I have a career ambition I have rarely said out loud: I aspire to lead at the highest levels of the NHS. Not because I am attached to a particular title, but because I want to contribute to healthcare at scale, shaping strategy, influencing systems and helping to build a health service that works better for patients, communities and staff.

As a woman from an ethnic minority background, I also understand what representation does: seeing people from different backgrounds in senior positions changes what feels possible for those coming behind them.

But aspiration alone is not enough. It needs access: to opportunity, sponsorship, strategic conversations and meaningful development experiences.

I believe the NHS remains too focused on career pathways when it should be building capability pathways.

Career pathways describe the sequence of jobs someone has held. Capability pathways focus on the skills, experiences and perspectives they have developed. The two are related, but they are not the same.

“Leave the NHS and come back”

Throughout my career, I have sought opportunities beyond my substantive role, working across transformation programmes, digital initiatives and national networks. These experiences have helped me understand how strategy, policy and delivery connect.

Yet I have repeatedly encountered the same question: where does someone go to gain recognised strategic leadership experience?

One piece of advice I received was particularly memorable: if you want to learn strategic leadership, leave the NHS, join a consultancy, gain strategic experience there and then come back.

Experience outside the NHS can be valuable. What concerns me is the assumption that aspiring NHS leaders must leave the service to learn how to lead it.

The NHS is already tackling some of the most complex strategic challenges imaginable, including financial sustainability, workforce transformation, digital innovation, health inequalities and integrated care. These are not lesser leadership experiences because they happen inside the NHS. The challenge is whether we intentionally create opportunities for emerging leaders to engage with them.

Strategic leadership is a capability

There is a familiar route to senior leadership: start in a professional role, progress into management, take on teams and budgets, then move towards executive leadership.

Operational experience remains an important foundation for leadership. The difficulty arises when operational management becomes the primary evidence of leadership potential.

Strategic leadership requires the ability to understand complexity, navigate uncertainty, influence without direct authority and make decisions across organisational boundaries. It involves bringing people together around a shared purpose, balancing competing priorities and preparing organisations for future challenges.¹˒²

Operational leadership can develop these capabilities, but it is not the only route. They can also be developed through transformation programmes, policy development, improvement work, research, digital innovation and cross-sector collaboration.

The more useful question is not, “What job has this person done?” but “What capabilities have they demonstrated, and what experience do they need next?”

Why this matters for diversity

This question becomes sharper through the lens of diversity.

While the NHS Workforce Race Equality Standard shows progress in the representation of senior leaders from ethnic minority backgrounds, significant inequalities in career progression remain. These differences are not only about recruitment decisions at senior levels. They also reflect who gains access to the developmental experiences that build leadership credibility long before a selection panel meets.³

If some groups have less access to sponsorship, stretch assignments or strategic exposure, inequality can become embedded early in a career. Building a genuinely diverse leadership pipeline therefore requires more than encouraging underrepresented candidates to apply for senior roles. It requires equitable access to the opportunities that create experience, visibility and confidence.⁴˒⁵

Experience is often treated as the prerequisite for opportunity, when opportunity is often what creates experience.

What capability pathways could look like

If we are serious about developing future leaders, we need to be clearer about the capabilities we value and more intentional about how people acquire them.

This could include exposure to boards and executive decision making, leadership of strategic programmes, opportunities to work across organisational boundaries, involvement in policy development, sponsorship from senior leaders and stretch assignments beyond a person’s substantive profession.

Rather than viewing leadership development as a ladder, we could treat it as a portfolio. Different people would need different experiences, but the goal would be the same: developing the breadth of experience, judgement and relationships required to lead effectively.

The responsibility of today’s leaders

Leadership pipelines are not accidental. They reflect the choices organisations make about who gets exposure, sponsorship and opportunity.

Boards and senior leaders therefore have a responsibility to create those opportunities deliberately. It requires recognising potential that may not look familiar, sponsoring people whose career journeys differ from their own and giving emerging leaders access to strategic conversations before they hold the titles that traditionally grant entry.

Instead of asking only, “Who is ready for the next role?”, leaders could ask, “Who has the potential to lead, and what experience can we provide to help them become ready?”

Leadership programmes can help, but programmes alone are not enough. Emerging leaders also need meaningful responsibility, exposure to decision making and sponsors willing to advocate for them when opportunities arise.⁴˒⁵

From aspiration to access

My ambition to lead at the highest level of the NHS has not changed. What has changed is how I understand the journey.

The NHS needs leaders who can connect operations and strategy, deliver today while preparing for tomorrow and navigate increasingly complex systems.

Capability pathways would not lower the bar for leadership. They would make it clearer, fairer and more accessible.

If the NHS wants a different generation of leaders tomorrow, it must design different opportunities today. Because aspiration without access is not a leadership strategy. It is wishful thinking.

References

1. Messenger G, Pollard L. Leadership for a Collaborative and Inclusive Future. London: Department of Health and Social Care; 2022. Leadership for a collaborative and inclusive future – GOV.UK
2. West M, Armit K, Loewenthal L, Eckert R, West T, Lee A. Leadership and Leadership Development in Health Care: The Evidence Base. London: The King’s Fund, Faculty of Medical Leadership and Management and Center for Creative Leadership; 2015. FMLM-Leadership and Leadership Dev in Healthcare 32pp 19022015.pdf
3. NHS England. NHS Workforce Race Equality Standard (WRES) 2024 Data Analysis Report for NHS Trusts. Leeds: NHS England; 2025. NHS England » NHS Workforce Race Equality Standard 2024 data analysis report for NHS trusts
4. Ibarra H, Carter NM, Silva C. Why men still get more promotions than women. Harvard Business Review. 2010;88(9):80–85, 126. (PDF) Why men still get more promotions than women
5. Department of Health and Social Care. Biggest shake-up in health and social care leadership in a generation to improve patient care [press release]. London: DHSC; 2022. Biggest shake-up in health and social care leadership in a generation to improve patient care – GOV.UK

Author

Marina Khan

Chief Pharmaceutical Officer’s Clinical Fellow 2025/26, NHS England.

Declarations of Interest
The views expressed in this article are my own and do not necessarily reflect those of NHS England or any other organisation with which I am affiliated.