Doctors who become chief executives in the NHS: from keen amateurs to skilled professionals

Summary

Objectives

To investigate the experiences of doctors who become chief executives of NHS organizations, with the aim of understanding their career paths and the facilitators and barriers encountered along the way.

Design

Twenty-two medical chief executives were identified and of these 20 were interviewed. In addition two former medical chief executives were interviewed. Information was collected about the age at which they became chief executives, the number of chief executive posts held, the training they received, and the opportunities, challenges and risks they experienced.

Setting

All NHS organizations in the United Kingdom in 2009.

Results

The age of medical chief executives on first appointment ranged from 36 to 64 years, the average being 48 years. The majority of those interviewed were either in their first chief executive post or had stepped down having held only one such post. The training and development accessed en route to becoming chief executives was highly variable. Interviewees were positive about the opportunity to bring about organizational and service improvement on a bigger scale than is possible in clinical work. At the same time, they emphasized the insecurities associated with being a chief executive. Doctors who become chief executives experience a change in their professional identity and the role of leaders occupying hybrid positions is not well recognized.

Conclusions

Doctors who become chief executives are self-styled ‘keen amateurs’ and there is a need to provide more structured support to enable them to become skilled professionals. The new faculty of medical leadership and management could have an important role in this process.

Introduction

After a decade or more in which NHS reform in England has been driven by ‘targets and terror’,¹ policymakers have argued that reform in future needs to be led locally with the full engagement of clinicians, especially doctors. The case for reform to be taken forward in this way derives in part from the limits of top down approaches to performance improvement in healthcare, and in part from the realization that lasting change is most likely to occur when it is based on the commitment of front-line staff delivering patient care. This argument was at the heart of the NHS Next Stage Review, led by Lord Darzi under the previous government, and it has been echoed in the plans set out by the Coalition Government elected in May.^2,3

Medical engagement in the NHS takes many forms, including the appointment of doctors as leaders of clinical teams, clinical directors within hospitals, medical directors in NHS trusts and primary care trusts, chief executives of NHS organizations and national clinical directors. This paper reports the results of a study of medical chief executives with the aim of identifying the facilitators and barriers to doctors taking on such roles in the future. At a time when plans to establish a faculty of medical leadership and management are at an advanced stage of development, the paper outlines an agenda of work for the faculty.

Methods

A list of medical chief executives was compiled based on the authors' knowledge of the chief executive community and information obtained from strategic health authorities. The emerging list was cross-checked against the Binley's NHS Directory which is the most comprehensive and up-to-date source of information about people in leadership roles in the NHS. This resulted in the identification of 22 medical chief executives at the time the study was initiated (June 2009), comprising approximately 4% of the total chief executive community in the NHS.

These 22 individuals were approached with a request to be interviewed and in the event 20 interviews were conducted between June and December 2009. In addition, two former medical chief executives were identified and interviewed, one of whom has since returned to take up a chief executive position within the NHS. One of the chief executives in the sample turned out to be a dentist and information gathered from this interview is included in the analysis.

A semi-structured questionnaire was used in the study, designed to understand the career paths taken and the facilitators and barriers encountered along the way. The emerging findings were shared with interviewees on completion of the fieldwork and were discussed with almost half of those interviewed at a seminar held in February 2010. A review of the international literature on doctors in leadership roles was drawn on in the interpretation of the material gathered during interviews and the writing of this paper.

Findings

The sample

Table 1 summarizes key data about those interviewed, including the medical training undertaken, the number of chief executive posts held, the year of first appointment as chief executive and age at first appointment. As Table 1 shows, the age of chief executives on first appointment ranged from 36 to 64 years, the average being 48 years. The majority (13/22) of those interviewed were either in their first chief executive roles at the time of interview or had stepped down from these roles having held only one such post.

Table 1.

Summary of key data about those interviewed

CE number	Medical training						Number of CE posts held	Year of first CE appointment	Age at first appointment
	GP	Public health	Secondary care (Mental Health)	Secondary care (Learning Disability)	Secondary care (Acute)	Dentistry
1					√		1	2007	47
2			√				1	2006	58
3		√					6	1989	42
4		√			√		2	2004	39
5	√						3	2002	40
6					√		1	2007	56
7					√		1	2008	45
8			√				1	2007	47
9	√						2	2000	44
10	√						2	2001	40
11					√		1	2008	57
12					√		2	1996	51
13					√		1	2001	46
14					√		1	2008	64
15						√	1	2004	46
16				√			1	2008	56
17	√	√					1	2007	49
18		√					1	2008	51
19	√	√					3	2001	43
20	√	√					3	2001	36
21	√	√			√		2	2004	46
22					√		1	2000	n/a

In our sample, a distinction can be drawn between those for whom becoming a chief executive came relatively late in their careers (typically in their 50s) following several years in other medical leadership roles, and those who were appointed in mid-career (either late 30s or 40s). Most interviewees fell into the latter category and many anticipated moving to other chief executive roles as opportunities rose. The factors influencing the time at which medical leaders become chief executives are discussed below.

Career paths

The career paths taken by our sample were many and varied. The most straightforward paths involved progression from clinical director to medical director and then to chief executive. This often included additional experience in one or more senior leadership roles, such as leading work on service reconfiguration or taking an operational management role, before appointment.

Interviewees who trained in general practice and public health used experience as primary care leaders or directors of public health as stepping stones to chief executive positions. Again it was usual for these interviewees to have spent time in other leadership roles, including in the civil service, along the way. A small number of interviewees described more varied careers involving experience of working in different countries and in the public and private sectors, including universities.

Advice and training

Interviewees received little in the way of structured advice and guidance as they moved into leadership roles. In most cases, they had to seek advice from more senior colleagues and were reliant on these colleagues and others who acted as coaches and mentors. This often led to opportunities to fill gaps in experience and eventually to appointment as chief executive. While a small number of interviewees emphasized the value of these opportunities, most argued that ‘the NHS’ had not shown interest in their careers and they had been reliant on their own efforts to succeed.

The training and development accessed by medical leaders en route to becoming chief executives was highly variable. Some benefited from formal training, in one case extending to taking a Masters degree in medical leadership. Others availed themselves of opportunities such as the executive programmes run by business schools and the leadership programmes offered by the British Association of Medical Managers (BAMM). Two interviewees had been appointed as chief executives after taking part in the recently established aspiring chief executive programmes organised by strategic health authorities.

Most interviewees emphasized the value they placed on learning on the job rather than taking part in formal programmes, comparing learning to be a leader with medical training and its emphasis on ‘see one, do one and teach one’. This raised the question for some of whether there was a need to move beyond medical leaders who were ‘keen amateurs’ to a more structured approach. The responsibilities of NHS chief executives and increasing public scrutiny of performance were felt to demand a greater degree of professionalism which required organized training and development that was simply not available to most of those interviewed when they started the leadership journey.

Combining leadership and clinical commitments

A major consideration for many interviewees was the impact on their clinical work of taking on leadership roles. Most interviewees who wanted to were able to combine clinical and leadership commitments until they became chief executives. The reported benefits included retaining credibility among clinical colleagues and maintaining the stimulation of seeing patients. As more than one commented, continuing contact with patients provided a reality check and a relative oasis of calm and predictability compared with the responsibilities of being a chief executive.

There were marked differences of opinion on how much time chief executives should commit to clinical work. One chief executive spent two days a week seeing patients whereas others took the view that being a chief executive should be a full time occupation leaving no time for clinical commitments. The transition from senior medical leadership roles to chief executive led most (17/22) to relinquish clinical work, although some continued to undertake this work albeit at a reduced level.

All recognized that the new arrangements for revalidation of doctors would have a bearing on this in future and might make it increasingly difficult for chief executives to combine clinical work with their leadership roles. Some went further to argue that it was not appropriate to retain clinical commitments given the demands of the role and the risk of being seen to be partisan in relation to the specialty or service in which the chief executive continued to practice. From this perspective, medical chief executives who retained part-time clinical activities reinforced the perception of people in this role being keen amateurs.

Re-defining professional identities

Doctors who take on leadership roles and become chief executives experience a shift in their professional identities. While some continued to see themselves as first and foremost doctors who were also chief executives, others described themselves as ‘a general manager first and a doctor second’. A more common response was for interviewees to describe themselves as leaders who combined clinical and managerial experience, thereby taking on a dual identity.

A number of interviewees acknowledged there had been a sense of loss when they moved into full-time leadership roles. The cultural divide between doctors and managers, summarized in the view that doctors who take on leadership roles are ‘going over to the dark side’, was mentioned on more than one occasion, as was a concern that becoming a chief executive meant ‘leaving the professional family’. Against this, some interviewees felt their identity had been enhanced because they were able to bridge the worlds of management and medicine and were therefore well placed to overcome the tribalism that is endemic in the NHS.

Opportunities, challenges and risks

A clear finding from this study is the opportunity chief executives have to bring about organizational and service improvements on a bigger scale than is possible in clinical work. One reported that being a chief executive was ‘the best job I’ve ever done' while another stated that ‘it can be a very satisfying job because you are doing what you want to do’. At the same time, there were many challenges in the ‘white water ride’ of leadership and the wide range of problems to be addressed. One interviewee likened himself and some of his peers to ‘adrenaline junkies’ who thrived on chaos and unpredictability.

Interviewees reflected on the disadvantages of being a chief executive as well as the benefits. A key theme here was the importance of recognizing gaps in competence and experience that needed to be filled by others. This had often resulted in the appointment of experienced colleagues as chief operating officers, medical directors and other roles to ensure that appropriate support was available.

The insecurities associated with being a chief executive were a recurring theme in the interviews. It is worth noting in this context, that during the period covered by our interviews, four of the chief executives still working in the NHS changed roles. One moved to a chief executive role in another healthcare system, a second moved to a chief executive role elsewhere in the NHS, a third was removed from his post, and a fourth resigned. In the opposite direction, a chief executive who had left the NHS to work in the private sector returned to take on an NHS role.

The fact that medical chief executives are in a small minority in the NHS was felt to be due in no small part to the risks associated with giving up a secure and predictable career for the uncertainties of being a chief executive. This explains why some of those interviewed retained a small clinical workload to keep open the option of a return to a clinical career in the event of failure. It also accounts for the decision of some to delay seeking a chief executive role until late in their careers when the consequences of failure would be easier to deal with.

Pay

A number of interviewees reported that they were not the most highly paid individuals within their organizations and they questioned whether this was appropriate. It was argued that pay differences could be a major deterrent for experienced hospital specialists with significant supplementary sources of income from private practice and other activities. Some interviewees reported that they had negotiated retention of their clinical salaries when they became chief executives to deal with pay differentials.

Discussion

The findings of this study lend support to other research into the fragile nature of clinical management roles in the NHS and the challenges facing leaders occupying hybrid positions. As Fitzgerald and colleagues noted in their review of change management in the NHS:

The hybrid group does not yet have a coherent work identity or credentialised knowledge base … there is no recognition of clinical management as a specialty, with limited educational opportunities or credentials – and an unwillingness to undertake major training. Other medical professionals do not consider clinical management to represent a medical specialty – rather clinical managers uncomfortably span the managerial/clinical divide and are not full or influential members of either occupational group.⁴

Montgomery's work on medical management in the United States has discussed the processes by which clinical management can become recognized as a specialty in its own right. These processes include ‘discovering colleagueship’ and ‘establishing legitimacy’, for example by forging a nucleus of people involved in these roles, forming a professional association and developing training programmes and an agreed curriculum.⁵

While some progress has been made on these issues in the NHS, for example through the work of BAMM, our study suggests that the role of clinical managers, including medical chief executives, is still not well recognized. The recent demise of BAMM underlines the challenges facing those who have championed medical leadership and the difficulty in securing financial and other support for doctors in leadership roles.⁶ It remains to be seen whether the faculty of medical leadership and management being developed by the Royal College of General Practitioners and the Royal College of Physicians will be more successful in raising the profile of medical leadership and standards of practice.

The work reported here suggests the faculty could play an important role in working with the NHS to:

• provide a focus for those working in medical leadership roles and set standards for leadership development;

• strengthen career planning, training and development, including the use of coaches and learning sets;

• develop clearer career paths that enable doctors to see how they can gain experience in different roles on the way to becoming chief executives;

• use existing medical and non-medical chief executives as role models, mentors and advisers;

• review pay differentials and ensure that clinical excellence awards can be used to reward medical leaders, even when they relinquish clinical work;

• develop a framework for continuing education and professional development that defines the competences and skills needed by medical leaders.

Equally important is the need to tackle barriers in the management culture in the NHS. At a time when there is continuing pressure to improve performance and intolerance of failure, it is not surprising that doctors who have successful clinical careers, including those who combine clinical work with leadership roles, are reluctant to become chief executives. Providing more structured training and support may help more doctors make the transition but other changes are also needed. These changes include finding ways of helping chief executives who get into difficulty and enabling them to return to clinical work or move on to other leadership roles if they lose their posts. England may be able to learn from Denmark in this regard where one month of re-training is made available to medical chief executives for every year of service.⁷

Conclusion

A clear message from this study is that the time has come to adopt a more structured and systematic approach to medical leadership in the NHS. The days of the ‘keen amateurs’ are numbered and the NHS will only be able to rise to the challenges that lie ahead by ensuring that the leaders in hybrid roles are supported and valued. This includes ensuring that medical chief executives in future are skilled professionals who have the experience and training to perform effectively in highly demanding roles. The adoption of the Medical Leadership Competency Framework developed by the Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement could provide a platform to support doctors to move into leadership roles and to help fulfil the aspirations of policymakers.

Footnotes

DECLARATIONS —

Competing interests PS, JC and KA are helping to support the establishment of the Faculty of Medical Leadership and Management

Funding The work on which this paper is based was funded by the NHS Institute for Innovation and Improvement and is reported in full in Ham C, et al. Medical Chief Executives in the NHS: Facilitators and Barriers to their Career Progress. London: NHS Institute for Innovation and Improvement; 2010

Ethical approval Not applicable

Guarantor CH

Contributorship CH drafted the paper and all other authors commented on the draft and contributed to the work on which it is based