Being an NHS chief executive has never been easy, but the job has arguably never been as difficult as it is now. After the extraordinary pressures of the Covid-19 pandemic, financial constraints are now felt acutely right across the entire health service. Staff are demoralised, with the recent doctors’ strikes – and earlier nursing strikes – creating a further strain on relationships, morale and service continuity.
Record waiting lists, structural reorganisation and shifting national direction compound the challenge, as does political rhetoric. Narratives stating that the NHS is “broken”, or where NHS leaders are characterised as “pen-pushers and bureaucrats”, create a difficult environment for leaders trying to sustain services, support their staff and implement long‑term improvements for patients.
So what impact is all this having on those NHS leaders? Over recent months, I’ve had a series of conversations with chief executives of NHS organisations – each of whom participated on the condition of anonymity – about the difficult decisions they face in their roles, and to discuss the possible moral distress that could accompany those decisions. Moral distress in health care has been defined as something that arises “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action”.
Before coming to the Nuffield Trust, I was the chief executive of an NHS trust, but my first career was as a clinical psychologist. For years, I have been interested in how different people navigate the stresses and strains of being an NHS leader. There has been work published on moral distress among army leaders and also among doctors and nurses, but little has been published about moral distress for leaders such as chief executives. There has not even been much debate and conversation about it.
Yet it is crucial that more is understood about it, not least because we have the highest ever turnover in NHS leadership and a landscape in which many NHS CEOs are expected to deliver more with less or the same money, all while under intense public scrutiny and with persistent structural uncertainty.
This is the context, described by many, within which the conversations with around 15 NHS chief executives took place.
What did they say?
Money, money, money
During my conversations with them, many experienced leaders described the current context as exceptionally challenging. They also stated that moral distress was not an occasional or exceptional feature of their role, but a routine and expected part of senior leadership.
What soon became abundantly clear during the conversations is that one part of their work makes their lives more difficult than any other, and that is money. The issue most consistently raised as the source of pressure was financial constraints, and in particular the lack of open, honest and system-wide conversations about what is realistically affordable.
Several CEOs prefaced their examples by saying, “you won’t be able to use this example as it will identify me and my system too clearly”. By the fifth example, it was clear this would not be the case.
One CEO, reflecting on the pressures of meeting financial targets, noted: “I've been told I'm too honest. How can you be too honest? You're either honest or you're not.”
Others described the experience of telling their region that the organisation could not meet mandated financial requirements:
“That was probably one of the most difficult things I've done in the x years of being chief executive. I got challenged back from the regional team that this isn't acceptable. I then got taken aside to be asked whether I knew whether I understood what I was doing, whether I understood the implications for the trust, whether I understood the implications for me personally.”
– an experienced CEO in the NHS
“Well, the most difficult decisions at the moment – and probably the most difficult that I've ever experienced – are not the money per se. It's the decisions you have to make because of the money. I think we've normalised harm and we are numb.”
– a new CEO in the NHS
All interviewees acknowledged the imperative of maintaining financial balance and recognised that this entailed difficult policy and operational trade‑offs. However, for several participants, the principal concern related to the prevailing emphasis on “efficiency” within the reform narrative, particularly in a context where they and their staff were experiencing reductions in resources:
“I get they have to be seen to spend taxpayers’ money wisely, but if they are not careful, they are going to make these jobs so tricky for relatively inexperienced CEOs that they'll struggle to fill them with the right people.”
– an NHS CEO
Most importantly, however, was that few felt supported and understood by those above them – whether that was their integrated care system, region, or NHS England (or all three). For some this was just “the way things are”, but for others – particularly those new in post – it felt challenging and, for some, lonely.
It felt to a couple of interviewees that their experiences of trying to explain the particular challenges they faced were dismissed. The response they received from commissioners and policymakers was that they could simply try harder.
“I've just started and they are telling me that if I don’t sort the money out, I wouldn't be in the job for more than a year.”
– an NHS CEO
It was clear from those I spoke to that the savings targets were often a source of great discomfort. Many simply felt they could not make those savings in a year in a way that was safe for their patients. They could imagine a situation where in three or four years those savings might become more feasible, or indeed would welcome a discussion on the choices that could be made, but when they wanted that discussion they found there was no room for it. Such experiences left them feeling very unheard and very unsupported.
Making difficult decisions: it’s the job
But it wasn’t just money that CEOs spoke about. They also described a wide spectrum of other difficult decisions in their roles – from everyday operational choices to challenging judgements about underperforming senior team members. They spoke about keeping someone with very complex learning disabilities on a paediatric ward because there simply wasn’t a placement outside of the hospital for them to go to. They spoke of supporting staff through clinically difficult situations, such as corridor care. They also spoke of challenging skill mix and a lack of staff.
They all saw making difficult decisions, and indeed leading their colleagues through that decision-making, as a vital part of their job. It was very noticeable that even those who had been experiencing significant pressure got a great deal of satisfaction and enjoyment from negotiating complexity and ethically complicated situations. They considered it “their job”, and supporting their teams and their boards in those situations often brought them a sense of satisfaction.
Feeling heard and receiving support
Repeatedly, the most important factor I heard from leaders on what could prevent damaging moral distress was being supported, being believed and feeling heard. These are all the components of psychological safety.
For most people I spoke to, it was talking to colleagues who “got it” that helped them get through it, and by knowing who in the system it was “ok to show emotion to”. They would be unlikely to talk about it in a big group, however, due to fears that they could be labelled “weak”.
But it’s a truism that talking helps. All interviewees talked about the protective function of being able to talk to colleagues (often outside of their own region) who understood, and of having a cohesive executive team with whom they could share the challenges. All, however, acknowledged that – in terms of their executive team – this was partial. Their role was to “carry the problem”.
“So I thought to myself, I am the breadwinner at home. My husband works, but he doesn't earn as much as I do. So how am I going to navigate my way through this by not letting go of who I am?”
– an NHS CEO
Experience and length of service matters, until it doesn’t
Two highly experienced CEOs of large trusts described encountering morally distressing and ethically challenging situations in their work. Their interviews, however, suggested that their positional power within the system afforded them additional protection and more scope to push back against policy asks than was available to less senior or less experienced colleagues. When asked whether they had ever received policy direction or guidance that they disagreed with ethically, one experienced CEO said: “Yes of course, regularly. I simply say no.”
“So I'll gently push back on some things, but equally I’ll work with the system. We've got to tick the box and keep them off our backs. I can provide a bit of air cover and a bit of a shield at times, but also speak truth to power that actually we're not just going to take it.”
– a very experienced CEO in the NHS on how to manage directives that they don’t agree with
There is some research that refers to the skill of long-standing CEOs as “organisational ambidexterity”. Over time, however, this can become wearing. Some later-career CEOs described feeling increasingly drained by repeated moral compromises and pressures. For some, this weariness became a turning point that contributed to their decision to step away from the role. The moral demands of the job were navigable, but they were not limitless.
“We're not valued, are we? NHS managers and leaders, there's a lack of value and appreciation for the complexity of the role that we do, the professionalism of the role, and part of that is because we're scarred by some really significant failures.”
– an NHS CEO
This is crucial. The emotional and ethical burden carried by leaders in the NHS is both significant and largely unspoken. Much of this work amounts to hidden emotional labour—an essential but often invisible part of leadership. Recognising, valuing and actively supporting this dimension of the role could be one factor in reducing CEO turnover, while also fostering a more emotionally intelligent and compassionate environment for all staff.
What can help: a good chair, confidential spaces and a code of conduct
Some factors did emerge as being important to make navigating moral distress more manageable. Besides a cohesive and functioning executive team, the key to CEOs’ mental wellbeing was a good relationship with their chair. Where chief executives felt they had faced the most morally distressing and challenging situations, it was the open, supportive and positive relationship with their chair that made them feel confident about their actions. In two conversations, CEOs described how a change of chair had substantially changed their ability to handle complex situations, as the new chair was no longer supportive, emotionally intelligent or “on the same page”. Both were considering leaving.
This of course could have been what the board wished to see, but the issue remains that the relationship between chair and CEO in navigating complex decisions is crucial. The ability to talk openly about dilemmas, rather than carry them alone, significantly protects the individual.
On training, most of those I spoke to hadn’t taken part in any specific leadership development programmes, but those who had said the programmes had offered them the space that later helped them to navigate morally difficult situations. All again emphasised the importance of informal and confidential spaces to talk about the pressures and dilemmas they faced, and those who had been working for many years reflected on how hard that currently felt:
“It's the difference between job satisfaction and frustration. I'm constantly frustrated by things that potentially are happening, coming down from our betters and then some of the stuff that comes from the ICB. That doesn't detract from the work I do leading my organisation, because it's a fantastic place and I love the job that I do. And part of the job is trying to manage the difficulty, although it has got significantly worse in the last six months.”
– an NHS CEO
CEOs also drew, where relevant, on their own professional identity and background to make sense of and withstand moments of moral strain. Without any prompting, several former clinicians talked about how their professional code of conduct was something they went back to as an anchor. Others found support through personal faith or religious belief, referencing this as their guiding framework. Nearly all those I spoke to referred to a strong ethical framework that guided their choices. This internal moral compass was not abstract – it was something they actively returned to in difficult moments.
Yet the conversations also highlighted the fragility of the conditions that make moral strain bearable, as shown by how quickly things can change once a good chair is replaced. Unsurprisingly, the experience of being bullied – or feeling coerced or unfairly pressured – was commonly reported as moral distress. A small group of ‘super‑CEOs’ who led large, powerful organisations often had more insulation from such behaviours; their stature allowed them to resist or ignore undue pressure more easily than their peers.
What is more positive – and which came through clearly – is how CEOs described but also then managed the moral distress they face. Many talked about how they had agency and control, noting that it was greater than that afforded to many front-line staff. This was key in being able to describe but not suffer from the moral distress they navigated. This capacity to influence events does therefore appear to offer CEOs a degree of psychological protection.
There was a great deal that I couldn't explore through these conversations. An important one was how navigating the immense pressures of being an NHS chief executive felt for people from minoritised groups. Understanding how race, gender and other identities intersect with moral distress would be an interesting area to explore in future work.
We must do better: my reflections on what NHS leaders told me
Being an NHS chief executive is very different from leading other types of businesses, such as a supermarket or bank. You are managing life and death, which makes it much more akin to the army. You are constantly in a moral and ethical frame. You must manage the critique that comes to you, day in and day out, about what you are doing and, just as importantly, what you are not doing.
Yet the NHS is also very much about people, and it’s clear from the people I spoke to that there is – as I already knew – a particular culture in the NHS of being “strong and resilient”. One of my least favourite words is “resilience”. I think it’s important, but it's often used as a mask. The situation you're in as an NHS leader could be rubbish, it could be tough beyond words, but we're going to encourage you to be “resilient” rather than also look at why that’s the situation you're in.
Many experienced NHS leaders are finding their current reality tougher than ever before. For some, the cumulative burden of moral distress is exhausting. While severe outcomes such as post-traumatic stress disorder (PTSD) are rare, sustained exposure can lead to burnout. Failure to recognise moral distress as a structural and governance issue, rather than just one of personal resilience, is likely to have damaging consequences. Every person I spoke to knew of someone – whether themselves or another chief executive – who was considering a premature departure from the role or from the sector. That has clear implications for leadership retention and for system stability. Addressing it requires explicit support.
It may sound small, but acknowledging that managing moral distress is a key part of being an NHS leader would be really validating and important for those who are doing it. I also think it should be celebrated. The people I spoke to were inspiring in how they talked about this as being part of their everyday work. It should be understood that it’s part of being a good professional leader in the NHS.
It means replacing what we currently have, which is a strongman vision of what leadership is. ‘If you're strong, if you're a good leader, you button it up, you keep it inside, you just go to the next thing’. Talking about moral distress and how people feel is seen as a sign of weakness, but in my view that is simply incorrect. Understanding who you are, and how you manage complexity, makes you a stronger leader.
As I’ve always argued, we need the NHS to be an emotionally intelligent and psychologically safe place in which its leaders thrive. It doesn’t mean that those chief executives won’t have to make difficult decisions, or that they won’t have to manage the finances, or that they won't have to manage corridor care. They will. But to show empathy on how hard it all is and to occasionally ask them how they are would still be welcome. The world won't come to an end by doing that.