When it’s time to go, is there anywhere for me to go? By Sue Holden

Leadership within the NHS has never been more critical. The need to support staff, remain resilient to the ongoing operational challenges create space to develop services which are locally responsive and inclusive are all pre-requisites for organisational success. However, for every leader there is also the need to know when it is time to move on, and the system can make that easier (or harder) to recognise and to act on.

All organisations go through periods where certain styles of leadership are needed to address the issues prevalent at a certain time in an organisation’s journey. In the early 2000’s there was much discussion around the type of leaders the NHS produced and those seen as successful were invariably of the ‘pacesetting’ type. In the literature, and in an era of competition and marketisation, this was seen as a style which ‘drove’ change, set clear objectives and managed delivery to tight timeframes. The downside is that this style of leadership, whilst applauded by regulators leaves staff exhausted, disengaged and inevitably ‘done to’ rather than ’done with’, and often makes the cross-organisational boundary working on which all health care depends harder not easier.

Cometh the new dawn. We now want leaders who can collaborate, include, engage, and enable. So, what happens to the previous incumbents of these very difficult roles, whose success and style was forged in a different era? It appears they have three options: retire, reinvent, or resist. It would be much better if we actively considered how we ensure that we do not lose the experience and wisdom of these individuals and align them to organisations where this style of leadership is needed, albeit for a defined period. If we are really serious about managing our NHS talent, then surely, we need to have an adult conversation and recognise the twin truths of “horses for courses” and that “timing is everything”? In my experience of supporting our most challenged NHS organisations the skills, knowledge and style of leadership required at the start of a recovery journey rarely are the same as those needed to create steady state and indeed accelerated improvement.

An additional challenge is the current interest in creating ‘group’ structures and what this means for aspiring CEOs who want to secure their first positions. Historically many new CEOs’ first destination organisation would have been a small local hospital. Now, with the advent of ‘groups’ these opportunities are diminished. Developing innovative and supportive processes where we recognise the talent, aspiration, and limitations of the environment we have created, requires thinking differently.

Developing a different contract with our CEOs where we can use their expertise and knowledge, gained over a career span whereby moving on is not seen as failure, could be a way of also re-energising a group of colleagues who do not always feel respected or appreciated for the roles they deliver and the contribution they make.

Is it time to start to create managed career breaks and career shifts for our most senior leaders? We could enable them to make way for the needed change, for others to come through and to allow them to refresh and deploy their talents in a useful, open and transparent way. So, are we able to consider ‘managed careers’ where active support, coaching and sponsorship means that our CEO’s do not need to ‘leave’ but are rather moved pro-actively where their skills are needed. Some would say this happens already, and indeed it does but without openness and overt appreciation for the talents these individuals have. And it does so unreliably: when it happens successfully it’s because of luck and individual efforts rather than as a standard process and expectation of how things are done. It’s worth noting that rotating leadership and deployment of senior leaders to specific contexts and tasks is absolutely standard in many industry sectors and organisations much smaller than the NHS.

A story: an organisation in SoF4[1] had a CEO who had all the skills and abilities to create a solid foundation built on process, accountability, and management, leading to increased confidence from the regulator. However, once those building blocks were in place this approach became stifling of innovation and started to feel ‘over-managed’ by other talented leaders within the organisation. It was time for a change in leadership, but the CEO didn’t want to leave ‘under a cloud’. The organisation needed someone with a more engaging, warmer and more open style. In sum, the organisation now needed ‘some loving’ and nurturing so that they could move into transforming. If another role had not come vacant at the right time and the CEO hadn’t been successful in getting a new position, many of the gains would have been lost—because they weren’t going to leave of their own accord, and it wouldn’t have been appropriate at all to dismiss them, so the space for a new CEO to move into post would never have materialised. The insight of the Chair ensured that the transition was positive and that the new CEO ‘fitted’ the different needs of the organisation at that time.

Isn’t it time for the NHS to start considering its cadre of senior leaders as its own ‘ecosystem of success’, taking a more active role in supporting deployment in a managed way?

I recognise that in writing this I will provoke different responses. But I consider that as we face some of the most challenging of times in our NHS we need to ensure that we maximise the utilisation of the skills and talents of our CEOs while at the same time supporting them to have maximum benefit to our patients by deploying their talents where they will have the most benefit and impact.

[1] SoF4 is the regulatory category given to the integrated care systems and organisations with the greatest level of challenge in the NHS in England


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Sue Holden

Sue has worked in the NHS for over 40 years. Sue trained as a nurse, then midwife and worked clinically for over 15 years before developing her interest in OD and learning. Sue worked as an Executive Director in a Teaching Trust before becoming an Improvement Director for NHSI in 2015. Sue then worked 5 years with Trusts in Quality and Financial Special Measures, and from 2019 – 2022  as NHSE, National Director for Intensive Support.

Sue is committed to providing support to organisations and systems to improve and recognises the need to create the conditions for people to do their best work. Sue has a particular interest in how we support leaders in these most challenging times and systems be their ‘best self’, looking after their own wellbeing whilst role modelling the leadership we need for collaboration.

Sue was appointed as Aqua’s Chief Executive in June 2022. Aqua is a NHS improvement organisation which has supported organisations predominantly in the North West. Since joining, Sue has expanded Aqua’s offer, so it now has national and international reach. She has developed close partnerships with agencies who share the values of improvement and developed a strong and diverse range of associates.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None

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