Last month, The King’s Fund and NHS Providers published their report looking at leadership in today’s NHS.
In the words of a NHS trust chief executive in our recent report: "Being a leader in the NHS – it’s bloody brilliant as a job. It really is. There’s nothing like it. But imagine if we got rid of all the sh** around at the moment, with being treated poorly and being under constant pressure, how much more brilliant would it be?"
Being a leader in today’s NHS is one of the most rewarding jobs going, but with this vocation, comes a huge amount of complexity, responsibility and risk. No surprise then that the leadership lifespan can be short: over half of executive directors (54%) were appointed in the past three years and the median tenure of a chief executive was only three years.
The leadership lifespan can be short: over half of executive directors (54%) were appointed in the past three years and the median tenure of a chief executive was only three years.
The relentless operational, financial and regulatory pressures facing senior leaders can put off even the most talented and resilient individuals. These pressures can make recruiting organisations risk-averse when considering those candidates from outside the NHS, those with 'non-traditional' career paths and those who have potential but less experience.
This makes the job of recruiting future NHS leaders even harder and, of course, narrows the diversity and experience of NHS leaders; diversity and inclusive leadership is something we need a lot more of in the NHS.
The diversity gap
Although there have been significant national and local efforts to improve diversity among NHS leadership, the headline picture is still deeply troubling.
In 2017, only 7% of very senior managers in the NHS were from a black and minority ethnic background. This is well below the black and minority ethnic representation in the NHS as a whole, which is 18%.
And although nearly half of all trust executive roles were held by women overall, women are underrepresented in some director groups, such as chief finance and medical director roles.
Things may be shifting a little, with greater honesty and willingness to discuss these issues at NHS boards, as the interviews in our report show. At the heart of tackling the diversity gap is cultural change. Individual schemes and initiatives help and everyone must play a part, but NHS leaders must spearhead this cultural change, and be clear that diversity and inclusivity matter at every level.
At the heart of tackling the diversity gap is cultural change. Individual schemes and initiatives help and everyone must play a part, but NHS leaders must spearhead this cultural change.
The background gap
As the daily pressures in the health and care system intensify, we are starting to see less emphasis being placed on attracting non-NHS leaders. The chairs and chief executives of the organisations we interviewed suggested that the desire for outside experience might be less desirable in the current climate. This could be linked to the expectations on leaders to 'hit the ground sprinting' as one national stakeholder told us.
Alongside this, however, there has been a more concerted effort to encourage more clinicians to take on very senior leader positions, in particular chief executive roles, which is a positive development.
We found that 9% of chief executives were medically qualified and 30% had another type of clinical qualification such as a nursing or physiotherapy. And this trend appears to be increasing – chief executives appointed in the past three years (2015-17) were more likely to have a clinical qualification than those appointed before 2015.
Chief executives appointed in the past three years (2015-17) were more likely to have a clinical qualification than those appointed before 2015.
However, getting more clinicians in to senior leadership positions in the NHS is not an end itself. Senior leaders with clinical backgrounds can bring crucial experience, credibility, and insight with them but in the words of a current trust chief executive "success as a chief executive is not predicated on your clinical exposure or clinical experience; it is predicated on [a] set of core skills and values around inclusive leadership…"
Tackling the gap
At the moment, it is difficult to see why people would want to take up these roles when the risk of failure is so great. In the end, the single biggest factor that would encourage and attract a diverse, talented and resilient pool of leaders just below board level to take the next step would be to help alleviate the pressure and the burden.
We have to challenge the current orthodoxy of 'change the leader, solve the problem' and make the top jobs do-able. These are highly challenging and often isolating roles. Those who hold them – particularly new leaders – need greater support and encouragement and a recognition that it takes time to develop the necessary skills and behaviours that are required to lead complex systems.
What our conversations with trust leaders has shown us is that it is time to break the NHS leadership mould. Or indeed challenge the notion that we should have a 'mould' at all. After all it is diversity in all its forms that is vital to ensuring the NHS can deliver high quality care - now and for future generations.