Greta McLachlan: How to navigate the NHS towards good leadership?

Leadership skills are still neglected among clinicians, says Greta McLachlan, and the NHS is the worse for it

The NHS employs approximately 1.3 million people in the UK, making it one of the largest employers in the world. Similar employers in terms of scale are the United States Department of Defence, the Chinese People’s Liberation Army, Walmart, China Railway, and McDonald’s. Approximately 2% of the British population work in the NHS. Put in this perspective, it’s easy to see that the NHS is a behemoth of an organisation. It is a juggernaut—and a glacial one at that.

Matt Hancock, while addressing the King’s Fund about his vision for improved leadership in the NHS, recently commented that Mcdonald’s “is nowhere near as important as the NHS . . . Yet they start leadership training at shift manager level. They drive leadership training through every level of their company.” He went on to highlight the need for more leadership training within the NHS and the need for more tech specialism within leadership. He emphasised that while people from a black or minority ethnic (BME) background make up 40% of hospital doctors, they fill only 7% of executive roles and called for more diversity of leadership. All good things then.

However, Hancock’s speech only paid lip service to Sir Ron Kerr’s review Empowering NHS leaders to lead, which came out the same day. This report found that bullying and discrimination are “prevalent and accepted” in the NHS and that some leaders “do not feel confident that speaking out would make a difference.”

Depressingly to those who work in the NHS, these are not surprising findings. We have all seen at least one boss, one manager, and one colleague who encapsulates these failings. While it is not everyone, it is ubiquitous.

How did we get to this situation? How is it that one of the world’s largest employers, which deals in compassion and care for its patients, has created such a toxic work environment for its employees? Suzie Bailey, director of leadership and organisational development at the Kings Fund, writes that “NHS leaders face a near toxic mix of pressure with widespread staffing vacancies, significant financial and performance challenges and a common culture of blaming individuals for failures beyond their control.” The average tenure of an NHS CEO is three years, which creates a change in captains more often than governments. This does not breed stability or the ability to learn from mistakessomething else Hancock called for.

In a post Francis report world, it is well established that a lack of or poor leadership leads to poor clinical outcomes. The Kerr report points to how this is exemplified in CQC ratings. Of those trusts with outstanding ratings, only 3.3% per cent had vacant executive posts. Those with inadequate ratings? It climbed to 14.3%. There are currently 20 unfilled CEO positions within the NHS. That’s 20 NHS trusts without a rudder to steer them. No wonder there is immense pressure on those left standing.

When clinicians are engaged in leadership, trusts have higher quality outcomes for patients. But at present leadership and management skills do not come as standard in either pre or postgrad medical curriculums. Of 25 medical school institutes asked, only 12 had formal evaluations for leadership training. A survey of 400 junior doctors found that 97% thought leadership and management training was important, but fewer than 50% felt they had their seniors’ support in trying to implement change. Leadership, while identified as a must for clinicians, is still neglected.

With his call for action on leadership training, Hancock is not trying to discover a brave new world. This call has been echoed for at least 10 years under consecutive governments. And in that time, numerous leadership initiatives have been introduced, including the London Leadership Academy, clinical schemes at the Faculty of Medical Leadership and Management, the Clinical Executive Fast Track Scheme, the Developing People – Improving Care framework, and GMC guidance on leadership and management skills, as well as NHS leadership competency frameworks, to name but a few.

Yet despite all this, in last year’s NHS staff survey almost a quarter of staff reported being bullied, harassed, or abused over the previous 12 months. And how many of the top positions were occupied by doctors? A survey carried out by NHS Providers in late 2017 found that of the 129 chief executives they had data on, only 9% were medically qualified.

Perhaps we are at that moment of slight disconnect that comes with sea changes. The change is coming but it’s still being trained. Maybe the NHS is having its #MeToo realisation: we’re starting to recognise that bullying and discrimination are not the marks of good leaders and that if we stand together, preferably with a hashtag (#hammeritout), we can change the culture of leadership in the NHS. But it will take everyone, from CEO to janitor to nurse to student, to make it happen. If we keep allowing toxic leaders to steer the ship, we will never make land.

Greta McLachlan is a general surgical trainee currently working at The BMJ as the editorial registrar. Twitter @geemclachlan

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I am on the National Medical Director’s Clinical Fellow scheme, which is mentioned in this article.