Leadership: Delivering the impossible

The UK NHS (National Health Service), like healthcare in other countries, is a complex system. It is one of the largest employers in the world – some NHS Trusts employ around 20,000 staff and have a turnover of more than £1 billion. The NHS is not a single organisation – there are many parts that make up the NHS.  However, these components do not operate as separate entities, they are interconnected and work together as a system. This creates challenges for those that lead these organisations.  

Set up to fail?

Healthcare leadership - humanfactors101.com

Incident investigations, across all industries, often conclude that individuals were “set up to fail” – perhaps by poorly-designed equipment, unworkable procedures, conflicting priorities or other human factors issues. These individuals are usually at the sharp end of the organisation – those in the direct line of fire – such as refinery technicians, airplane pilots, train drivers or nurses.

However, we must also consider that organisations can set leaders up to fail. This is suggested by the subtitle of a recent report on leadership by The King’s Fund: “Delivering the impossible”.  On reading the report, you could understandably question whether senior leadership roles in the NHS are still “do-able”.

“We have created something that is almost impossible to manage. Even if God was to run the NHS he would struggle”

(Lord Prior of Brampton, a current NHS Trust chair and former health minister). 

So, what does the “impossible” look like?

  • Unrelenting financial and operational pressures (44 per cent of NHS Trusts are in deficit)
  • Patient waiting-time performance standards are not being met
  • Increased regulatory burden and the burden of information requests
  • Unprecedented media and political attention
  • Increasing complexity of the health service system
  • Structural changes have created a lack of clarity on accountability and a dilution of decision-making (i.e. leaders not being able to lead).

Senior leadership roles in the NHS are complex roles in complex organisations.

“The combination of prolonged austerity, increasing demand for services and growing shortages of clinical staff has created a near-toxic cocktail of pressures for senior NHS leaders. This is starting to take a toll both on those currently in leadership positions and on future leaders aspiring to these positions”. 

The blame game: Delivering the impossible, with little forgiveness

In recent years, several Chief Executives and directors have been removed from their posts due to financial or performance. A culture of blame and negativity continues to thrive in the NHS. Individual leaders are feeling more personally exposed if targets are not met (despite the ‘impossible’ task that they face). The rhetoric of a “no blame” culture is not preventing blame from being assigned.  

“We need to feel safe and nobody feels safe. Everyone is looking behind them and just waiting for the axe to come down”

(NHS Trust Chief Executive)
Healthcare leadership - humanfactors101.com

If we simply blame a single leader when the ‘impossible’ cannot be delivered, then we risk others not wanting to put themselves forward to take on the challenge of leading these organisations.  The culture of blaming individual leaders for failure makes these roles less attractive. Potential candidates are not applying for senior roles in the NHS because the risk of ‘failing’ is so high and there appears to be little tolerance of failure.  

“Removing senior leaders from their roles for failing to manage the unmanageable plays a huge part in putting potential leaders off taking senior jobs”.

Could this be why eight per cent of executive director posts in the NHS are either vacant or filled by an interim appointment?  And why 37 per cent of all NHS Trusts have at least one vacant post for a Board-level executive?

A recent review of leadership by NHS Providers stated that the culture of regarding CEOs as wholly dispensable is damaging to individuals, to organisations and the reputation of the wider NHS.

Leadership – but for how long?

Research shows positive links between how long senior leaders remain in post and the performance of the organisations they lead. It is also evident that transitioning into a Chief Executive role takes some time, for example to develop an understanding of the culture and the wider system in which the organisation operates.

However, the average length of tenure of a CEO in an NHS Trust is just 3 years. This impacts on the focus of the leader, but also impacts negatively on the culture, as perceived by front-line staff. The picture is worse when looking at all executive directors – the average tenure for all substantive executive directors was found to be only two years.

The negative impacts of such leadership churn include strategic paralysis, a loss of organisational memory, diminished credibility of leaders and lack of staff engagement.

“You can see paralysis in the organisation: an absolute lack of decision-making and an absolute lack of progress”

 (NHS Trust Chief Executive)

Short term leaders have little incentive to address poor performing staff (which can be an extended process) and so poor-quality care may be tolerated by the organisation. The eventual impacts of poor leadership in the healthcare environment are on patients. 

Not only is the length of tenure a concern, more than half of the substantive NHS Chief Executives were in their first Chief Executive role.

The ‘inverse leadership law’

The King’s Fund report discusses the ‘inverse leadership law’ – those areas of the NHS having the most significant performance challenges experience higher levels of leadership churn and have the shortest leadership tenures. ‘Special measures’ apply when Trusts have serious problems and there are concerns that the existing leadership cannot make the necessary improvements without support. The average tenure of a Chief Executive of an ‘outstanding’ NHS Trust was more than seven years, compared with just eleven months for the Chief Executive of a Trust in ‘special measures’.

These are exactly the organisations that would benefit from stability and leaders that are supported. Unfortunately, these organisations enter a vicious circle, where they experience a high level of leadership turnover because they are challenged, and they are challenged because they have a high turnover

A lack of diversity

NHS leadership is not diverse in terms of background, experience, gender or minority representation. The senior leadership does not reflect the wider workforce, or the communities they serve. For example, only seven per cent of senior leaders are from a black or minority ethnic background. Due to the enormous pressures on the NHS, recruiting organisations are being more risk-averse when considering candidates, adding to the problem. 

The proportion of men and women in executive director roles is roughly equal; however, women tend to hold Chief Nurse and human resources director roles, rather than senior financial roles. There are multiple glass ceilings.

This lack of diversity can support ‘group think’ – reaching a consensus decision without considering alternative courses of action or evaluating contradictory views.

Moving forward

Increasing the number of clinicians in leadership positions is one option, but successful senior leaders require much more than clinical experience. The changing nature of the NHS landscape and widening boundaries requires leaders to adopt a systems approach. The need for leadership of ‘systems’ rather than individual institutions has become more crucial. Is the training of future leaders keeping pace with the organisational changes?

One option adopted in some NHS organisations is for an inward-facing Managing Director; allowing the Chief Executive to be more strategic and focus on wider stakeholders. Other Trusts have rotated aspects of director’s portfolios, increasing perspectives and networks, whilst maintaining interest and motivation.

There has been substantial progress in developing NHS leaders of the future, and in building greater national and regional support for existing leaders. With the significant organisational changes and the associated challenges of senior leadership roles, regional talent management can help to build context and perspectives. However, talent management must not stop when people leave the ‘leadership pipeline’ and take up a senior role – support for leaders must be ongoing. 

Creating networks that provide experience from other organisations will provide support during difficult periods. Positive and collaborative relationships with external partners, building a shared understanding of roles and challenges, will also assist. Evidently, the NHS needs to improve how it learns from both successes and failures. Never before has a focus on people, leadership and culture been so important for the delivery of healthcare. 

However, these initiatives will have little impact unless the wider system and culture is addressed. Performance challenges, rising demand and workforce shortages are widespread throughout the NHS. Removing individual Chief Executives and other senior leaders from their posts should not be the default position during difficult times. Focusing on individuals will not address the root causes of under-performance; the wider human factors and organisational issues also need to be managed. 

Back to the subtitle of this report – ‘delivering the impossible’ – what can reasonably be delivered by even the best NHS leaders?  Fundamental changes are required to address funding, workforce and structural challenges in the healthcare system. Focusing on a few key leaders struggling to deliver in extremely challenging circumstances prevents the real learning and continuous improvement that is needed. 

Leadership in today’s NHS: Delivering the impossible, published by The King’s Fund, 2018.  The King’s Fund is an independent charity working to improve health and care in England.  http://www.kingsfund.org.uk

Other articles on Leadership:

Nimrod XV230: Parallels with healthcare

What can you learn from the Nimrod disaster?

Ten questions on organisational failures

Buncefield, 11 December 2005

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