“Doctors need to step up”—why are there still so few medical chief executives in the NHS?
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4341 (Published 25 June 2019) Cite this as: BMJ 2019;365:l4341
When Navina Evans, a consultant psychiatrist at East London NHS Foundation Trust, was asked by the trust’s chief executive, the forensic psychiatrist Robert Dolan, to consider starting the journey potentially to take his place, she was taken aback.
Evans was fulfilled in her clinical work and told The BMJ that it had “never occurred to her” as a possibility. After thinking it over, she told Dolan that her answer was no. “Go away, think again, and come back with a different answer,” he replied.
She remains “so very grateful” that she did. Dolan’s instincts for talent were right: after spells as chief operating officer and deputy chief executive, Evans succeeded him in 2016. For the past two years she has been named second most influential chief executive in the NHS by the Health Service Journal.1
She has a strong message for doctors who feel how she once did. She finds it sad when she watches Question Time, reads Twitter, or goes to dinner parties and hears doctors talk about how awful working in the NHS is. “Doctors need to step up,” she says. “We need to come together and believe that we can actually make a difference and change the narrative.”
The number of clinical NHS chief executives is growing. In one survey of 129 NHS chief executives in England 8.3% of those appointed before 2015 were medically qualified, but in 2015-17 the proportion had grown to 10.5%.2 In a later survey of 78 chief executives a third were clinically trained, mostly as nurses and doctors, with a few as pharmacists and other health professionals.3
Many doctor chief executives in the NHS have come from countries where this path is more common, such as the Netherlands, Australia, Belgium, and Canada.4
The peer and surgeon Ara Darzi put a focus on clinical leadership in his 2008 NHS Next Stage Review.5 As health secretary for England, Jeremy Hunt effected measures to advance his ambition of having more home grown clinician chief executives.6 This month’s Interim NHS People Plan proposes introducing more structured career paths for clinicians to pursue a career in leadership.7
Fear of the dark side
Opinions differ on why so few home grown doctors “go to the dark side,” as some put it. Evans sees no “them or us” scenario pitching doctors against NHS managers, nor any cause for friction among doctors and nurses or pharmacists who have gone down the clinical leadership route. “We need to take out that element of competition, because there’s plenty of room for everybody,” she says.
The consultant geriatrician and BMJ columnist David Oliver notes that many doctors are already clinical leaders, directing quality, safety, and service delivery, heading their own departments or divisions, or working as medical directors. Many simply don’t want the top job, he told The BMJ, with its perceived huge responsibility and accountability. “Maybe there’s no problem to solve,” he said.
Not all doctors would necessarily make a good chief executive, though growing evidence indicates that expert leaders, such as doctors, are associated with improved organisational performance.8
A researcher in leadership and performance, Amanda Goodall, has used reports from UK and international doctors on their line managers who are also doctors in a study of the relation between clinical skills and managerial performance (unpublished working paper “The best in both worlds: why talented clinicians make talented managers”). The results indicate that line managers who are rated as good or outstanding clinicians are associated with high levels of job satisfaction among employees and low intentions to quit. In other words, great doctors seem to make great managers.
Innate curiosity and a desire to fix
One common factor among medical chief executives is having done an extraordinary range of different jobs, and they are fascinated by doing something new. Adrian Bull, chief executive of East Sussex Healthcare NHS Trust,9 and former chief executive at the specialist burns hospital Queen Victoria Hospital in West Sussex, has gone from being a doctor in the Royal Navy, and training as a GP, to a career in public health medicine, medical director at an NHS trust, and a 12 year stint in the private sector with the health insurance providers AXA PPP and Carillion Health.
He realised, aged about 30, that his ambitions lay in leading. “I was much more interested in how the system around me was working.” As a public health consultant he admits that he was “a bit cocky” and wanted to run the show. “I thought, people aren’t doing public health quite the way I think it should be done.”
Like Bull, Matthew Shaw, chief executive of Great Ormond Street Hospital in London, also worked in the private sector and, unusually, is a surgeon turned chief executive. A year after becoming a consultant spinal surgeon at the Royal National Orthopaedic Hospital, north London, he became clinical director, then a year later medical director, followed by deputy chief executive. After working for the private healthcare group Bupa for 15 months as medical director, he joined GOSH in the same role and was appointed chief executive in December. He’s 44.
Shaw says, “As I was starting my career it was pretty obvious that there were lots of things that needed fixing. I thought, ‘Why wait until I’m in my 50s or 60s to get stuck in and try to improve stuff?’” He acknowledges always being “slightly different from my tribe.”
Others have not worked in the private sector but have filled varied roles in the NHS. Jackie Bene, who has been chief executive at Bolton NHS Foundation Trust for six years, switched from being a consultant geriatrician to acute medicine, as well as being divisional lead and then medical director at the trust.
She says, “I’ve recognised over the years that I get bored and like variety. [My job] has lots of really good challenges. I find myself getting entrenched in politics and socioeconomic and strategic discussions, and it’s all very interesting.”
Like surgeons, fewer GPs become NHS chief executives. Claire Fuller, senior responsible officer for Surrey Heartlands Health and Care Partnership, an integrated care system, is a GP who started down the leadership path after she had children. She went from clinical chair at Surrey Downs Clinical Commissioning Group to clinical chief officer, and then to the integrated care system’s clinical lead role at Surrey Heartlands before taking the top job. In 2017 she was named clinical leader of the year by the Health Service Journal.10
She finds her role fascinating. “Working closer with local government, on devolution, there’s always something new to find out about.”
Impact on a wider scale
Saffron Cordery, deputy chief executive at NHS Providers, a trade association for NHS organisations, says that feedback in response to her organisation’s 2018 joint report with the NHS Leadership Academy showed that medical chief executives tend to fall into two categories.3 There are those who think that to achieve what they want they need to work beyond the clinical realm, and then those who are more reluctant but realise that their organisation—the staff and patients—requires them to step up.
Bene was very much in the second camp. When she became a consultant geriatrician in 1998, becoming chief executive was the “last thing on my mind,” she says, but she added to her responsibilities by becoming a divisional lead and then medical director.
When the trust got into financial difficulties, and the regulator intervened,11 the executive chair encouraged her into the deputy chief executive role, acting up as chief executive. It took 6-12 months to persuade her to go for the substantive post. Bene says that it’s probably the best job she’s ever had, enormously rewarding because of what she can achieve, organisationally, for thousands of patients and hundreds of staff. “The sphere of influence you have to really make a difference is enormous. The reach is great.”
Other leaders echo having this level of influence. East London’s Evans says, “You’re having an impact on millions, which is amazing.” Bull moved back to the NHS from the private sector because he was aware that his efforts there were relevant to relatively few people and he wanted to affect more people.
Dispelling stigma
Communicating this impact and the professional and personal rewards are difficult because of persistent stigma about clinical managers.
Evans thinks there’s an “old school” of doctors who say, “I didn’t go into medicine to be a manager,” but who as consultants are already acting as “micro-chief executives.” She says, “They need to really look at what they’re doing.”
Shaw recently gave a talk on leadership to a room full of clinicians and asked them to raise their hands if they would like to shadow him. No one did, but afterwards three people emailed expressing interest.
He says the stigma about being a manager in the clinical world must be dispelled. “We all serve a purpose in a job, we’re all part of the cogs that turn the wheels, and therefore don’t be afraid of stepping out, doing different things, and going where your interests lie.”
Cordery says that shadowing such as offered by Shaw is critical. “Everyone needs exposure to what the [chief executive] role really is. Everyone needs to hear more from those who are already doing it to understand and to learn.”
Responsibility overload
Cordery adds that doctors who are used to being in control of their environment and their realm may find “stepping out” uncomfortable, but she believes that their rigorous training, practical and intellectual, equips them for the job.
It is a “colossal job,” says Bene, “but it’s very doable.” She adds, “You’ve got all the skills you need as a doctor, as a consultant. You’ve got a lot of leadership skills already that are just intrinsic, and it’s easy to translate them into a wider leadership role.”
Fuller agrees: “I’m just a jobbing GP. There’s nothing exceptional in the skills I have got along the way. It’s putting them together in the right place—and being brave enough to give it a go.”
Lack of credibility
A common reason for doctors’ reluctance to move into senior leadership is not wanting to give up their clinical practice and losing professional credibility. Oliver makes the point that nurses in senior management don’t seem to have this concern.
Three of the five bosses The BMJ spoke to chose to stop practising completely, two of them reluctantly. Evans stopped last year after sometimes feeling anxious about doing so little clinical work. Shaw stopped operating in April, which he found difficult, “because I’ve trained long and hard to get where I got.” Bull gave up his licence years ago when he went to work for AXA PPP.
Evans says it doesn’t affect her credibility. “The most important thing about being a doctor is the human connection, not your technical skills. I feel I can hold my own with any doctors.”
The others still do a small amount of clinical work, not for credibility but for satisfaction. Bene does a morning session a week in acute medicine. She would like a system where it is natural for chief executives to retain some clinical practice. Fuller, who does one day a week, thinks this is too little to make her credible as a GP. “I tried not doing it but I really missed it.”
But Cordery believes that influencing the delivery of care and adding highly complex challenges to your skillset “is the ultimate credibility.”
Unless the NHS accepts that many doctors would never want to be a chief executive if they had to give up practising completely, it may lose out on some outstanding candidates.
Job insecurity and the future
Giving up your licence to practise makes it much harder to go back to medicine if you are sacked—a high risk for NHS chief executives, who last just three years on average.2 This is a significant barrier, given that GPs and consultants have high job security.
Evans was again influenced by her boss Dolan, who told her, “Don’t become a chief executive until you can afford not to have a job.” Her plan B is to do an English degree.
For younger doctors, the risk is greater. Shaw said he thought long and hard about this point but decided to be pragmatic, an attitude he found in abundance in the private sector, where job turnover is high.
Cordery says the system needs to dispel the idea that every time something goes wrong the chief executive needs to be removed. “We’ve got to stop sacrificing the leaders—clinical and non-clinical—that we so desperately need,” she says.
If the route to becoming chief executive isn’t clear to you, make your own, say the doctors who have got there. Shaw says, “You don’t have to be a consultant for 10 years before you apply for clinical leadership. Make your own path, make an impact, and opportunities will arise.”
How talent is being nurtured
The number of schemes aimed at encouraging young doctors with an interest in leadership is growing. Budding doctors with leadership potential need to be spotted early and nurtured, and the route to leadership should be clear and formalised while allowing them to maintain clinical practice. There are also programmes to help mid-career doctors who weren’t among that early self identifying cadre with a burning desire to lead.
Health Education England and the Royal College of Physicians of London are piloting portfolio training in which core medical trainees take one day a week out of their clinical training to develop in medical education, quality improvement research, or clinical informatics, with an emphasis on leadership.12
The Royal College of Physicians’ chief registrar scheme provides protected time for senior trainees to practise leadership and quality improvement while remaining in clinical practice. In 2019-20 a total of 55 trusts are involved.13
For more senior doctors, the NHS Leadership Academy is running the third cohort of its Aspiring Chief Executive programme, with 14 clinical and non-clinical participants.14 It also runs the clinical executive fast track scheme.
Darzi fellowships in clinical leadership are full time for one year and available In London and Kent, Surrey, and Sussex. Fellows also complete a leadership development programme (PG Certificate in Leadership in Health) at London South Bank University.15 In the first six cohorts 200 fellowships were awarded, with many recipients finding it an “invaluable learning experience.”16
The National Medical Director’s Clinical Fellow Scheme for trainee doctors in England is managed by the Faculty of Medical Management and Leadership of the UK medical royal colleges and is sponsored by NHS England. Fellows spend 12 months in a national healthcare affiliated organisation outside clinical practice to develop their skills in leadership, management, strategy, project management, and health policy. Organisations include NHS England, NICE, royal colleges, and BMJ. The scheme has close links to similar schemes in Wales, Northern Ireland, and Scotland.17
The Health Foundation runs Generation Q, a leadership and quality improvement programme for clinical and non-clinical fellows.18
Masters degrees courses in healthcare leadership include the executive masters in medical leadership (EMML) at Cass Business School in London, which is open only to doctors, now running with its second cohort of 13 people.
Saffron Cordery, deputy chief executive at NHS Providers, says the challenges of NHS chief executive roles have never been greater, which is why such programmes have a key role. “We are seeing a really high success rate, with new leaders feeling equipped to make a positive impact and bring their experiences to these frontline roles,” she says. “The reason these programmes work well is the focus on development, through learning as a group and from the skills of others. This is playing its part in creating a bigger pool of talented and credible future leaders.”
Footnotes
Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.