It's Good To Talk

Would the NHS benefit from a single, identifiable leader? An email conversation

BMJ 2003; 327 doi: (Published 18 December 2003) Cite this as: BMJ 2003;327:1421
  1. Don Berwick, president1 (,
  2. Chris Ham, director2,
  3. Richard Smith, editor3
  1. 1Institute for Healthcare Improvement, Boston, MA 02215, USA
  2. 2Strategy Unit, Department of Health, London SW1A 2NS, 3 BMJ, London WC1H 9JR
  3. 3BMJ, London WC1H 9JR
  1. Correspondence to

    Would an identifiable leader of the NHS solve all of its problems alone or overnight—or is that magical thinking?

    The NHS suffers from having no single, identifiable leader

    Richard Smith, editor of the BMJ, writes: Britain's national health service, one of the world's largest public sector organisations, is highly unusual in not having a leader. Most organisations—and certainly all major corporations—have a leader. Tony Blair is the leader of Britain. Greg Dyke leads the BBC, and that huge organisation, which is comparable in some ways to the NHS, has changed dramatically since Dyke took over from John Birt. One of the best ways to change an organisation is to change its leader. This is not a cult of personality. But it does seem to be important—perhaps simply because people prefer people to abstractions—to have somebody who embodies power and accountability.

    So who is the leader of the NHS? One immediate problem is that there are four NHSs—in England, Scotland, Wales, and Northern Ireland. Who then is the leader in England? Is it Sir Nigel Crisp, the chief executive of the NHS in England and also permanent secretary in the Department of Health? If he is the leader, then he's exercising a uniquely anonymous form of leadership. I doubt if one doctor in 50 could identify him.

    If there is a leader of the NHS in England then it's the secretary of state for health. Unfortunately, however, secretaries of state feel like the leaders of an occupying power. The relationship between a doctor in the NHS and the secretary of state is like the relationship between an Indian villager and the viceroy of India in the 19th century: these are far away people with different sets of values. Few doctors, I suggest, would regard the secretary of state as the leader of the NHS.

    We need lots of leaders at all levels in the NHS, not a single leader

    Chris Ham, professor …

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