Intended for healthcare professionals


Executives are “not in tune” with how doctors feel about NHS

BMJ 2014; 348 doi: (Published 21 May 2014) Cite this as: BMJ 2014;348:g3461
  1. Matthew Limb, freelance journalist, London, UK
  1. limb{at}

NHS boards are “not in tune” with how doctors and other clinical staff feel about their organisations and how they view key components of compassionate care, analysis by the King’s Fund has found.1

The think tank said that it was particularly worried by the “lack of consensus” found on facets such as openness, honesty, and the ability of staff to raise concerns effectively.

“The disconnect between the views of executive directors and other staff, especially nurses and doctors, is cause for concern,” said Nicola Hartley, director of leadership development at the King’s Fund. “Creating truly compassionate patient services requires collective leadership, where all staff take responsibility for the success of the organisation and this is actively promoted by leaders in the organisation.”

The fund has published a survey of NHS staff alongside two reports on collective leadership,23 and it argued that NHS boards should make developing collective leadership a priority. Some 2000 NHS managers and clinicians were questioned in February and March 2014 about leadership, care, and culture. Just over half worked in acute organisations, the rest in mental health, community, commissioning, and primary care settings. The most notable finding, said the King’s Fund, was a “consistent discrepancy” between the views of executive directors and those of other staff, especially doctors and nurses.

Respondents as a whole were split on whether their organisations were characterised by “openness, honesty, and challenge,” qualities deemed central to compassionate cultures of care demanded by, among others, Robert Francis QC’s inquiry into failings in care at Mid Staffordshire NHS Foundation Trust. The same proportion, 39%, agreed as disagreed with the statement.

However, responses varied “significantly” between job roles. Though 84% of executive directors believed that their organisation had such characteristics, only 37% of doctors and 31% of nurses did.

Executive directors in the survey were much more “positive” than other staff about their working environment and culture. Some 63% of executive directors believed there to be a sense of “pride and optimism” among staff, but only 23% of doctors and 20% of nurses thought this was the case.

There was also a notable difference in the way staff saw their ability to raise concerns about how organisations were providing services. Nearly all (94%) of the executives and 79% of senior managers said they could do this, the proportion falling to 66% of doctors and 57% of nurses.

Senior managers were more confident than clinical staff that, when concerns were raised, they would be dealt with appropriately. However, a noticeable proportion of executive board members (16%) did not think that swift and effective action was taken to deal with inappropriate behaviour and performance. Overall, 43% of respondents shared that view.

The King’s Fund said that there has been “clear improvement” over the past year in how NHS staff viewed the quality of leadership in the NHS. In 2014 22% of staff thought the quality of leadership in the NHS was “good” or “very good,” compared with 14% in a previous survey on leadership carried out by the fund in 2013. While in 2013 40% of staff regarded the quality of leadership as “poor” or “very poor,” only 28% did so in 2014.

In the 2014 survey 37% of respondents rated quality of leadership in their organisation as “good” or “very good,” the same proportion as in 2013. A large majority of staff (89%) thought that feedback from patients was encouraged where they worked, and 61% thought that this feedback would be acted on.

The King’s Fund said that the survey painted a “mixed picture” of leadership and compassion in the NHS and showed that NHS boards were “not in tune with how staff are feeling about their organisations.” However, respondents did provide examples showing how compassionate care was being developed, including through training and supporting staff.

Hartley said, “It is important that NHS organisations engage in dialogue and debate to achieve a shared understanding of the challenges they face and what the solutions are.”

Norman Williams, president of the Royal College of Surgeons, commented, “It is important that when problems emerge clinicians and managers do not bury their heads in the sand and so become guilty of passive inaction. Early and effective action to address concerns before the quality of patient care deteriorates is crucial.”

The reports make the case for action to improve leadership, described as “the most important determinant of the development and maintenance of an organisation’s culture.” Produced by the King’s Fund and the Centre for Creative Leadership, the analyses focus on boards’ responsibilities to develop a strategy for “collective leadership,” described as “everyone taking responsibility for the success of the organisation as a whole—not just for their own jobs or work area.” The reports said that this contrasted with traditional approaches to leadership, which have focused more on developing individual capability.

Collective leadership required continual learning, said the reports, and “high levels of dialogue, debate and discussion to achieve shared understanding about quality problems and solutions.” They said, “Understanding culture alone is insufficient; conscious, deliberate attention must be paid to enabling people at every level within the organisation to adopt leadership practices that nurture the cultures the NHS requires.”

The reports argued that, for healthcare organisations to be good places in which to work and to receive compassionate, high quality care, their cultures must genuinely value, support, and nurture “the front line,” and, among other things, achieve high staff engagement at all levels, a strong connection to the organisation’s shared purpose, promote and value clinical leadership, and ensure transparency, openness, and candour.

Williams said, “This report rightly highlights that all staff have a responsibility for the success of an organisation. Leaders must work with their staff to encourage and support a culture in which concerns can be raised openly, safely and in a timely manner.”