iceberg.
The loss of talent is largely a result of the government’s restructuring. The exit terms rightly offered to these senior people after lengthy service are hugely attractive. HSJ spoke to a leader (not one of those mentioned above) who desperately wants to stay in his post, which will survive the reorganisation, but could never look his family in the eye again if he turned down the money on offer.
He, of course, is already being courted by management consultants.
The NHS is papering over the widening cracks in its leadership base - often by using a growing band of interim executives. This jerry-rigging will not hold forever as the financial and reconfiguration gales pick up force. But look out across these choppy waters and it is possible to see a real storm on the horizon. The Francis inquiry into care failings at Mid Staffordshire Foundation Trust may prove to be the final straw.
HSJ has spoken to one NHS leader who says they will resign on principle if they are criticised. But, more significantly, many fear the wave of opprobrium the inquiry - and more particularly its media coverage - could unleash on NHS leaders and the surge of increased regulation it might inspire.
There is no neat solution to the growing gap in leadership capacity and, no doubt, new leaders will rise to the challenge. But in the meantime the Department of Health, commissioning board and Trust Development Authority should pay serious attention to persuading some of those eyeing the sun lounger to stay around long enough to give the new generation a chance to build the necessary knowledge and experience.