Is the NHS facing a leadership crisis?

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Is the NHS facing a leadership crisis?

Published 25 octubre 2018

According to a recent report there is a crisis at the top of NHS management. The relentless pressures of the job mean that the median tenure of a chief executive is just three years. Mark Gould asks what the NHS is doing to ensure the brightest and best are recruited – and want to stay?

“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.”

So say NHS Providers Deputy Chief Executive Saffron Cordery and the King’s Fund’s Director of Leadership Suzie Bailey. The two organisations recently produced, Delivering the Impossible – the title taken from a quote from one of the interviewees, a report which reveals serious recruitment and retention problems at the top of the NHS.

The report highlights the negative impacts of high vacancies and short tenures such as “strategic paralysis, a loss of organisational memory and diminished credibility of leaders”.

It also reveals a paucity of people from black and minority ethnic (BAME) backgrounds at the highest level; just 7% of top-tier staff identified as coming from BAME groups when BAME representation across the NHS stands at 18%.

The report drew on a survey sent to NHS trusts and Foundation trusts that received responses from 897 executive director posts, across 145 of these organisations.

It found that over half of executive directors (54%) were appointed in the past three years, and that the median tenure of a chief executive was only three years. Nearly 40% of trusts had at least one vacant executive director role and 8% of executive director roles were vacant or filled by an interim.

It also reveals issues relating to the ‘passing of the torch’ as a cadre of experienced NHS leaders retire. Nine of the ten long-standing chief executives of the prestigious Shelford Group of hospitals – which once claimed 200 years of leadership experience between them – have announced their retirement, or have already left the service, since 2013.

The inverse leadership law

Organisations with the most significant performance challenges experienced higher levels of leadership ‘churn’. In trusts rated ‘outstanding’ by the Care Quality Commission last year, 3% of executive posts were vacant and 20% of executives had been appointed in 2017. But in ‘inadequate’ trusts up to 14% of posts were vacant and a significant 72% of executives had been appointed in 2017.

“There is little evidence that national bodies are tackling this ‘inverse leadership law’ effectively,” the authors conclude.
Interviewees called for a more finely calibrated and transparent judgement of when it was appropriate to remove a leader.
Siva Anandaciva, Chief Analyst at The Kings Fund, one of the report's authors, says this fear culture stifles ambition. “Chief operating officer used to be a plum job on the route to chief exec, but many told me that the balance between risk and reward does not make sense to take the next step up. It's seen as a career killer.”

The NHS Leadership Academy is making changes to boost recruitment and retention to ensure NHS leaders are representative of the workforce and communities they serve (see box). It says chief executives should stay in post for at least five years to give organisations the stability they need for effective strategic planning.

This would also root out poor performers. One NHS trust director told the authors: “There were some poorly performing staff – both clinical and managerial – in the organisation who I would call ‘cute’. They knew the average lifespan of an NHS CEO is two years and would tell me: ‘All I have to do is keep my head down and not be found out, and then my clock restarts because a new CEO will come in'.”

Capricious world

Anandaciva agrees with the need for NHS leaders to have longer tenures and said proposals by the NHS Leadership Academy, in terms of “nurturing and sharing talent across the NHS”, were a welcome “aspiration”.

“But we also need to acknowledge the reality of where we are. At the moment leaders are being held to account for things that are beyond their control. It’s a really capricious world where people need to see heads on spikes. More compassion and more understanding are needed to support NHS leaders.”

He feels all parts of the NHS should emulate the most successful trusts that can identify their top 100 leaders of the future “and offer them a clear narrative for the rise to the top, and show details of the numbers who have risen up that path”.
While there is evidence of a positive discourse on the drive for equality, Anandaciva says this was blunted by “unconscious bias”.

“There is a conflation between equality and equity – the sort of ‘we give everyone a fair chance to apply so we have fulfilled the criteria’ argument.”

But he is optimistic about the fact that knowledge gleaned from WRES (Workforce Race Equality Standard) data, galvanised provider chief executives and boards “so they could actually see how they compared on diversity at a national level and start talking about how to improve it”.

While there is a long way to go, this knowledge is changing recruitment practices. Some trusts insist on interview panels that contain at least one person who identifies as BAME. Others have developed targeted offers for candidates from under-represented groups to take part in projects that give them the chance to develop, or demonstrate the skills they would need at board level, such as building relationships with external stakeholders.

They also used more formal agendas such as the Insight Programme, organised by executive recruitment company GatenbySanderson for aspiring non-executive directors. It provides opportunities for under-represented staff to shadow existing post holders so they become more au fait with the “relationships, lingo and priorities of boards”.


DAC Beachcroft Partner Udara Ranasinghe, who is an employment specialist, is not surprised at the findings. “The issue of good leadership plays directly into development of an engaged and well-led workforce.”

He welcomes initiatives to reduce pressure on executives, and the re-energised leadership development strategy being adopted by the NHS Leadership Academy.

But he says that where trusts get into public difficulties, there has always been a tendency to sacrifice the leader in spite of apparent contradiction of the drive across the NHS for a ‘blame-free’ culture.

Ranasinghe feels the amount of time and commitment put in by leaders is not reflected in remuneration. “Senior salaries may seem generous but not when compared to similar sized organisations in the private sector. Factor in changes to the NHS Pension Scheme and the draw of a generous public sector pension scheme may not be as strong as it used to. It may be that leaders need some alternative remuneration package that doesn't contribute to the pension scheme? Maybe long-term bonus arrangements for hitting targets? The problem of course with such schemes, would be where the money comes from and the perception around these types of payment in the public sector.”

Work/life balance

Claire Pullar, National Officer at Managers in Partnership (MiP), the trade union that represents top-tier NHS managers, says NHS leaders leave due to excessive hours, with no time for family life, and because of the pressure of working in a blame culture.

“I am supporting one of our members leaving his current job and he said: 'If I had known the job was as bad as this I would never have applied. I can’t sleep at night due to worry.'

“The Department of Health and Social Care must stop relying on unpaid excessive overtime from managers, and other staff, and allow the NHS to be run in a way that will attract and encourage talented staff to stay.”

Cordery and Bailey agree more people would come into leadership if these pressures and burdens were reduced.

“But how can that be done when we are seeing new threats, such as the spectre of corporate manslaughter, adding to the relentless operational, financial and regulatory pressures already facing senior leaders?”


To discuss the issues raised in this article, please contact Udara Ranasinghe on +44(0)20 7894 6727 or   


Udara Ranasinghe

Udara Ranasinghe

London - Walbrook

+44 (0)20 7894 6727

Key Contacts

Udara Ranasinghe

Udara Ranasinghe

London - Walbrook

+44 (0)20 7894 6727

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