The chiefexecutive’s taleViews from the front line ofthe NHSAuthorNicholas TimminsMay 2016

The chief executive’s eware a ‘better yesterday’ 93The NHS is not a single organisation 10And, of course, it is the cash 10But more importantly the system 12And above all the regulation 12Which has produced a loss of support 16And an interesting reaction.17And other unintended losses 18To whom do chief executives feel accountable?20And to whom do they look for support and how do they cope?20And are they confident that there is a strongpipeline of successors?21So what’s it like being a chief executive?23In their own words: the interviewees25Angela Pedder25Contents 1

The chief executive’s tale14234Ben Gowland30Catherine Beardshaw33Edward Colgan37John Pelly41Sir Jonathan Michael45Karen Dowman50Keith McNeil54Mark Newbold60Sir Robert Naylor64Steve Shrubb70Tim Smart74A leadership and organisational developmentperspective78References83About the author84 Contents 2

The chief executive’s tale1234ForewordIt was the best of times, it was the worst of times.Charles Dickens’ memorable words from A tale of two cities echo down the yearsand offer an apposite, albeit incomplete, epitome of the story, or stories, that willunfold in the pages that follow. The King’s Fund and NHS Providers are indebted toNicholas Timmins for eagerly accepting our challenge of talking to a small numberof chief executives to capture their reflections on life as a chief executive, most ofthem at or towards the end of their career in the NHS. We are equally indebted tothe chief executives who responded positively to our invitation to take part and toshare their experiences – as far as possible in their own words and on the record –with a wider audience.The sense of possibility in being a chief executive within the NHS is palpable inthe stories that Nick has recorded. The ability to make a difference to people andpatients through the leadership of often large and complex organisations such ashospitals is a key driver of the experience of the chief executives who took part.From this perspective, being a chief executive can properly be described as ‘the bestof times’, giving a feeling of achievement and fulfilment that would be difficult torealise in most other leadership roles, as those who had experience of these otherroles readily testified.The sense of pressure and constraint, in some cases bordering on bullying, is alsopalpable. Without exception, those who took part described an NHS in whichautonomy was increasingly circumscribed, and regulation ever present. A numberof the chief executives whom Nick interviewed left their post as a result of criticalreports by the regulators, specifically the Care Quality Commission and Monitor.Some of those who left did so in circumstances in which they were put under somuch pressure by the regulators that being a chief executive came to feel like ‘theworst of times’.The high personal cost for these individuals is hard to exaggerate. The cost to theNHS of the loss of experienced leaders is in some ways even higher at a time ofgrowing concern about vacancies in top leadership positions. With the NHS inForeword 3

The chief executive’s tale1234England facing financial and performance challenges that are arguably greater thanat any time in its history, there is an urgent need to find better ways of supportingleaders who get into difficulty rather than replacing them pour encourager les autres.Many of the support systems that used to exist are no longer available, and today’schief executives operate in a more isolated and sometimes hostile environment thanin the past.This matters for a number of reasons, most obviously in deterring the next generationof top leaders from putting themselves forward for chief executive roles. This is oneof the reasons why both NHS Providers and The King’s Fund are offering supportto leaders. We are also working with NHS Improvement under its new leadership tobring about the changes needed to enable leaders to thrive in difficult times.We strongly endorse the views of Ed Smith, chair of NHS Improvement, on thepernicious impact of ‘firing squads’ who sack chief executives and chairs whenthings go wrong (Ham 2016). Like Ed, we believe that ‘regulated trust’ is muchless effective than ‘real trust’, which is based on a belief that leaders have a strongintrinsic motivation to perform to the best of their abilities. Real trust is not fosteredthrough a reliance on rules but rather through positive organisational cultures thatencourage calculated risk-taking and avoid blame.These cultures support people to act in a way that is trustworthy and to do the rightthing. They encourage behaviours and instincts that enable people to behave withintegrity at all times. Positive cultures take time to develop and require sustainedeffort by leaders and followers at all levels. Rules and regulations designed toincrease trust all too often have the opposite effect, resulting in over-relianceon compliance rather than the nurturing of commitment. Real trust cannot bemandated and emerges through the actions of leaders who create the conditionsin which people are supported to be effective.Dickens’ passage in A tale of two cities continues with words that are less wellremembered, namely: ‘ it was the age of wisdom, it was the age of foolishness,it was the epoch of belief, it was the epoch of incredulity, it was the season of Light,it was the season of Darkness, it was the spring of hope, it was the winter of despair’.The NHS now needs to value wisdom, belief, light and hope to counter the forcesof foolishness, incredulity, darkness and despair that are gathering at the gates.Foreword 4

The chief executive’s tale1234We hope that those who read this report will see it as a wake-up call to change theculture in which talented people are ground down, however well intentioned theregulators and performance managers may be. Good leaders do not thrive when, asDon Berwick put it in his review of patient safety (Department of Health 2013), thereis a culture of fear that creates risk aversion and inhibits creativity and innovation.The culture of fear needs to be replaced, and rapidly, if the NHS and its leaders areto rise to the challenges with which they are faced.Chris Ham,The King’s FundChris Hopson,NHS ProvidersReferencesDepartment of Health (2013). A promise to learn – a commitment to act: improving the safetyof patients in England. London: Department of Health. Available at: into-patient-safety (accessed on 13 April 2016).Ham C (2016). ‘Real trust rather than regulated trust should be the foundation for improvement inthe NHS’. Blog. The King’s Fund website. Available at: -nhs (accessed on 14 April 2016).Foreword 5

The chief executive’s tale11234IntroductionWhat follows is the product of two organisations having the same idea. In late2015 it turned out that both The King’s Fund and NHS Providers had decided toseek to interview a clutch of recently departed, or soon to be departed, NHS chiefexecutives, plus a few who were simply changing jobs within health care.The motivation was the continuing perception that there is ‘a crisis of leadership’within the NHS.Surveys over the past 18 months suggest that the mean tenure of an NHS providerchief executive is just three years, and possibly less (NHS Providers 2016; Barnes 2015;Health Service Journal 2015; Janjua 2014). Significant numbers of chief executive postsare vacant or are currently filled by interims. There is a view that it is becomingmore difficult to recruit directors – whether clinical, financial or operational – andin turn that it is becoming more difficult to persuade people to step up from directorposts to become chief executives. All that, plus the unquestionable fact that, in 2015,a number of the longest-serving chief executives – people who have held the jobin one form or another for 20 years and more (Sir Robert Naylor, Karen Dowman,Angela Pedder, Steve Shrubb and Sir Jonathan Michael to name but five) – were allshortly to retire from their current posts.It seemed important to give such people a voice, and by interviewing a dozen ofthem to give them, so to speak, a form of collective voice – not that they all hold,by any means, the same views about everything.Both The King’s Fund and NHS Providers had started doing the interviews and, whilewe were asking slightly different questions, there was sufficient overlap for it to makesense to merge the two. So some of the interviews reported here were conducted bySivakumar Anandaciva of NHS Providers, the majority by Nick Timmins.Our essential recommendation would be to read the interviews. They are the keypart of this report. They are full of wit and wisdom. They explain why people wantto become chief executives – partly to be the boss, of course, but also to be able toinfluence health care for the good for large numbers of people, not just individualIntroduction 6

The chief executive’s tale1234patients, a point particularly made by those who started out as clinicians. They tellof the dark side and the bright side of being an NHS chief executive. They containlessons learned and much else. And from these interviews readers will, inevitably,draw their own conclusions and quite possibly different ones from those outlinedin the next section.It should be understood that each interview is the product of at least an hour-longconversation. The transcripts typically ran to between 9,000 and 10,000 words. So theyhave been heavily edited to the point where only around 20 per cent of those wordssurvive in the transcripts in order to produce a document of manageable length.We have deliberately tried to keep the conversational tone – these are, after all,the chief executives’ tales. And we have sought to edit them to bring out commonthemes while avoiding excessive repetition.So, for example, it was notable how many of the interviewees, when asked to whomthey felt accountable, instantly volunteered ‘the patients’ – way ahead of themthen spelling out their formal accountability to their chair or their board or theircommissioners or their regulator or the Public Accounts Committee. But to avoidrepetition we haven’t highlighted this in every interview.Nor have we reflected every common theme in each of the transcripts. What wehave tried to do is draw out the common themes in the overview section, which onoccasions includes quotes that are not in the transcripts.Introduction 7

The chief executive’s tale12234OverviewIt is important to state that this report doesn’t present the views of a scientificallyselected sample of chief executives across the NHS. Rather, it presents the viewsof a dozen who were generous enough, or in some cases brave enough, to agree tointerviews and then find the time for them. To all of them we are immensely grateful.It is also not a piece of balanced reporting. Various organisations – the regulators,NHS England and some clinical commissioning groups – come under fire here.They will doubtless have their own views on the merit, or otherwise, of some of whatis related. They have not, however, been approached to give their side of the storybecause that was not the object of the exercise.The object was to give a voice to a dozen NHS chief executives about what the jobis like now, how it compares to the past, how they cope and coped, to whom theyfeel or felt accountable, how far they feel there is a pipeline of successors to followthem, and so on. But it remains a voice, not the voice, and with the regulators’voice missing.Those qualifications aside, this report does have the advantage that the dozeninterviewees represent a fair spectrum of NHS care, from teaching hospitals todistrict general hospitals, from community to mental health services, from providers(including in one case a GP provider) to commissioners. They include clinicianswho became chief executives and people who started out as general managementtrainees – plus some who did both – and some who came to the NHS from anon-health private sector background. And most were in a position to be free, orrelatively free, about their views, because they did not have to worry about theirnext appointment.Take, for example, Karen Dowman’s story. A few months back she binned, as a wasteof time, half a dozen emails from higher up the ‘food chain’, while conceding thatfive or ten years ago, when younger in the job, she might not have felt able to. OrKeith McNeil’s assault over being at the wrong end of a Care Quality Commission(CQC) inspection, in an organisation whose own self-diagnosis was that it requiredimprovement but which did not believe itself – and does not believe itself – to beOverview 8

The chief executive’s tale1234‘inadequate’. Or Catherine Beardshaw’s anger at being in a meeting with half a dozenpeople on her side of the table while there were 38 on the other side, hammering herabout her hospital’s performance. And so on.So what emerges?Beware a ‘better yesterday’ Well, first of all it is worth stating that both the interviewers and interviewees werekeen to guard against ‘a better yesterday’ even if some readers may judge that wehave fallen into that trap.Guarding against ‘a better yesterday’ was deliberately raised in the course of manyof the interviews and some of the interviewees have been around long enough toremember as far back as 1987. This was a time when the NHS was in so much debtto its suppliers that it was technically bankrupt, when it closed 4,000 beds almostovernight and when it cancelled countless operations, with fatal consequences insome instances. It was that crisis that led to the then Conservative government’sreview of the NHS, which in turn led to the original purchaser/provider split.In the early 1990s, the average tenure of an NHS chief executive was little more thant

chief executive is just three years, and possibly less (NHS Providers 2016; Barnes 2015; Health Service Journal 2015; Janjua 2014). Significant numbers of chief executive posts are vacant or are currently filled by interims. There is a view that it is becoming more difficult to recruit directors – whether clinical, financial or operational – and in turn that it is becoming more difficult .