Compassion and rhino skin: could you be an NHS executive?

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Written by Chris Lake on 23 January 2017

Operating at the most senior level in the NHS can be a very lonely and demanding business. ‘Top jobs’ are highly pressured in any sector, but our chief executives and their senior teams are also dealing with unprecedented regulatory pressures, severe financial constraints, enormous public scrutiny and a predatory media that seems to enjoy bashing the bureaucrats rather than celebrating the public servants.

Consider today’s pre-requisites for the top jobs: politically astute and commercially savvy, underpinned by steely determination and bolstered by personal resilience of rhino skin proportions. You’ll also need to draw on the knowledge, skills, attitudes, behaviours and experience in the multi-agency, uber-complex system that is today’s health and care landscape. You must be caring, compassionate, patient-focused and sensitive to legions of staff too.

And that’s just the personal stuff. Think about the workload! Capacity planning and bed management, safety and quality assurance, super-complex budgeting, financial monitoring on a large scale, performance measures, a punishing and often unsupportive regulatory regime… Unsurprisingly, I know many highly intelligent and capable people who have lost the desire to move onto the next level into executive board roles because they feel that what’s expected of them just isn’t possible.

Chief executive roles are easier to get wrong than right

In short, executive director jobs, and especially chief executive roles, are easier to get wrong than right. The more senior the role, the less it reflects the values and experiences many of us joined the NHS for. The other risk is that the pressure of today’s executive positions demands an increasingly narrow range of personality traits in the people courageous enough to carry them out. I blogged recently about pressure in the NHS system and the resulting necessity for resilience as a character trait.1 This is worrying, because as we move from a strategy that encourages executives to focus on ‘my organisation’ towards sustainability and transformation plans (STPs), shared budgets and system-wide care, we’re going to need people who can engage and build alliances with a wide range of professionals and across organisational boundaries.

There’s much talk of ‘talent management’ across the NHS right now: the establishment of regional talent boards, talent pipelines and talent pools to identify, develop, fast-track and place those with potential into top jobs. It’s hoped that better talent management will increase the numbers of people putting their hands up for top jobs and so bolster executive and chief executive recruitment shortlists, reduce the number of vacancies and roles filled with interim directors, and lengthen the average tenure of an NHS chief executive beyond 30 months.2

I’m all for the wise identification of talent and I support the nurturing of those identified so they can grow into capable leaders of decent, values-led organisations. However we must be careful not to over-focus on talent management as the universal cure. It is, after all, a strategy; a set of processes to push people through a talent pipeline - pushing anything up a pipe can causes blockages!

‘Culture eats strategy for breakfast’ is the insightful cautionary counsel often mis-attributed to Peter Drucker (by the way, if strategy is what culture has for breakfast, I’ve always wondered what it has for lunch and dinner?  I suspect for lunch it dines on bureaucracy, and for dinner it devours ‘good intentions’). A decent culture, with doable jobs where people are rewarded and respected for their contributions, would encourage more people to take on the most senior roles in our health system. If talent management is the ‘push’, then a nurturing culture with rewarding and doable jobs is the ‘pull.’

It’s never been more imperative that we support leaders

It’s never been more imperative that we support leaders across the entire health and care system. Not only do they have a difficult job to do in their own organisations, they’ll also be expected to build new relationships and shape new ways of working by engaging, empowering and exciting staff and communities across and beyond organisational boundaries.

There’s certainly demand for more support. The first cohort of the Leadership Academy’s Aspiring chief executive programme received 66 applications for just 14 places in the first cohort. So far, successful participants have:

  • Listened to some valuable and frankly gritty reflections from an ex-chief executive about how to build resilience in adversity and how to remain optimistic about the future in very difficult personal circumstances.
  • Developed two new relationships: a patient partner (a service user with a long term condition) and a reverse staff mentor (a junior front line worker) both of whom have helped the aspiring leader to solidly connect with the real - shop floor and frontline -  purpose of the NHS.
  • Had an open, honest and frank discussion about the CEO role of provider trusts in the emerging landscape of systems leadership and accountable care organisations with Jim Mackey, chief executive of NHS Improvement.
  • Tested their approaches with David Sloman, chief executive at the Royal Free London NHS Foundation Trust, drawing on his years of experience leading a trust with an enviable track record in performance, culture and reputation.
  • Formed a network of deeply supportive relationships to draw on, because, to update the old adage: ‘when the going get’s tough, the effective call on their friends’.

Five of the 14 have already secured chief executive roles before the one-year programme has finished.

The fact that many ways of working are exhausting for today’s executives and unfit for tomorrow’s health service presents an area of tension that NHS colleagues will have to navigate for some time. In the meantime, however, our programmes are there to help.




About the author

Chris Lake is head of professional development at the NHS Leadership Academy.


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