Cassandra Cameron: The NHS must support more clinicians into senior trust leadership roles

Compared to other national healthcare systems, the English NHS has relatively fewer chief executives with a clinical background. While clinical expertise is not a prerequisite for success in the role, research has shown a strong clinical voice helps keep a trust board focused on safety, patient experience, and quality improvement.

At a time when over a third of trusts have at least one vacant executive director role, the NHS needs to do more to encourage and support those with clinical expertise into executive leadership positions. Leaders with clinical experience can help reinforce a trust’s ability to “hold the line” on quality, as they know from experience how short-term financial or operational efficiency imperatives can undermine quality, damage staff morale, and cost more in the longer term.  

Clinician to chief executive: Supporting leaders of the future, a joint project between NHS Providers and the NHS Leadership Academy, sheds light on what encourages clinicians to see NHS executive management positions as viable and appealing. Despite the challenges identified for clinicians aspiring to NHS management roles, a third of current NHS trust chief executives do have a clinical background: two thirds from nursing, one fifth are doctors, and the remainder are pharmacists and allied health professionals. Their backgrounds are diverse—nursing, radiology, paediatrics, haematology, and psychiatry to name a few. These are people to learn from and who can serve as role models to others.

Through a survey and 13 case studies we explored what clinically-trained trust chief executives consider valuable about a clinical perspective in their role, the career path they followed, and their advice on how to attract more clinicians to follow their example. Their responses consistently reinforced the message that making a positive impact for large patient populations, and for staff, provides the biggest personal reward, and biggest challenge, of their work. They also recognised there are barriers to clinicians entering senior management roles which must be addressed.

The challenges of maintaining professional practice are a valid concern. Amongst our survey respondents, 79% of clinically trained chief executives are no longer practising since becoming a chief executive, primarily due to a lack of time and limited exposure to patients or clinical practice. However, almost 50% of chief executives with a clinical background have retained their professional registration. Those who are still registered are mostly specialised in nursing (59%), followed by medicine (36%), and pharmacy (5%). The different professional requirements around revalidation may, in part, explain why a higher number of nurses remain on the register compared to doctors.

Chief executives who are still practising still welcomed the opportunity to undertake regular shifts when they can schedule it effectively with their CEO duties, shadowing their full-time clinical staff and visiting wards where they can be involved in directly delivering care to patients in their professional speciality. This was clearly a valuable aspect of the role for them, helping to put the pressures they face into perspective and to remind them of the value of their work.

How do we build a pipeline of clinicians aspiring to NHS leadership positions? There is a clear need to give clinicians experience and training in NHS management much earlier in their career. Respondents suggested that a clinician’s ability to lead a healthcare organisation will benefit by gaining real “on the job” experience—spending time with a range of chief executives leading NHS provider organisations, expanding the range of roles they work in throughout their career. Diverse experience will build their knowledge and abilities to develop innovative solutions and learn how common problems can be solved in different ways. Formal mentorship/mentoring opportunities for senior clinicians with NHS chief executives could also help provide insight into the demands of executive management.

Finally, with an average tenure of three years and 7% of NHS chief executive positions currently vacant or filled by an interim, the NHS must develop pathways for clinicians who desire to return to practice after their tenure as a chief executive. The high vacancies amongst executive directors in key strategic roles such as operations, strategy, and finance—where many clinical chief executives broaden their managerial experience before stepping up—must also be recognised as a sign that these roles are becoming too complex, and seen as a risky by clinicians. Until the NHS demonstrates a more visibly supportive approach to chief executives in the most demanding and challenged positions, the role will fail to develop broader appeal.

Our research suggests it is time to promote the value and reward that a clinical background brings to performance as an NHS trust chief executive. Foremost among these is an understanding of what matters most to patients, their loved ones, and staff—helping them lead organisations that can “hold that line” under pressure. NHS Providers and the NHS Leadership Academy and are currently exploring how best to do this and to provide more opportunities for clinicians to become future NHS leaders.

Cassandra Cameron is a policy advisor at NHS Providers.

Competing interests: None declared.