Ending the crisis in nhs leadership - FUTURE OF NHS LEADERSHIP
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FUTURE OF
NHS LEADERSHIP
ending the crisis
in NHS leadership
a plan for renewal
June 2015Inquiry members
FUTURE OF
NHS LEADERSHIP Chair Sir Robert Naylor, chief
executive of University College
London Hospitals Foundation
Trust
Stephen Dorrell, chaired the
House of Commons health
committee 2010-2014
HSJ commissioned this inquiry into the future of NHS Sir Sam Everington, chair of
leadership in 2013. We asked Sir Robert Naylor, a “child” Tower Hamlets Clinical
of the Griffiths reforms and one of the leading health Commissioning Group
service managers of his generation, to chair it. Together we
assembled an inquiry panel containing some of the brightest
minds in healthcare.
Richard Lewis, partner and
The inquiry held a series of meetings at which members health leader at management
consultants EY
invited leading experts to share their views. Attendees
included senior figures from national policy bodies; thought
leaders and academics; patient leaders and advocates;
clinicians; and leadership experts. The panel also considered
the wider evidence gathered through a public call for Dame Gill Morgan, chair of
evidence. NHS Providers
Alastair McLellan, editor, HSJ
Professor Laura Serrant,
professor of community and
public health nursing at
Wolverhampton University
Cover: Delegates at the 2015 NHS Confederation annual conference; Guzelian
Dr Emma Stanton, associate
chief medical officer at Beacon
Health Options and chief
executive at Beacon UK
Full biographies are on page 11
2 HSJ Future of NHS Leadership June 2015 hsj.co.ukIntroduction
Leadership in the NHS is an endlessly debated It was, precisely, the right diagnosis for the
topic – but discussions rarely go beyond the time. It led to the introduction of general
expression of bland platitudes and well-worn management in the NHS – a form of leadership
truisms. Only very occasionally do these debates which replaced the “consensus management”
produce actionable conclusions with lasting that had arrived with the 1974 reorganisation of
impact on the management of the NHS. the NHS.
This report is an attempt to go beyond that Consensus had failed because it effectively Today’s debate
uninspiring conversation, to provide real gave a veto to any member of the team and too
insight into the challenges faced by current and often produced, in Sir Roy’s words, “lowest on healthcare
future NHS leaders, and to make some concrete
recommendations on how they may be
common denominator decisions”, if any
decision at all. leadership is all
overcome.
Thirty years ago Roy Griffiths produced his
Today’s debate on healthcare leadership,
nationally and internationally, is all about
about integration
landmark report containing the defining phrase integration and system leadership – perhaps and system
that “if Florence Nightingale were carrying her a reinvention of consensus management, but
lamp through the corridors of the NHS today this time between organisations rather than leadership
she would almost certainly be searching for the within them.
people in charge”.
The context
What the NHS needed, Griffiths said, was “the Indeed, he argued that “a small, strong general
responsibility drawn together in one person, at management body is necessary at the centre
different levels of the organisation, for (and that is almost all that is necessary at the
planning, implementation and control of centre for the management of the NHS)”. He
performance”. That general manager, he said, judged that the centre then – as might be said
should be appointed regardless of discipline. now – “is still too much involved in too many of
Without the creation of general management, the wrong things and too little involved in some
the 1991 reforms, including the introduction of that really matter.”
the purchaser/provider split and the creation of Sir Roy added: “The NHS is in no condition
NHS trusts, might well not have happened – to take another restructuring, and much more
because there would have been no-one to can be achieved by making the existing
implement them. In the eyes of the majority, the organisation work in practice”. This is as true
Griffiths report has shaped the NHS since then today as it was then, but unfortunately we have
and some would argue that it saved the NHS. inherited a structure that is full of bureaucratic
It was, however, the last time that a and regulatory obstacles that stifle innovation
government sponsored inquiry looked and limit the extent to which leadership can
comprehensively at leadership in the NHS. HSJ flourish.
decided that it was time to revisit the issue – not However, significant change to how NHS
least because, as we will spell out, NHS leaders operate can and must be achieved
leadership is in many respects in crisis. without the need for another formal
Thirty years is a long time, and times change. restructuring.
But before turning to our diagnosis and The consistent themes we heard during our
recommendations it is worth revisiting some of inquiry were the need for:
the other themes from Sir Roy’s report which l a new generation of clinical leaders across
still have relevance today. It was not just about the NHS;
the introduction of general management. l empowered leadership devolved close to the
Doctors, he said, should not just be eligible to frontline;
become general managers. They should also l a commitment from the professional bodies
take responsibility for their own budgets at that strong leadership is essential to enabling
hospital level because “their decisions largely high quality clinical practice;
dictate the use of all resources, and they must l a reduction in bureaucracy and regulation;
accept the management responsibility which l an organic reduction in the number of
goes with clinical freedom”. provider and commissioning organisations to
It was not, he said, “for the centre to engage maximise the use of scarce leadership
in the day to day management of the NHS”. resources.
hsj.co.uk June 2015 HSJ Future of NHS Leadership 3The evidence for a
crisis in leadership
There is no doubt that a crisis in leadership recently, that if Florence Nightingale were
exists, though not quite everywhere in the NHS. walking NHS wards today, she would be
There are excellent examples of clinical looking beyond them: out into general practice;
engagement in some trusts and the introduction into community services; into the private and
of clinical commissioning groups has seen a voluntary sectors; and into social care. She
revival of leadership in general practice. would be looking for the other leaders who
However, general practice is itself under would help her make her wards work better2.
pressure, with recruitment difficulties For it has been clear for many years that the
compounding the fact that more is being NHS cannot provide the best outcomes and
demanded of it. Already there is anecdotal experience for patients – and indeed cannot
evidence that some CCG leaders are becoming solve its own problems – alone. That message
disillusioned given the sheer scale and runs like a golden thread through the whole of
complexity of leading change in the current the Five Year Forward View.
NHS and social care system. Among those to whom Florence Nightingale
A survey conducted last year by this inquiry would also be looking are patients. And all
in conjunction with the King’s Fund, to which those on the outside would be looking back at
virtually every NHS trust replied, shows that a her for exactly the same reasons – given the
third of trusts either have vacancies at board growing realisation that the whole of health
level for key leaders, or they have (often highly and social care provision should become ever
expensive) interims in post1. The largest vacancy more interdependent if the best results, the best
rate is for finance directors and chief operating experience and best value for money is to be
officers – 20 per cent. The figure for directors of achieved in an inevitably cash-constrained
nursing was nearly as high. More than one in six environment.
trusts have no substantive chief executive and The NHS needs high quality leadership
almost one in six have no substantive medical within hospitals, mental health and community
director. The overall position is worst in mental providers, general practice and commissioning.
health trusts where 37 per cent have at least one But, just as critically, it also needs system
of these posts vacant or filled on a temporary leadership that works in partnership – across
basis, the same being true of a third of acute organisations and in places where there is no
hospitals. direct line management control – to construct
One in 10 trusts has retained the same chief the services that are needed.
executive in post for a decade. But the median This means the skills required by today’s
time in post for a trust CEO was a mere two and NHS leaders are very different to those in
a half years, while one in five had been in post Griffiths’ time; different even to those of 10
for less than a year. This remarkable level of years ago. “Command and control” and
“churn” is just another way of spelling “crisis”. A “protectionism” are no longer appropriate in an
host of academic and anecdotal evidence environment focused on integration. We need
supports the view of Nigel Edwards, the leaders capable of building partnerships and
Nuffield Trust’s chief executive, and of Ruth operating across institutions and sectors. This
Lewis, previously an associate at the King’s report suggests ways in which we can identify
Fund, that high executive turnover “has a and foster such leaders.
chilling effect on the willingness of chief Our key conclusion, and the one on which
executives to take bold initiatives and our recommendations are built: if leadership
encourages a passive and responsive culture”. within the NHS and across health and social care
NHS leadership is in crisis in another way. If is to be strengthened and successful, then the task
Roy Griffiths’ diagnosis was correct for its time, must be made more manageable, more attractive
it is equally true, as the King’s Fund remarked and more sustainable.
If leadership is to be strengthened and
successful, then the task must be made
more manageable, more attractive and
more sustainable
4 HSJ Future of NHS Leadership June 2015 hsj.co.ukThe causes of the crisis
The inquiry received a large quantity of written result in part of repeated reorganisations which
evidence and oral evidence from a wide range have seen too many experienced leaders leave.
of stakeholders. We discovered that there is: Consequent to that is the dilution of the
l A growing burden placed on those doing informal “mentoring” networks that supported
senior NHS jobs by regulation, inspection, younger leaders, again both clinical and non-
information demands, instant accountability to clinical, as they progressed. Despite the
a growing number of bodies, and performance l The impression that the NHS management
management – despite the 2012 reforms which, training scheme remains a good one but that rhetoric of a ‘no
in theory, were meant to dilute central
interference.
there is far too little continuing support after
entrants have, so to speak, graduated. blame’ culture,
l A marked tendency to move people or sack
them when problems emerge, rather than
l A widely held belief the NHS has too many
organisations and, as a result, too many chief
blame continues
seeking to understand and address the executive and other board level positions. This to be heaped
underlying issues. Despite the rhetoric of a “no means the NHS’s available talent is spread too
blame” culture, blame continues to be heaped thinly. on senior
on senior leaders for any perceived failure in
performance, contributing to the “churn”
l A difficulty in attracting system leaders
because of the sheer complexity of engineering leaders for any
described above.
l A cadre of people who operate well in
service change. Near the end of its tenure,
London Strategic Health Authority worked
perceived failure
second-tier leadership positions but who are out that the plethora of consultation and
reluctant to step into chief executive and other assurance processes applicable to service
board level posts, in part because of the sheer reconfigurations meant the minimum time to
exposure that comes with the job. achieve one, without a judicial review, was two
l An increase in the degree of political and a half years. Since then, the position has
exposure experienced by senior NHS leaders – worsened and created a daunting and
which, while always to be expected in a tax dispiriting prospect for many NHS leaders.
funded healthcare system, has now reached Those working on the proposed changes in
unsustainable levels. Manchester calculate that there are some 200
l A loss over the years of a “community” of assurance and consultation processes that need
managers, both clinical and non-clinical – the to be gone through3.
Clinical leaders
The inquiry also heard compelling and As Sir Duncan Nichol, the former NHS chief
consistent evidence about the difficulties faced executive, put it back in 2008: “If you have an
by clinicians entering NHS leadership. MBA in the States and you’re a doctor, people
A key characteristic of many of the most think you’re a sharp guy. Here they think, well,
successful healthcare organisations the world you’re a grubby businessman, a bit of a
over is their ability to collapse hierarchies, quisling, and it’s beneath you. The medical
flatten organisational structures and encourage profession in this country kind of abdicated its
clinicians to fill key leadership roles. leadership role in management to managers,
One of Sir Roy’s goals was to see more and then bitched about the result.”4
clinicians take up general management/chief One reason for a reluctance among clinicians
executive posts. One of his proudest accolades – both doctors and others – to take on the most
was being president of the now defunct British senior roles is that since the early 2000s they
Association of Medical Managers. face a “double jeopardy” when things go
Huge progress has been made in medics wrong, or are perceived to have gone wrong.
taking on the role of clinical directors. However, This danger persists even when subsequent
it is proving harder to get them to take the next investigation proves the clinical leader involved
step of being a medical director and even more was not to blame.
difficult to persuade them to move into chief Not only can such problems put their
executive posts, especially as doing so may leadership role at risk, they can face parallel
reduce their earnings potential. Equally, while and separate action from the General Medical
many nurses have entered management roles, Council, the Nursing and Midwifery Council or
too few other clinical staff have made the move similar professional regulators.
into key leadership positions. Clinical leaders can suspend their
We heard frequently that clinicians of all registration if they enter a managerial or
types are still seen by too many staff to have leadership role and cease to practise. But that is
moved “to the dark side” if they take on not possible for medical directors and chief
leadership positions. This problem is not new. nurses, where it is a condition of the job.
hsj.co.uk June 2015 HSJ Future of NHS Leadership 5The changing nature of the
NHS and its leadership
Leadership means the ability to direct the Many leadership roles in the NHS rely on
activities of a group towards a shared goal while personal influence and relationships at a local
coping with change. It concerns the alignment level. As our health and social care system
of an organisation’s workforce and operating evolves to have leaders who will sit across
procedures with its vision, values and objectives. multiple, geographically distributed locations,
Leaders create visions, management is about so must their “approach” to leadership style
implementing them. evolve.
The essential personal attributes of leaders For example, while several NHS chief
are IQ, experience and most importantly executives are active on Twitter, the potential
emotional intelligence. The first two speak for influence of social media in galvanising the
themselves, but emotional intelligence is more NHS workforce is underpowered. In addition to
ethereal. It can be defined as self awareness providing routes for rapidly sharing best
(knowing how we feel), self regulation (control practice, online networks also provide a
Autonomous of our emotions), empathy (how others feel)
and social skills (influencing and inspiring
means of connecting otherwise isolated leaders
to share their challenges and frustrations.
healthcare others). Supportive leadership means building
relationships with employees to increase
An effective online presence represents
position and influence in another dimension –
workers, positivity and motivation. one that is pervasive and growing; one that we
The literature is awash with definitions of believe will be a hallmark of future NHS
particularly leadership styles – transformational, leadership.
doctors, collaborative, shared and distributive, to name
but a few. Current leaders require skills across
The era of managing single NHS
organisations is coming to an end and future
respond badly all these dimensions to influence attitudes and
motivate performance beyond expectations.
managers will need to learn to influence across
primary and secondary care, as well as between
to authoritarian This is a significant challenge because health and social care in an increasingly
healthcare systems are as complex as they come. complex consumer driven environment.
leadership The NHS contains many powerful Leaders need to be the first to model
professional groups with associated subcultures collaborative behaviours and nurture
which are often in conflict. These groups come interdependency across these traditional
together in multidisciplinary teams with boundaries.
sometimes multidirectional goals. Autonomous The Five Year Forward View and the Dalton
healthcare workers, particularly doctors, report both challenge traditional NHS
respond badly to authoritarian leadership. organisational models and could lead to the
Leaders need to focus on creating the right creation of integrated and accountable care
environment for professional activity to thrive, organisations which may fundamentally change
within agreed professional standards and the NHS landscape and increase the repertoire
guidelines. of skills needed by leaders.
6 HSJ Future of NHS Leadership June 2015 hsj.co.ukRecommendations
In the course of our inquiry we heard many Equally, we have rejected suggestions for
suggestions for change. A large number some sort of “royal college” of NHS leadership.
involved culture change – for example, the age- Not least because one of our recommendations
old call for less “politicisation” of the NHS, is that the royal colleges collectively need to
although there were few concrete suggestions embed support for clinical leadership into
for how that might be achieved. However, it everything they do. A recently established
would be welcome if politicians could achieve Faculty for Medical Leadership and Appointing a ‘chief
cross-party agreement on how to avoid Management already exists and should be
becoming too closely involved in the encouraged in its work. Further separating patient officer’ or
management of the NHS.
Before setting out our recommendations, we
leadership out as something distinct from the
day to day activity of many NHS staff would be equivalent to the
should briefly address the propositions put to us
that we have rejected.
a retrograde step.
Our recommendations are presented in three
board of every
Patients clearly need to be much more linked groups. Together we believe they would NHS organisation
intimately involved in the design of current and make NHS leadership positions more
future services. But we have rejected the manageable, attractive and sustainable. would be tokenistic
suggestion that a “chief patient officer” or Most of our recommendations focus on
equivalent should be appointed to the board of developing senior leaders within the NHS –
every NHS organisation. That feels to us because this is where we believe the most
tokenistic, and begs the question of which sort immediate impact can be delivered. However,
of patient. Ticking a box that says “we have a many of the principles, beliefs and
patient representative” will not bring about the recommendations set out in our report can
close involvement of patients at all levels in enhance leadership development at all levels in
service design that is needed. the service.
Making system leadership
more manageable
1
Consultation and assessment of change The new government should urgently
Those who seek to make change across health institute a complete review of all
and social care organisations face daunting consultation and assurance processes
challenges in the consultation and assurance to produce something much simpler
process. Each reorganisation of the NHS has and swifter, while still allowing for
tended to build new requirements on top of the proper engagement with staff and the public.
old. Aside from formal consultation, there are This government review should also
the inequalities and other impact assessments introduce a requirement for all relevant bodies
to be done. Different assurance processes are involved in appraising specific service change
run by NHS England, the Finance and proposals to liaise during their deliberations.
Investment Group, Monitor and the Trust NHS England should coordinate this work to a
Development Authority. Despite the creation of strict timetable so that a decision which has the
health and wellbeing boards in which local support of all involved can be reached within
authorities are key players, reviews by local six months of the process beginning.
authority scrutiny committees remain. There Once an agreed single approach to
are clinical senates and the Independent consultation on, and appraisal of, changes has
Reconfiguration Panel. That list is not been reached, any decision referred to the
exhaustive and leaves aside the risk of judicial Department of Health should be accepted or
review. While each of these processes are well rejected within three months to prevent
meant, cumulatively they create multiple changes being kicked into the long grass for
barriers to change. That discourages innovation political or other unjustified reasons.
because of the unnecessary time, cost and effort
involved in overcoming them.
hsj.co.uk June 2015 HSJ Future of NHS Leadership 7Rationalisation of reporting and regulation Inspect system not silos
The current confused regulatory and oversight If system change is to be achieved, then system
regime has curtailed local autonomy. One prime regulation and inspection is needed – not just
example concerns foundation trusts. The entire inspection of individual silos of care. Again, we
rationale in creating FTs was to grant are aware that central bodies have begun work
managerial and financial freedoms to the best on how far it might be possible to inspect a
led organisations. Yet those liberties have been system of care – rather than its component
severely eroded. This trend must be urgently parts, therefore dealing with sometimes
reversed. conflicting demands that can be placed on
There is evidence from all sectors, not just organisations. This too needs to pursued
3
health, that leaders deliver better results when at pace.
they are trusted and subject to proportionate To give leaders clear line of sight, we
regulation, inspection and reporting recommend that NHS system
requirements. regulation be established by the year
In the NHS, the current burden has become 2017-18, with shadow running taking
too great and, despite improvements, it is still place during 2016-17. The review
insufficiently risk-based. It is not just the direct should also ensure an appropriate and
costs involved – the Care Quality Commission proportionate reduction in the inspection
alone has a budget of some £250m, for example burden placed on individual organisations.
– but the cost in clinical and managerial time to
those being inspected which must amount to at Reducing the number of organisations
least as much again. Failure to tackle the It is the inquiry’s view that there are too many
complexities of the current regulatory and separate NHS organisations given the talent
oversight regimes will have a continued available to staff them all at board level. There
negative impact on leadership, producing a are more than 200 CCG chairs, with a matching
defensive mindset that discourages innovation. number of chief officers. The boards of the 250
The Five Year Forward View acknowledges provider organisations typically have half a
the need for greater coordination of regulation dozen executive directors. To this total of
and of reporting requirements between the approximately 2,000 leadership posts must be
seven arm’s-length bodies that currently make added the significant number of senior
up “the top of the NHS”: NHS England, positions in the Department of Health and the
Monitor, the Trust Development Authority, the seven main arm’s-length bodies. One is drawn
CQC, Public Health England, Health Education to the irresistible conclusion that we are looking
England and the National Institute for Health for far too many leaders.
and Care Excellence. We are aware that this Some CCGs are themselves recognising the
work is underway, but it needs to be pursued problem and moving towards shared leadership
with greater vigour to rationalise reporting arrangements, a development we welcome. On
requirements, to better align targets, and to the provider side, however, there has not been an
provide the flexibility in regulation that will be effective failure regime for unsustainable
needed to achieve some of the system change organisations. This must be addressed, with a
2
called for in the Forward View. clear plan put in place for the 80 trusts which
All seven of the arm’s-length bodies have not yet gained foundation trust status. The
together with the Department of recommendations of the Dalton review, with its
Health should set out publicly what suggestions for chains or franchises – with
information they require from NHS leading trusts able to take over unsustainable
organisations. This should then be ones – can play a part here. However, we
reviewed for duplication, and to ensure the acknowledge the risk of successful trusts
requests are proportionate, relevant and spreading their management and leadership
4
necessary. A working group of senior NHS talent too thin.
leaders should sign off the final list. If the same By the end of July 2015 the Trust
data is required by more than one organisation, Development Authority should
it must be collected once and then shared. publish its assessment of which
NHS trusts are not sustainable in
existing form. The TDA, together
with NHS England, Monitor, the CQC and
Department of Health, should then identify two
groups of these “unsustainable” organisations
and offer the opportunity for leading NHS
organisations to formally take them over,
incorporate them into chains or to run them as
franchise operations. The resulting new
arrangements should be in place no later than
April 2016. This initiative should be taken
forward in line with the recently announced
decision to establish the first four nascent
foundation trust chains.
8 HSJ Future of NHS Leadership June 2015 hsj.co.ukMaking leadership more
attractive
6
End the denigration of NHS leadership Attracting more clinicians to take up
It is not acceptable, 30 years after the Griffiths chief executive positions in the NHS
report, that clinicians who enter management requires a more sensitive benchmark
and leadership roles can still be seen as having than the prime minister’s salary.
“gone over to the dark side”. Many world class A senior group of NHS leaders
hospitals in other healthcare systems take pride should be convened by NHS Providers and the
in the fact that their most senior leaders are NHS Confederation to recommend levels of
clinicians who recognise that they can do far
more for the “community” of patients in these
remuneration for chief executives with clinical
backgrounds which reflect career risk,
It is not acceptable,
roles. This is a cultural issue that itself requires
leadership, chiefly from the medical and other
experience and the type of organisation they
would lead. We would also encourage them to
30 years after the
royal colleges, the nursing and other unions explore the development of other incentives for Griffiths report,
and the British Medical Association. developing clinical leaders such as talent
In reality, these organisations all recognise management, coaching and mentoring (see that clinicians who
that clinical leadership and high quality
management is essential to the delivery of high
recommendation 11).
While we are not naive enough to expect
enter management
quality care. But they do not always behave as
such nor do they always encourage their
formal government backing for this, we would
expect it not to attack the proposals and for the
and leadership
members to recognise that. It is as much a BMA and medical royal colleges to offer their roles can still be
responsibility of the leaders in those support.
7
organisations as it is for politicians to eschew seen as having
small “p” political and populist attacks on
management and managers. Short term
We also recommend that clinical
excellence awards are overhauled to
gone over to the
headlines often result in irreparable damage to
those taking on leadership positions, the
reward leadership excellence as much
as clinical excellence. In addition to
dark side
organisations they represent and ultimately the incentivising medical and clinical
5
patients they serve. director roles, this would serve as a clear
We recommend that HSJ invites the acknowledgment that leadership is an integral
leadership of all the clinical unions part of the role of any senior clinician. A
and royal colleges to a workshop to separate and similar award should be
agree a “statement of principles” on considered for other clinical staff who show
how leadership and management in leadership excellence.
the NHS should be addressed in
communications and policy statements. The End ‘double jeopardy’ for clinical leaders
statement of principles – once agreed – would “Double jeopardy”, in which clinical leaders can
then be publicised, with HSJ and the signatories face not only disciplinary action by the NHS
policing adherence. and potential loss of their leadership role, but
also separate and parallel investigation from
Pay the best clinical leaders more their professional regulatory body, must be
8
As we have already stated, “clinical leadership” tackled.
is not synonymous with “medical leadership”. This is a sensitive and difficult issue.
Nevertheless, we recognise that there are Plainly by their management and
specific barriers which prevent medics taking leadership actions – refusing to
on senior leadership roles. The most obvious is acknowledge problems, burying
remuneration. Someone with a substantial them, requiring that unacceptable
private practice can face a serious loss of practices continue for financial or other reasons
income if they become a full-time clinical and – a clinician can do as much if not more
managerial leader. It is not ideal that NHS damage to patients as in a strictly clinical role.
leaders should be paid different rates for the When that has clearly happened, action by
same job, which will be a challenge in tackling their registration bodies is justified. But the bar
this issue, but it is the world in which we live for investigation and action by the General
and the issue needs to be addressed. Medical Council, the Nursing and Midwifery
The number of board vacancies identified by Council and the other professional bodies needs
our research will continue to increase and the to be set at a reasonable height. An independent
quality of leadership will degrade if government-appointed review should be
remuneration for the top jobs in the NHS is undertaken across the professional bodies to
suppressed. Essentially you get what you pay address the issue of double jeopardy. The
for and inappropriate restraint on reward will review should be completed by June 2016.
result in fewer people aspiring to leadership
positions and poorer candidates for interview,
especially clinicians.
hsj.co.uk June 2015 HSJ Future of NHS Leadership 9Making leadership more
sustainable
A requirement for management and Identifying and supporting potential
leadership training leaders
The service’s management and leadership One notable, and in truth downright
training schemes have, like so much of the embarrassing, facet of NHS leadership is its
NHS, been undermined by repeated lack of diversity. Partly in terms of gender but
The NHS has reorganisation. The NHS Leadership Academy
now has a good suite of courses, aimed both at
most notably in the remarkably few members of
the black and minority ethnic communities who
rightly been clinical and non-clinical staff, that in some
cases lead on to formal qualification. Some
occupy senior leadership positions. The NHS
has rightly been accused of having a “snowy
accused of having organisations, though too few, also offer white peak” that reflects neither the ethnic mix
impressive training and accreditation. of society as a whole, nor that of its own
a ‘snowy white Training needs to emphasise the skills now workforce. If anywhere should be an equal
required of leaders, including emotional opportunities employer, then it should be the
peak’ that reflects
10
intelligence and the ability to connect across NHS. This is an issue the NHS must tackle.
neither the ethnic organisations. It should draw on the best
practice from sectors outside the NHS – in local
As part of the “minimum
requirement” for
mix of society as a government and the third sector, for example, management and leadership
both of which have a deep interest in system training set out above, NHS
whole, nor that of leadership – while also looking to the private organisations should be
sector where organisations in the developing required to demonstrate active searching for,
its own workforce digital economy have pioneered new non- and encouragement of, black and minority
hierarchical ways of working. These behaviours ethnic entrants to management and leadership
should be actively used in the appraisal of all positions.
NHS leaders, including those with clinical
9
backgrounds. Learning by doing
We recommend that the NHS While we believe training is important, the
Leadership Academy be allowed to acquisition of leadership skills is also through
continue its current work but working alongside those who are already
with greater coordination – not a leaders. It should no longer be acceptable for
takeover – of the good work being leadership and management training to involve
done in trusts. simply being sent on a series of courses. The
11
The Leadership Academy should develop a NHS needs more apprentice leaders.
“minimum requirement” for management and We therefore recommend the
leadership training which all NHS Leadership Academy,
organisations should achieve. This requirement nationally, and individual
should become part of the judgment that the NHS organisations working
CQC makes when it decides whether an together across local health
organisation is “well led”. We would also look to and care systems, develop a more formal
the NHS Confederation, NHS Providers and the approach to identifying potential leaders;
royal colleges to encourage their members to instigating a greater degree of talent
provide leadership training for all relevant staff. management and succession planning than is
Although we ask the Leadership Academy to currently available. Developing leaders should
play a significant role, it is just as important be buddied with contemporaries and provide
that individual NHS organisations be highly mentoring from experienced leaders.
proactive in developing leadership at all levels. Those taking up their first chief executive
To create momentum in this area, and to post should, in particular, be given a well
establish best practice, leading NHS structured and extensive support package
organisations should be encouraged and during their first few years.
incentivised to offer their leadership and All chief executives and board directors with
management training programmes to others at least five years’ experience in the role should
within their health economy. These should be required as part of their annual appraisal to
develop into regional centres of excellence demonstrate they have provided active
within the national framework set by the mentoring to a less experienced counterpart in
Leadership Academy. their or another organisation.
More on the
inquiry and NHS
leadership at
hsj.co.uk/
future-leadership
10 HSJ Future of NHS Leadership June 2015 hsj.co.ukBuilding leadership into the clinical References About the panel
curriculum 1 Leadership vacancies in the NHS, The
Undergraduate clinical training as it now King’s Fund and HSJ Future of NHS Sir Robert Naylor is chief executive of
stands produces individuals with a strong sense Leadership Inquiry 2014, University College Hospitals Foundation
of belonging to their profession. This is right www.kingsfund.org.uk/publications/ Trust, a role he has held since 2000.
and proper and to be encouraged. But the leadership-vacancies-nhs
inquiry firmly believes that sense of kinship 2 The Practice of System Leadership: Stephen Dorrell is a former health secretary
with a profession must be matched with a sense Being Comfortable with Chaos. The and chaired the House of Commons health
of belonging to the NHS as an institution King’s Fund 2015, www.kingsfund.org. select committee in the last parliament. He is
comprised of specific organisations. It is rare uk/publications/practice-system- now a senior advisor to KPMG, which has
for a newly qualified clinician to have an leadership been contracted to deliver some of the
understanding of the environment in which he 3 Ruth Carnall in The Practice of System programmes commissioned by the NHS
or she will be discharging their duties. It is Leadership: Being Comfortable with Leadership Academy.
equally rare for these individuals to have any Chaos. The King’s Fund 2015,
formal grounding in leadership. www.kingsfund.org.uk/publications/ Sir Sam Everington has been a GP in Tower
Other sectors would make sure new recruits practice-system-leadership Hamlets since 1989. He is chair of NHS Tower
entered the workplace with a real 4Rejuvenate or Retire: Views of the Hamlets Clinical Commissioning Group and a
understanding of the organisation they are NHS at 60, The Nuffield Trust 2008, board member of NHS Clinical
working for, its priorities and the context within www.nuffieldtrust.org.uk/publications/ Commissioners.
it operates. rejuvenate-or-retire-views-nhs-60
An element of “system knowledge” needs to Richard Lewis is partner and health leader at
be built into clinical curriculums in an engaging EY. Prior to joining EY, Richard was a senior
way, along with an early understanding of what fellow at the King’s Fund and led the health
is involved in leadership. This should not team in the prime minister’s delivery unit.
simply be a classroom presentation of
12
organisational structures and funding flows. Dame Gill Morgan is chair of NHS Providers.
We recommend that Health She started her career in healthcare as a
Education England, the doctor, before moving into management. She
General Medical Council, and was permanent secretary of the Welsh
all other regulatory bodies for Assembly government between May 2008
clinical professions come and August 2012.
together to ensure that graduates have a grasp
of how the NHS functions, and develop an Dr Emma Stanton is associate chief medical
understanding that they will need to lead officer at Beacon Health Options and chief
managerially as well as clinically as their career executive at Beacon UK, which works with
progresses. the NHS to improve mental healthcare. She
spent almost 15 years as a psychiatrist at
South London and Maudsley Foundation
Trust.
Professor Laura Serrant is professor of
community and public health nursing at
Wolverhampton University. She is currently
Final observation
on secondment to NHS England, where she is
head of evidence and strategy in the nursing
directorate.
Claire Read is secretary to the HSJ Future of
Our final point is not a recommendation but a NHS Leadership inquiry and a regular
deliberately challenging observation. Sir Roy contributor to HSJ. She has written about
Griffiths’ report quite rightly destroyed the healthcare since 2000.
consensus management of its day. But
paradoxically we need to go back to a different Nicholas Timmins is the author of the HSJ
version of that idea. Not one where everyone Future of NHS Leadership inquiry’s final
has a veto, but a version in which we build report. He is a senior fellow at the King’s
system leaders who recognise that the best Fund and was previously public policy editor
outcome for patients may not always be the one at the Financial Times.
that is in the interests of their own organisation,
– or indeed, in the short term, themselves – and
then engineer the consensus that allows that to
happen. In that sense, we need to go back to the
future. It is an enormous challenge. But it is the
one that everyone in the NHS who has any
claim to leadership has to address. l
hsj.co.uk June 2015 HSJ Future of NHS Leadership 11FUTURE OF NHS LEADERSHIP
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