We are in danger of putting off a generation of leaders

11 May 2016

The job of a chief executive of an NHS trust should be one of the most sought-after roles in the public sector. But, as our new report with The King’s Fund reveals, the NHS trust CEO role is in danger of becoming so difficult that far too few are able to succeed in it and far too few will therefore aspire to it.

We asked 12 CEOs – among some of the most experienced leaders working in the NHS – to tell us how life as a CEO has changed during their lengthy careers. Most of the CEOs were either towards the end of their careers or about to retire. Between them, they have over 250 years of experience, and all have been at the forefront of significant changes to the ways in which health care is delivered.

We wanted to get their thoughts on the overall strategic, policy and delivery environment and how it impacts on their role as a provider trust CEO.

Between them, the CEOs reveal first hand just how all-consuming the job of running an NHS trust is these days. CEOs and their colleagues are being squeezed by regulation, inspection, targets and form filling – all in the context of the longest running financial squeeze in the NHS’ history, rapidly growing demand, and increasing patient expectations.

Reading the interviews in a chief executive’s tale, you get a palpable sense of just how much more hostile the operating environment is for leaders running trusts today compared to five, ten or fifteen years ago. Many of the CEOs interviewed described a gradual erosion of autonomy, increasing grip from the system leadership, and ever present regulation and oversight.


CEOs and their colleagues are being squeezed by regulation, inspection, targets and form filling – all in the context of the longest running financial squeeze in the NHS’ history, growing demand, and tough performance targets

Some CEOs described how they left their positions following critical inspection reports from regulators. The sense of loss of high quality leaders from the service as a result of this oversight is marked; not to mention the damaging impact on the individuals themselves. No one is arguing for an absence of accountability but the interviews pose real questions about whether our current system has the accountability framework set on the right way.

There may be limited sympathy in some quarters for the CEOs interviewed in our report – after all, they are well remunerated and lead some of the most powerful institutions in the NHS. But that would be a mistake, especially when you consider the likely implications for the next generation of CEOs.

We know that more and more trusts are struggling to recruit to their top roles, and many are increasingly relying on interims to fill CEO positions. The average tenure of a CEO has fallen to under three years and, anecdotally, we hear of an increasing reluctance among executive directors to aspire to the top position.

If we do not get to grips with this problem we are in danger of putting off a generation of people from wanting to become CEOs in future. This cannot be good for patients or taxpayers. And I have always believed that one of the best success measures of any system is the strength of the pipeline for its most senior leadership positions.

Quote mark We cannot afford to adopt a Premier League football club approach to sacking leaders and replacing them in a relentless cycle of boom and bust – this simply does not work

So, what can we do to improve the status quo? First, we should do much more to support CEOs running our hospital, mental health, community and ambulance trusts. We need to recognise they have some of the most difficult jobs going and that they deserve and need our support as they grapple with some world class problems in the full glare of the media and public spotlight.

Specifically, we need to restore some of the support systems that were in place for many of the CEOs interviewed for our report when they were starting out. As Sir Robert Naylor and Angela Pedder said, we need to spot emerging talent and find ways of supporting and nurturing them as they embark on the journey to becoming a CEO. At no time will this be more essential than when inexperienced CEOs encounter difficulties for the first time or when CEOs are asked to turnaround trusts facing big challenges.

We cannot afford to adopt a Premier League football club approach to sacking leaders and replacing them in a relentless cycle of boom and bust. Moving leaders on because they “fail”. Encouraging someone to fill their shoes, promising them support. Then heaping totally unrealistic expectations as soon as they arrive in post, triggering another “failure”.

At NHS Providers we are going to play our part by upping our support to leaders, particularly through working with NHS Improvement under its new leadership to help leaders survive and thrive in today’s more hostile environment. We’re proud, for example, to have created a development programme with NHS Improvement and NHS Leadership Academy for aspiring CEOs. The first cohort of 14 has already produced its first permanent CEOs and we are about to run an assessment centre to identify the second cohort of 14. This sits alongside a new programme run by the same partners to support newly appointed CEOs.

With the majority of trusts in deficit we understand the temptation to resort to top-down ‘grip’, but this needs to be gradually rowed back so that we once again put our trust in CEOs and their colleagues to deliver the most effective, high-quality and efficient care to their patients and local communities

As well as providing support to CEOs, policy-makers also need to restore freedoms and autonomy to Trust CEOs that enable them to get on with the task in hand – with a proportionate amount of oversight and regulation. With the majority of trusts in deficit we understand the temptation to resort to top-down ‘grip’. But, in the end, it can only be local provider Boards who lead the process of improving the care provided to their patients and local communities.

At a time of growing concern about vacancies in top leadership positions in the NHS, we hope our report with The King’s Fund will spark debate and discussion on the CEO role and what we need to do to nurture and protect leaders. Not just for the current crop but, crucially, for the next generation too.



The chief executive's tale is available to download from The King's Fund website.