Intended for healthcare professionals


“Crisis” in NHS leadership needs urgent action, says Institute of Healthcare Management

BMJ 2016; 354 doi: (Published 22 July 2016) Cite this as: BMJ 2016;354:i4113
  1. Matthew Limb
  1. BMJ Careers
  1. limb{at}

Urgent action is needed to tackle a “leadership crisis” in the NHS and bring down barriers that deter would-be leaders from rising through the ranks, a report by the Institute of Healthcare Management has concluded.

A survey by the institute, an independent membership organisation for health and social care managers, found that aspiration to top level NHS positions remained high among management and leadership trainees. But many were being put off by “unrealistic demands” and believed that they wouldn’t be empowered to make change even once in post.

In the report the institute said, “It is fair to suggest that measures to address the leadership crisis will be akin to rearranging the deckchairs on the Titanic unless the overall leadership offer can be made more attractive.”

Shirley Cramer, the institute’s chief executive, said, “Above all, we need to empower and back those who are the future of health and care leadership to be the change they so passionately want to see in the system, rather than making them terrified of failure.”

Many top level NHS posts were unfilled, and trusts were operating a “revolving door” of senior staff, said the report. A third of NHS trusts had vacancies for key leaders at board level or interim people in post, and the average tenure of an NHS chief executive was only two and a half years. One in six trusts had no substantive chief executive and the same number had no substantive medical director.

The institute said that it was no surprise that leadership positions had become “less attractive” amid rising financial pressures, perceptions of a “blame culture,” the burden of regulation, and increased political exposure. Many talented “second tier” leaders were unwilling to step into the firing line, it said.

The report examined what effect the current NHS leadership crisis was having on the next generation of healthcare leaders and what could be done to overcome barriers. It was based on an online survey of 111 students in health and care management and leadership courses across the United Kingdom, including official NHS leadership programmes, and focus group interviews.

The research found that two thirds of respondents aspired to an executive board level position, while the remainder said they did not or were unsure. Among those targeting top positions the vast majority (92%) said that they were motivated by a desire to implement change.

But a “significant minority” (41%) did not think that they would actually be empowered to do so. Of those who were either unsure or did not aspire to fill top executive posts, 74% saw the biggest deterrent as the “unrealistic demands” of delivering services with currently available resources.

The institute said, “This suggests that top level health service jobs are simply regarded as too challenging in the current climate to be attractive to many.” However, only 24% cited high turnover and vacancy rates as significant deterrent factors. This group was also asked what factors could potentially motivate them to change their mind and pursue an executive board level position.

Most respondents (53%) wanted more freedom to innovate and implement change in these posts, and 50% hoped for a “less hostile political and media environment for NHS leaders.” Only a minority of trainee managers (29%) thought that there was a clear pathway for progression to executive board level.

Half of trainee mangers said that health and care leadership did not reflect the diversity of the workforce. Only 15% said it was as easy for black and minority ethnic managers to reach top posts as it was for their white counterparts.

Cramer said that taking on a senior role in the current climate was a “daunting task” and that the leadership crisis should not be seen as a problem only for the present. “We should be thankful so many aspiring professionals are up for the challenge,” she said. “However, to bring through the very best, we need to do what we can to make the leadership offer more attractive.”

The institute recommended that more should be done to “acclimatise” aspiring leaders early in their careers as to how they could implement meaningful change, with “less tendency to blame and more freedom to constructively fail.” Stronger emphasis should also be put on developing the “soft” political skills needed to lead in the current climate, it said.