Leaders in the NHS

On Tuesday Matt Hancock released a research paper on empowering leaders in the NHS and provided his own “vision” of that. Did the two versions coincide? No. Both recognized that the culture of the NHS was a problem but neither had a credible solution. The Secretary of State’s vision is to broaden the pool from which leaders are drawn whereas Sir Ron Kerr’s analysis revealed the key problem as excessive bureaucracy arising from the superstructure of the DHSC, top NHS management and its 26 or so quangos. Constant questioning and interference from on-high makes the job of any leader in #OurPreciousNHS nigh impossible.

Matt Hancock wants more diversity in top NHS management: more clinicians, women and ethnic minorities. There are a couple of problems with this vision. Converting good doctors and nurses, of which the NHS is short, into decent managers, of which the NHS has a surplus, can only makes the problems worse. Furthermore there is no evidence that clinicians, women or ethnic minorities are intrinsically better leaders than their male white non-clinician counterparts. The NHS needs the best leaders for the toughest of jobs, not stereotypes. Hancock has lost the plot..

The armed forces and most large firms identify the characteristics of their currently successful leaders, search without prejudice for more of the same in the younger generation and then provide them with pathways to senior roles. There is no shortage of research in this area but it seems to have been overlooked. Both papers, however, make the important point that the NHS leadership employment borders should be porous, i.e. promotion to leadership should not just for NHS lifers but be open to those who have shown leadership in other areas.

It is open to question whether young doctors should be seen as the main source of future leaders at all. Research published last month claims: “The movement towards developing medical students as leaders has to be contrasted against the fact that high school exam performance and academic achievement continues to be the primary basis for selection to medical school. Not surprisingly, the smart kids are studying medicine. Unfortunately, there is a person–job mismatch between the initial skills that allows an individual entry to medical school and what the job will actually entail. For example, higher levels of intelligence are associated with less effective leadership styles.”

Sir Ron Kerr was asked to address three issues:

  1. “the expectations and support available for leaders - particularly in some of our most challenged organisations;

  2. the alignment of performance expectations at the organisational and system level; and

  3. the level of administrative burden placed upon executive leaders.”

Apparently although the performance of a hospital correlates closely with its leadership, the Care Quality Commission (CQC) “has not tackled the three specific issues looked at in this review.” Presumably it has been too busy ticking boxes.

Kerr’s report begins “The NHS must empower leaders to lead, encouraging them to celebrate their successes and learn from their mistakes. In reality, a culture of blame and negativity continues to pervade the NHS.”

It is quaint that leaders are appointed but not empowered: the root of this problem, as noted above, is the high level of interference, questioning and micro-management from above. The only solution offered is to have the NHS Regional Managers (the immediate bosses of hospital and Clinical Commissioning Groups) sit in on the leaders’ management meetings. The distinction between leaders and managers is not addressed nor how this would work with the subordinates looking to the Regional Managers as a higher authority.

One of the few areas where Hancock’s speech and Kerr’s report coincide is converting the culture of the NHS from cover up to transparency. Yes of course we should all learn from mistakes but there is a big difference between small administrative error and patients dying. The only other UK major employer that has a similar problem is the MOD and yet they have many great leaders within the armed forces. Both cause the wrong people to die and both have a cover-up culture in consequence.

In short, Hancock and Kerr have identified the problems but not the solutions. The Secretary of State could make a start by getting rid of the absurd superstructure of the NHS, the DHSC and its quangos. The NHS should be divided into manageable, NHS Scotland-sized, units. Calling for transparency when serious mistakes are made, and thinking this will lead to anything other than litigous action rather than real learning, is probably wishful thinking. Some other means of learning need to be found and that requires serious thought, not platitudinous sound bites.