Medically trained staff needed in NHS top jobs

There are many organisations in the NHS. In the provider environment alone, there are around 260 NHS and foundation trusts. Each business has a chief executive, yet medically trained professionals account for just 5 per cent of CEOs in the NHS. A recent search for medically qualified chief executives, carried out by the Faculty of Medical Leadership and Management and the NHS Leadership Academy, found just 13 individuals. Why are there so few doctors in the top job?

‘Opportunities exist, through NHS Top Leaders and regional senior leadership programmes, to create a future cohort of possible candidates suitable for chief roles’

Hospitals were once run collectively by groups of doctors, nurses and administrators. However the 1988 Griffiths report changed all that. It signalled the growth of the hospital manager in response to a perceived absence of control and excessive medical power. Griffiths had really hoped for better clinical leadership supported by a professional management cadre, yet his reforms created an effective loss of authority for doctors and nurses. Medical disengagement is often dated from that point.

Does doctor know best?

Nobody can say whether Griffiths influenced a change in quality or efficiency but Karen Lynas, deputy managing director at the NHS Leadership Academy, believes “general managers have often been better, more impartial patient advocates than many of their clinical colleagues”. Indeed, much of the way hospitals now work, such as trauma networks, day case rates and the “Productive” series, are down to management ability. It is down to innovation at organisation and system level, something not all medical staff possess. Ms Lynas is not alone in her thinking.

In contrast there is plenty of published evidence suggesting good clinical leadership with strong board level influence improves quality and outcomes. It seems clear that medical innovation and knowledge, working closely with strong management skills, provides the best for patients.

It’s possible that doctors leading hospitals might actually make them safer. There’s no literature on quality of medically led organisations in the UK, but a recent paper surveyed the top 100 American hospitals, asking how many have a qualified doctor as a chief executive. A surprisingly large 40 per cent of these top 100 hospitals were run by qualified doctors, compared with a 3.5 per cent national average. A strong correlation between medical CEO and nationally scored hospital performance was also found.

There is a link between medically led hospitals and higher quality. This research, together with the evidence around clinical leadership, suggests an added value of doctors in accountable control of trusts. This idea has been supported by national policy makers over the last decade, but there are now even fewer medical chief executives than in 2010. Why?  

It may be a lack of medical interest or a lack of career opportunity. Maybe it’s a shortage of enlightened employers? In hospitals, the medical career ladder has traditionally stood apart from the rest. Doctors aspired to be GPs, consultants or professors rather than medical managers.

Career ladder

In recent years more enticing clinical leadership roles such as regional network chairs and tsars have gained a stronger voice, showing the ability of leaders to influence improvement. In hospitals, divisional directorate roles have become more accountable and the medical director is becoming professionalised.

In contrast, chances to step over to the “dark side” and get stuck into management at executive director level have remained rare. Opportunities appear unattractive from a career development point of view. The risks seem high and rewards are sometimes difficult to see. Risks include loss of influence with colleagues, diminished clinical credibility and loss of “tribal” support.

There are doubts around career progression, with few visible long term opportunities for ambitious medical managers. There is also financial risk and job insecurity, particularly for those moving off the NHS consultant contract. The rewards that encourage doctors to substantially give up clinical work are less about money and more about opportunities to “make a difference”. It is about positively influencing the delivery of healthcare to patient populations beyond the capability of their traditional one-to-one clinical interaction.

There are doctors in this category who are excited by the challenge of leading organisations but they need the opportunities to develop themselves for the role of accountable officer.

Rise to the top

Being chief executive is a tough job but it’s a privilege to lead a complex organisation with such important local influence and impact. It seems very different to anything most medical leaders will have experienced, showing skills and experience quite unrelated to medical practice: the people you employ, the responsibility and accountability, the resilience and integrity.

‘Being chief executive is a tough job but it’s a privilege to lead a complex organisation with such important local influence and impact’

In reality there’s a lot of duplication of skills already possessed by senior medical leaders that can be successfully translated into an executive context, although the CV will look very different.

So how can more doctors become chief executives in the NHS? There’s a real and growing interest among them to become the CEO. Stronger leadership at specialty levels makes the upward move seem much more possible to doctors and their trusts. Those who are becoming interested can see an emerging, although still faint, career path upwards.

Opportunities exist, through NHS Top Leaders and regional senior leadership programmes now being joined by medical leaders, to create a future cohort of possible candidates suitable for chief roles. There are now more medically qualified strategy directors and chief operating officers; the managing director role is becoming more operational, accountable and often advertised as a full time career option. It’s becoming likely we will see more doctors acquiring the skills needed to become chief executives.

To generate a robust stream of applicants for doctor CEO posts we must offer opportunities early on in postgraduate training. Engagement of new consultants in hospitals will encourage those with aptitude to develop themselves.

We need to build recognition of the physician leader as a desirable role model and generate a career pipeline that has opportunities for more doctors to apply for board level posts other than medical director. By clearly defining a career path and having strong, visible role models it will be much easier for NHS appointment panels to see the value of these people and consider selecting them for the top job. In this way, the medical profession can take its place in significant numbers alongside the rest of the NHS at every level, demonstrating the patient-focused leadership the service so clearly needs.

Dr Chris Gordon is programme director for QIPP at the NHS Leadership Academy