Effective leadership and a positive and inclusive culture are fundamental to the success of the NHS – nationally and locally.

This is even more the case at a time of mounting pressure with the need to improve performance, transform services, and close the workforce gap.

Staff engagement is impacted by leadership – at all levels – and culture within trusts, and these together, as the Care Quality Commission has recognised, are linked to care quality[1].

Valuing and developing the NHS’ diverse workforce – which supports inclusive and high-quality care – requires positive and inclusive cultures and leaders with the values and skills to foster them. Leadership is not just limited to board level. Line managers at all levels hold the responsibility of sharing the vision, values and activities of the team, department and organisation and have a big huge impact on engagement and retention. This is key to the challenge of eliminating bullying at all levels of trusts and improving the experiences of black and minority ethnic staff.

Yet provider trust leadership capacity and capability is being stretched thinner and thinner. Trusts tell us they are finding it more and more difficult to recruit and retain board-level leaders to provide the stability and sustained focus required. Chief executive roles, in particular, are hard to do and difficult to fill, especially at trusts facing the greatest performance challenges.

Figure 8 illustrates the results of our most recent board remuneration survey, and reveals that 57% of provider trust executive directors had been in post for two years or fewer.

Figure 8

Provider trusts are expected to meet a wide and ever growing range of objectives and priorities. There is a need for much greater honesty and realism on what it is reasonable to expect trust leaders to deliver given the complexity and extent of the strategic challenges providers face. The Department of Health and the NHS national bodies need to be much clearer on what really are the priorities to enable the matching of available leadership capacity to these.

NHS national bodies also need to recognise that their primary role is to support provider trust leaders – modelling the compassionate leadership they want to see. This support must be much better balanced with the present ‘regulate and hold to account’ approach. While NHS trust boards must be held to account for delivery, including an appropriate degree of performance stretch, removal of senior leaders should always be the last resort. They also need to publicly communicate the valuable role played by provider trust leaders and acknowledge the difficulty and complexity of these roles in the current environment.

Investment in leadership skills and capacity is vital. The leadership pipeline needs to be addressed, building on the national framework for improvement and leadership development (NHS Improvement), the aspiring chief executive programme, and the wider work of the NHS Leadership Academy following its incorporation within Health Education England.

Leadership and culture – what needs to happen

The Department of Health and the NHS national bodies should:

  • Publicly value frontline leaders’ roles, acknowledging the pressure they are under, take a realistic view of what can be achieved and support them to deliver it;

  • work with provider trusts to address the leadership pipeline, building the national framework for improvement and leadership development, the aspiring chief executive programme, and the wider work of the NHS Leadership Academy;

  • continue to support provider trusts with programmes to develop positive and inclusive cultures that empower staff to deliver safe and high-quality care for patients.