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NHS trusts facing leadership crisis as senior posts go unfilled

Financial/performance/demand pressures and 'blame culture' driving shortages

Caroline White

Wednesday, 18 July 2018

NHS trusts are facing a leadership crisis, thanks to ongoing financial/performance/demand pressures and a “personalised” blame culture, concludes a new report* jointly published today by health think tank The King's Fund and trust membership body, NHS Providers.

A survey of 145 NHS trusts carried out for the report shows that trusts are struggling to recruit and retain senior leaders, such as chief executives, finance, medical, and nursing directors, and chief operating officers.

Analysis of the responses shows that nearly one in 10 (8%) of executive director posts are vacant, while over a third (37%) of trusts have at least one vacant executive director role, with vacancy rates and/or short tenures particularly high for director of operations, finance and strategy roles.

Half (54%) of executive directors have been appointed in the past three years, which also happens to be the median tenure of a chief executive.

Short tenure is an issue for all executive director roles, but particularly acute for chief operating officer roles.

Research shows that a high level of churn in leadership roles has a detrimental effect on the culture and performance of trusts. Leaders interviewed for the report also suggested it generates short-term decision-making, which can paralyse organisations at a time when they should be developing new ways of delivering care.

The report highlights an “inverse leadership law”, whereby high vacancies and turnover disproportionally affect the organisations with the most significant performance challenges.

In trusts rated as “outstanding” by the health and social services regulator, the Care Quality Commission (CQC), only 3% of posts were vacant and 20% of executives had been appointed within the last year (2017). But trusts rated “inadequate” had a 14% vacancy rate and nearly three out of four (72%) of executive directors had been appointed in 2017.

NHS leaders viewed their jobs as both a vocation and privilege. But they highlighted an increased risk of regulatory “decapitation”, suggesting that the consequences of poor performance or failure are perceived to be increasingly “personalised” and laid at the door of individual leaders by some national bodies, politicians, and the media.

This can put people off taking on these challenging roles and discourage bold leadership once in post, they said.

The authors also warn that the leadership of NHS trusts isn’t diverse and doesn’t reflect the wider NHS workforce or local communities: only 7% of very senior managers in the NHS come from a black and minority ethnic background.

There are signs that publishing data on leadership diversity is beginning to effect change. But pressures on the NHS are making this problem worse because recruiting organisations are less willing to take risks with more inexperienced candidates, further narrowing the diversity and experience of NHS leaders.

Responsibility for leadership has to be spread across the system, and an overly centralist approach won’t work, insists the report.

Rebuilding the regional talent management functions previously performed by strategic health authorities should be a priority for the new joint NHS England and NHS Improvement regional teams, it suggests. National leadership development programmes should expand their focus to include those board roles that are particularly difficult to fill, it says.

As organisations are now being asked to work collaboratively in integrated local systems of care, greater recognition of the importance of system leadership is needed in appointing future leaders, the report argues.

Suzie Bailey, director of Leadership and Organisational Development at The King's Fund said: “Leaders in today’s NHS operate in a climate of extreme pressure. Leaders tell us the job of being a leader in the NHS is still rewarding but is not getting any easier or any less complex, and at present there is not enough support or respect for the people in these incredibly difficult roles.

“Responsibility for NHS leadership is everyone's business - attracting and supporting the right kind of future NHS leaders should be central to the NHS 10-year plan and the work of the national bodies.”

Saffron Cordery, director of Policy and Strategy and deputy chief executive at NHS Providers said: “We need a new approach to supporting the most challenged trusts and systems to develop their leaders rather than continuing with a revolving door approach. This includes finding ways of enticing high-performing leaders into struggling trusts but that isn’t easy to do when a culture of blaming individuals for perceived failures exists. These are complex roles in complex organisations and we need to recognise and appreciate the significant leadership challenges involved.”

Niall Dickson, chief executive of the NHS Confederation, added: “There is a lot of nonsense talked about senior NHS managers - these are among the most demanding jobs in the public or private sectors and the pressures at the top are greater than ever.

“We need to start valuing these dedicated men and women who are daily coping with immense challenges running highly complex and often very large organisations. High turnover is in nobody’s interest - it not only affects the services for which they are responsible, it disrupts the relationships that are so important for local organisations to work effectively together.”


*Leadership in today's NHS: Delivering the impossible. A report prepared by The King's Fund and NHS Providers, July 2018.

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