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The NHS sets leaders up to fail – and then recruits more in the same mould

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Too often, leaders in the NHS are remote and isolated. Photograph: Lucas Veuve/Getty Images

It’s my job to support and develop senior NHS managers. And I’m deeply worried that we’re setting them up to fail – then recruiting more in the same mould.

I’m a former primary care trust director; I now work as an executive coach, helping NHS executives to improve their skills. Many of my clients lead trusts whose leadership has been deemed “inadequate” or “requires improvement” by the Care Quality Commission – but few of them are genuinely bad leaders. The problem is that they were hired to do one job, and the requirement is now for something quite different. Yet they’re not being helped to change their approach, and when their trusts run into trouble they are being replaced with people likely to encounter exactly the same set of problems.

Most of these leaders were hired to lead foundation trusts at a time when NHS providers were being encouraged to compete with other trusts for business; to invest in new services; to develop their own organisations at the expense of other providers. To make use of the freedoms granted to foundation trusts – including the ability to borrow money at commercial rates – they hired leaders with commercial, transactional and financial skills: hard-edged, competitive businesspeople who could expand their market share.

But then the environment changed. Trusts were – quite rightly – put under greater pressure to improve service quality and patient safety. And demand rose much more quickly than budgets, so the tariffs paid for trust services were cut year after year. Soon, many new services were struggling to repay the investments made in them. In a world of shrinking revenues, those skills in business growth suddenly looked out of place.

Meanwhile, health system leaders began pushing a new agenda – one built around collaboration between organisations, professionals and sectors. To protect healthcare nowadays we need people to work together, rather than to compete: the emphasis is on building services around the patients’ needs, rather than the providers’. The Sustainability and Transformation Plans and the Five Year Forward View create a need for leaders who have emotional intelligence; who are approachable and listen to their staff; who put the public’s needs above those of their trust; who can share power and responsibilities with other organisations. And in that context, the skills and approach of many NHS leaders look hopelessly outdated.

Too often, leaders are remote and isolated. Poor links between ward and board mean that board members often remain unaware of emerging problems. To deliver great care, you need your staff behind you – but we’ve spent years recruiting empire-building business leaders who have no feel for the kind of hands-on, visible leadership required.

The characteristics once seen as assets have become liabilities

We end up with chief executives who find themselves receiving a lot of criticism, and being pushed out – creating huge damage to their careers and reputations. But it’s the system that’s let them down, not them letting down the system. Nobody’s given them the right advice or development or challenge, and the characteristics once seen as assets have become liabilities.

Unfortunately, trusts’ recruitment practices haven’t changed to reflect the need for a new kind of leader – so when these more commercial, transactional managers fail, trusts are too often replacing them with new figures cut from the same cloth. Many trust chairs are still stuck in an empire-building mindset; job descriptions focus on financial and operational experience; and recruiters are often cynical about the softer skills required for staff engagement and partnership working. So the trusts select new managers well-suited to facing the challenges of five years ago, and organisations head off towards a fresh set of failures.

What’s to be done? For a start, trusts need to refresh their recruitment practices – taking their cue from NHS Improvement’s new leadership framework, and shifting away from a narrow focus on technical competences towards a values-based approach. The solution is not simply to swap our existing leaders for a new set. The NHS cannot afford to lose a swath of senior managers. Many of these people could develop the skills we need, we just need to help them to do so. After all, we require doctors and nurses to refresh their skills regularly, revalidating their qualifications; and these days, the disciplines of management and leadership are changing just as fast as medical practice.

It’s hard for senior leaders and managers to reflect, train and change their approach. Most already work 60 hours a week, and seeking new skills is too often seen as a confession of weakness or incompetence. But this is a nettle we must grasp. For many of our senior leaders are ill-suited to the task in hand. If we are to serve the interests of NHS organisations, staff, leaders themselves and, above all, patients, we must reshape our leadership cadre – equipping it to understand and address the vast new financial and organisational challenges facing the NHS.

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