Staying accountable: NHS leadership in hard times

Alongside our new report today on accountability, Helen Buckingham looks at whether promises made nationally to improve leadership behaviour are being kept, and emphasises the stark consequences of getting it wrong.

Blog post

Published: 15/11/2017

Last month, the BBC launched their NHS Tracker with the depressing news that the NHS in England, Wales and Northern Ireland had failed to achieve key standards in waiting times for emergency care, cancer care and planned surgery for the last 18 months.

In September, we saw two trust chief executives suddenly resign due to poor A&E performance, and few weeks have gone by without the resignation of at least one CCG leader, closely associated with reports of poor performance on finances or targets – or both – in their areas.

Only last weekend, we read that Theresa May is reportedly holding Simon Stevens, the Chief Executive of NHS England, personally accountable for the performance of the NHS this winter.

Our report today is set in this context. A year ago, the Nuffield Trust set out to find how CCG accountable officers and local leaders in NHS England felt as they tried to find the right balance around accountability, autonomy and performance management – both to deliver now and for future strategic change.

What we found

It won’t surprise many that a significant proportion of the leaders we spoke to felt the current approach to recognising accountability and managing performance could be described as skewed to the stick, rather than the carrot. As one NHS England leader noted ruefully:

“There’s a quality angle to the role but if you looked at my diary, about 80 per cent of my time is spent on performance management.”

We found that most energy was spent addressing current performance and financial pressures, rather than on supporting CCGs and local systems with longer-term approaches that are more likely to deliver sustainable change, but might take time to show results.

With NHS commissioning organisations in England already restructured seven times since the early 1990s – each iteration looking to improve the accountability and performance management systems that came before – sustainability and transformation partnerships (STPs), accountable care organisations and accountable care systems are an eighth change. How can we learn from past lessons?

NHS England, NHS Improvement and other national bodies have recognised many of the issues described in our report, and set out plans to address them.

What has been promised?

Structurally, NHS England and NHS Improvement have agreed to test the appointment of joint regional directors in the south of England, and there are already joint nurse directors in London and the south. Over winter, each STP area will be overseen by a single regional director acting on behalf of both NHS England and NHS Improvement, and there will be a single escalation framework, overseen by the joint National Director of Urgent and Emergency Care.   

But whatever the structure, ultimately it is leadership behaviour that will have a long-term impact on organisations and systems.

Last December, six national bodies jointly published the National Framework for Improvement and Leadership Development: Developing people, improving care. This described how NHS England, NHS Improvement and other national partners had agreed to develop skills in systems leadership, improvement and compassionate, inclusive leadership. The framework made three pledges:

  • We will model in all our dealings with the service and in our own organisations the inclusive, compassionate leadership and attention to people development that establish continuous improvement cultures.
  • We will support local decision-makers through collectively reshaping the regulatory and oversight environment. In particular, we owe local organisations and systems time and space to establish continuous improvement cultures.
  • We will use the framework as a guide when we do anything at a national level concerning leadership, improvement and talent management so we engage across the service with one voice.

Are the promises being kept?

Honouring these pledges is essential for STPs, accountable care systems and accountable care organisations to realise their potential. It is extraordinarily difficult to do that with such huge operational pressure in the service, but that only magnifies how important it is to support local leaders tackling those pressures every day.

So, a year on from our interviews and the publication of Developing people, improving care, have things really changed?

There is great work going on in parts of NHS England and NHS Improvement to foster innovation and quality improvement, and to support local leaders in making change on the ground, such as through the work of the new care models team at NHS England, or the nursing team at NHS Improvement.

But there also continue to be examples of pretty robust ‘directive’ and ‘pace-setting’ management – an approach described by the HSJ’s Andy Cowper as ‘management by admonishment’.

We are still seeing responses to urgent short-term imperatives crowd out the time needed for important long-term work. We are still seeing the NHS and local authorities enjoined to collaborate at a local level, while actions taken nationally heighten tensions in those relationships. There is a dissonance between actions and words, and people leading local organisations feel that.

And that makes their job harder. One of the striking points from our interviews was the responsibility leaders felt about supporting their staff through more change and more pressure. We see that too in leaders of provider organisations, who have made recent statements on social media about the pressures on frontline staff.

The NHS Constitution states that “it is the commitment, professionalism and dedication of staff working for the benefit of the people the NHS serves that really make the difference”.

The leaders in CCGs, trusts and STPs count among those staff, and we must not take their professionalism and dedication for granted. If we are not able to look after the leaders of the organisations we have now, we risk having no leaders for the organisations of the future.


“Do the wise thing and the kind thing too, and make the best of us and not the worst.” (Charles Dickens, Hard Times.)

Suggested citation

Buckingham, H (2017) "Staying accountable: NHS leadership in hard times", Nuffield Trust comment.