The announcement of the Messenger Review triggered some immediate concerns. The service has been subjected to a string of leadership reviews over the last decade. The initial media briefing, attributed to ministers, came across as unfairly critical of current NHS leadership. And there were worries about the potential for unhelpful distraction at a time of huge operational pressure. But the review brings a vital opportunity we must not miss. Because there are four areas of growing consensus on where the NHS can improve its leadership capability and capacity.
The review brings a vital opportunity we must not miss.
First, most large systems offering a national service through multiple local delivery arms – for example, supermarket chains and banks – invest heavily in a robust, rigorous, consistent approach to leadership development at all levels. This approach is planned and methodical, deliberately exploiting opportunities of scale. Leaders are equipped not just with the right skills, but also the right developmental experiences, to be outstanding. As part of this approach, those systems take a proactive approach to talent management. Deploying leaders, in a planned way, to roles that match their skills and experience and where they are needed most. Ensuring leaders are tested in a range of different environments with a robust identification of resulting strengths and development needs. Accompanied by rigorous assessment of capability for promotion and investment in linked, supportive, development.
Although it has begun to improve of late, the NHS' approach has been more fragmented with a strong focus on individual organisations securing the best talent for themselves. That echoes the strong emphasis on competition between trusts in the 2012 Health and Social Care Act. But the NHS is, rightly, moving to collaboration across integrated health and care systems as its key organising principle. Our approach to leadership needs to reflect that shift.
We don't have the right incentive and support structure to ensure that some of our best leaders are consistently attracted into the most difficult jobs
Second, we don't have the right incentive and support structure to ensure that some of our best leaders are consistently attracted into the most difficult jobs where their skills are needed most. There are many reasons why a number of trusts have been challenged for long periods of time. They are often grappling with a range of complex structural problems. These include challenging service configurations across multiple, geographically distant, sites; deprived populations with high health needs; remote geographies that are hard to recruit to; and long-running financial issues that have led to significant capital under-investment.
It's much too simplistic to pretend that these challenges can be spirited away by changing leaders or importing leaders from outside the sector. But that doesn't change the basic principle that the most challenged trusts will need some of the strongest leadership teams and high and consistent support from national leaders. And that the NHS should organise itself accordingly.
Third, the review needs to ensure greater diversity in NHS leadership. We still have far too many snowy white peaks. The data clearly shows that it is too difficult for colleagues from ethnic minority backgrounds to progress to leadership roles. We need a consistent approach to tackle the systemic, structural, barriers that exist in the NHS, as they exist in society as a whole. It is depressing and frustrating when right wing commentators attack the NHS when we invest time and resource to address those barriers. But that must not deter us.
We need more planned mid-career routes for clinicians who want to move into management and for successful general managers from other sectors.
Fourth, the NHS doesn't offer sufficient mid-career lateral entry routes into NHS general management. We have a strong Graduate Management Training Scheme. But we need more planned mid-career routes for clinicians who want to move into management and for successful general managers from other sectors. Managers from other sectors won't immediately become trust chief executives or chief operating officers on joining the NHS. But effective, mid-career, lateral entry could create a bigger talent pool that could lead to those roles over time.
The review must also avoid concentrating on just the chief executive and most senior leadership community. We need to build leadership capacity and capability at all levels. One of the most consistent pieces of feedback NHS Providers gets from our board development work is that failure to develop a strong middle management team pulls board leaders into the operational day to day, as opposed to the more strategic, where the board should be operating. And the review also needs to focus on how we create the compassionate and inclusive culture, and emphasis on making the NHS a great place to work, set out in the NHS People Plan.
Unlike supermarket and bank chains, the NHS is not a single organisation. It's a system.
The review offers the potential to address all these issues. But recognising the unique NHS context will be vital. Because, unlike supermarket and bank chains, the NHS is not a single organisation. It's a system. The majority of NHS leaders, numerically, sit in 212 trusts and foundation trusts. They will shortly be joined by integrated care board (ICB) leadership teams. For the last 20 years those trusts have been the key unit of organisation for the delivery of secondary care services where the majority of NHS staff are employed, and the majority of its budget is spent. That's the right unit of organisation given the size, complexity and risk involved in delivering those services, as the current Health and Care Bill confirms. Unitary trust boards are accountable for all that happens within their trust. And you can't hold a board accountable if it can't appoint its own leaders, given that quality of leadership is one of the single biggest determinants of success.
So the review must marry a more planned and systematic approach to NHS leadership with the reality of unitary trust, and ICB, boards with appropriate autonomy. Past interventions show that, to avoid a report that sits on the shelf unimplemented, local leaders must genuinely co-create the proposed approach. There is appetite for improvement. The review must harness that appetite and avoid any sense of top-down imposition.
This blog was first published by HSJ.