Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Why aren’t more doctors NHS chief executives?

BMJ 2019; 365 doi: (Published 09 April 2019) Cite this as: BMJ 2019;365:l1627
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic
  2. davidoliver372{at}
  3. Follow David on Twitter: @mancunianmedic

Last month, Susan Gilby joined a small band of doctor CEOs in the NHS acute sector when she was confirmed as chief executive of the Countess of Chester Hospital.1 Other names on this small list include Jackie Bene at Bolton,2 Marcel Levi at University College,3 David Rosser in Birmingham,4 and Tim Orchard at Imperial College.5 Their CVs make interesting case studies. Even executive medical directors rarely make the jump to CEO.

We see more doctor CEOs outside the hospital sector, but it’s still a small minority. NHS Providers found that only a third of NHS CEOs had clinical qualifications, 63% of whom trained as nurses, but only 19% as medical doctors and 15% as pharmacists or allied health professionals.6

Better results

Just before Gilby’s appointment was announced I attended a lecture where Amanda Goodall, of City University of London, discussed the rationale for more clinically led organisations.7 She and her research colleagues have found that, across several sectors including hospitals and healthcare systems,8 organisations led by technical experts—with training and experience in the sector they’re leading, who understand the business intimately—generally deliver better results.9 Her work with 300 hospitals in the US found that those led by doctors, on average, outperformed those led by managers.10 More generally, there’s a growing consensus that clinically led teams and organisations are better able to meet challenges around quality, improvement, and safety.1112 After all, clinicians are the biggest payroll cost, they make the decisions that use resources, and they develop the evidence base, innovation, guidelines, and education to drive practice.

But operational and strategic management require a different skill set from those traditionally taught in medical training. No one’s suggesting that simply having clinical training and credibility is sufficient to become a competent senior manager or executive. But I bet it’s easier to select clinicians who show an aptitude for management and give them the right development and training than to give managers from a non-clinical background a deep understanding of the service they’re managing—and credibility with patient facing clinical staff.

The NHS certainly has, in my career, invested in giving doctors middle and senior management roles as clinical directors or clinical commissioning group leads, although the amount of development on offer in these roles still varies. There’s also a well worn path from nursing into management, hence the far higher number of CEOs and very senior NHS managers who qualified as nurses. It’s hard for a nurse or allied health professional to progress to higher salary bands and remain in clinical practice. And practitioner-manager roles such as ward sister or charge nurse give nurses an early experience of responsibility for large staff teams and budgets and are a stepping stone to pure management roles.


NHS Providers6 and the Faculty of Medical Leadership and Management (FMLM)13 have both produced reports on the benefits of medical and clinical leadership and the barriers and enablers for doctors entering senior management and executive roles. Barriers include doctors’ identity being wrapped up with ongoing clinical practice and a reluctance to stop seeing patients. Another is a suspicion of pure executive roles—their exposed accountabilities, the perceived difficulty in returning to clinical work, a lack of confidence and training in the required competencies, and concerns about relations with medical colleagues in a culture that’s traditionally been one of being equal peers.

The FMLM, health think tanks, and university departments offer leadership and management development programmes for doctors, as increasingly do individual organisations and NHS regional networks. The NHS Leadership Academy offers a wide range of support.1415

In many overseas health systems it’s normal for senior healthcare executives to be doctors. Those populations may be surprised to hear that career managers tend to call the shots in the NHS—right up to NHS England and NHS Improvement or the Care Quality Commission, despite the expert clinical advisers in their ranks.

Many of the overseas health systems we would like to learn from have medical leadership from top to bottom, with clinically defined processes, standards, outcomes values, and accountabilities. In the NHS, however, managerialism over clinical leadership has been rife since deliberate decisions taken after the Griffiths review into NHS management during Margaret Thatcher’s government.16 We have a big culture of centrally dictated performance management, based on regulatory metrics and cost containment.

In such a system, perhaps the people who do understand the business are career managers. Perhaps, for more doctors to enter the boardroom, they need more say in defining what real quality looks like.