An independent group of the brightest minds in healthcare has put forward a new plan for how to solve the crisis in NHS leadership.
In 2013 – 30 years after the seminal Griffiths Report, which introduced general management to the NHS – HSJ commissioned an inquiry into the future of NHS leadership, inviting Sir Robert Naylor to chair it. A ‘child’ of the Griffiths reforms and one of the leading health service managers of his generation, Sir Robert is the chief executive of University College London Hospitals NHS Foundation Trust.
With an inquiry panel containing some of the most respected names in healthcare, the inquiry heard evidence over 8 months, from leading experts including senior figures from national policy bodies; thought leaders and academics; patient leaders and advocates; clinicians; and leadership experts. They also considered wider viewpoints gathered through a public call for evidence.
The inquiry panel includes Stephen Dorrell, chair of the House of Commons Health Select Committee 2010-2014; Sir Sam Everington, chair of Tower Hamlets Clinical Commissioning Group; Richard Lewis, partner and health leader at management consultants EY; Dame Gill Morgan, chair of NHS Providers; Professor Laura Serrant, professor of community and public health nursing at Wolverhampton University and Dr Emma Stanton, associate chief medical officer at Beacon Health Options and chief executive at Beacon UK.
Conclusions of the Inquiry
Thirty years ago the landmark Griffiths Report replaced consensus management, where there was effectively no one in charge, with one person accountable for management and leadership at every level of the NHS. This has stood the test of time contributing to today’s NHS being one of the most successful in the world. But our analysis, having consulted all the leading opinion makers in the NHS, is that leadership is currently in crisis. One in three Trusts have vacancies at Board level and one in five hospitals don’t have a Finance Director. The average lifetime of a CEO in the NHS is 2 ½ years.
So why is this the case? These jobs are pretty difficult – a CEO in the NHS does essentially the same as in any other walk of life, but in an ever-changing political landscape where every problem is, quite rightly, subject to public scrutiny. Previous attempts to bring in private sector management have consistently failed and recent criticism of the excessive costs of management consultancies.
Public demand, demographic change, new technology and financial constraints all add up to a toxic mix of competing demands. Added to this is the need to move from institutional management to system leadership, working across boundaries between health and social care, between the public and private sectors.
Key recommendations
Firstly, the Inquiry believes that the leadership challenge should be made more manageable. The NHS has multiple consultation and assurance processes meaning that urgent changes, particularly in the current economic climate, become virtually impossible to implement because of the conflicting interest of multiple parties.
Inquiry recommendation: The new government should urgently institute a complete review of all consultation and assurance processes to produce something much simpler and swifter, while still allowing for proper engagement with staff and the public.
Secondly, the NHS has far too many fragmented organisations with bureaucracy built layer upon layer. The NHS has failed to find sufficient leaders for all these organisations and repeated restructuring has meant losing capable leadership at regular intervals.
Inquiry recommendation: Through the organic reduction of the number of NHS organisations, the current leadership talent pool can be spread more evenly and operate more effectively.
Thirdly, unlike many other healthcare systems, we have failed to get clinicians to take on leadership positions because we denigrate and understate its importance. The professional bodies need to come together to support clinicians to take on these responsibilities rather than refer to them ‘going to the dark side’. Effective organizational leadership is an essential platform for individual clinicians to deliver the best care to their patients.
Inquiry recommendation: An agreed ‘statement of principles’ on how leadership and management in the NHS should be addressed in communications and policy statements. In addition the report recommends incentivizing clinicians to take up leadership roles, which should include the correct remuneration package.
The independent inquiry and its recommendations are aimed at addressing these challenges.
Sir Robert Naylor, chief executive of University College London Hospitals NHS Foundation Trust, said:
“There is no doubt that we are currently facing a crisis in NHS leadership – the inquiry heard extensive evidence of this, and it is backed up by research into high level vacancies conducted as part of our work. There is also no doubt that the skills required by today’s NHS leaders are very different to those required by previous generations: we need leaders capable of building partnerships and operating across institutions and sectors.
“We firmly believe that the first order of business in addressing the crisis and these new needs will be to make the task of leadership more manageable, more attractive and more sustainable. We suggest that remuneration will be central to that, particularly in addressing the long-stated desire to increase the number of clinicians in leadership roles.
“I believe that the recommendations of this Inquiry are fundamental in securing the excellence in leadership that the NHS needs and deserves for future generations to come.”
Richard Lewis, partner and health leader at management consultants EY
“The Five Year Forward View has set out a clear path for the future of the health service. However, for its vision to become a reality we will not only need strong leadership, but also leadership of a different kind to that which we’ve seen in the past.
“The days of leaders just focusing on their own organisations have gone. We need our future NHS leaders to have greater diversity and to increasingly work as part of broader health and care systems with an emphasis on delivering change collaboratively.
“Transparency about which NHS trusts are not sustainable in their existing form is also vital so that we can really begin to implement new care models across local health economies.”
The evidence for a crisis in leadership
• A survey conducted last year by this inquiry in conjunction with The King’s Fund, to which virtually every NHS Trust replied, shows that a third of trusts either have vacancies at board level for key leaders, or they have (often highly expensive) interims in post.
• The largest vacancy rate is for finance directors and chief operating officers – 20 per cent. The figure for directors of nursing was nearly as high.
• More than one in six trusts have no substantive chief executive and almost one in six have no substantive medical director. The overall position is worst in mental health trusts where 37 per cent have at least one of these posts vacant or filled on a temporary basis, the same being true of a third of acute hospitals.
• One in 10 trusts had retained the same chief executive in post for a decade. But the median time in post for a trust CEO was a mere two-and-a-half years, while one in five had been in post for less than a year.
About the Inquiry
Between August 2014 and March 2015 the inquiry held a series of meetings at which they 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 wider viewpoints gathered through a public call for evidence.
Inquiry members
• Chair: Sir Robert Naylor, chief executive of University College London Hospitals NHS Foundation Trust
• Stephen Dorrell, chaired the House of Commons Health Select Committee 2010-2014
• Sir Sam Everington, chair of Tower Hamlets Clinical Commissioning Group
• Richard Lewis, partner and health leader at management consultants EY
• Dame Gill Morgan, chair of NHS Providers
• Professor Laura Serrant, professor of community and public health nursing at Wolverhampton University
• Dr Emma Stanton, associate chief medical officer at Beacon Health Options and chief executive at Beacon UK