Health Secretary Wes Streeting’s reform agenda for the NHS, which includes publishing performance league tables, introducing new targets, and sweeping management overhaul, has produced mixed reactions.
Undoubtedly, the UK urgently needs to reform leadership and management to tackle the productivity crisis in healthcare. Polling commissioned by UCL Global Business School for Health found that more than three-fifths (61%) of the 1,506 participants surveyed in October believe NHS managers should be dismissed if they cannot improve patient care at their organisation.
When asked about what the public wanted to see from their NHS leaders, bringing down waiting lists was the top priority, followed by improving A&E services, bringing in the right staff to provide high-quality care, and working to deliver more healthcare in the community. The question is whether these proposed reforms will provide that.
NHS leaders are right to raise questions on exactly what behaviour the reform agenda will promote and whether this new approach will kick the can down the road on the broader, more complex challenges facing underfunded and overstretched NHS trusts.
Introducing league tables to support running public services is not new, but it has certainly fallen out of favour in education circles. One of the main arguments for changing that approach is that schools at the bottom of the league tables tend to be in areas of high social deprivation. From my experience working across the health and education sectors, I can see how this problem will also manifest in the NHS.
The creation of league tables risks encouraging NHS leaders to focus disproportionately on what is being measured rather than on what truly needs improvement. As seen with Ofsted’s role in education, placing undue emphasis on narrowly defined metrics can distort priorities.
In healthcare, this could mean focusing on achieving favourable short-term targets, such as reducing waiting times, at the expense of tackling deeper, systemic issues like workforce retention, integration of services, or addressing health inequalities. These areas are harder to measure but are critical to the long-term improvement of patient outcomes.
Transformation in any healthcare system is extremely difficult. Numerous reviews and studies have been undertaken to understand the NHS—often focusing on the challenges of leadership and management. Implicit to most is the notion that good leaders gravitate to the best-ranked hospitals and health centres. But it should be recognised there is a postcode lottery at play, and those leading the most challenging trusts are given little credit for taking on these demanding roles that a league table may not recognise.
In Sir Ron Kerr’s report on ‘Empowering NHS Leaders to Lead’, an NHS Providers survey is quoted, ‘The culture of seeing CEOs as wholly dispensable is damaging to individuals, to organisations and the reputation of the wider NHS’. Moreover, analysis from The King’s Fund on the NHS Providers survey data, found that Trusts rated ‘outstanding’ by the Care Quality Commission had only three percent of executive posts with vacancies while ‘poorly’ rated Trusts had 20 percent of executives who were appointed in the last two years.
If we go back to the building blocks of what helped turn around our schools, we see that several factors require us to support our leaders to stay in the game so the building blocks of success can flourish.
Healthcare support should revolve around ensuring appropriate tenure for our NHS leaders, especially those in our challenged Trusts.
We need to ensure that they are given the time and space to do what is best without focusing solely on short-termism, which is already a byproduct of the relationship between our political and health systems. Studies across other sectors have demonstrated that tenures of five or more years are successful in building long-term thinking and an understanding of the communities and populations being served.
Such an approach to ensuring adequate tenure for our NHS leaders also requires us to educate our boards on what breeds success.
Many do not appreciate that the rotating door they have established for their CEO is the problem. CEOs and senior team members need time to form strong teams if they are to be high-performing and successful.
Lastly, we need to recognise that many of our struggling Trusts are in areas experiencing health inequity, with social factors that make community relationship building and understanding the context of care integral to success. Results in such locations require empathy as well as capability. However, demonstrating this long-term commitment to these communities through engagement and improved services will not be a quick fix.
Ultimately, providing our NHS leaders with the time and space to prioritise long-term goals is crucial, rather than being driven by short-term pressures—an issue already ingrained in the dynamic between our political and health system. Introducing performance league tables risks exacerbating this problem, creating perverse incentives that shift focus from what truly matters. NHS leaders should be empowered to tackle the root causes of inefficiencies and inequities rather than merely playing to the metrics that make the league table look good.
As the Darzi review rightly points out, transforming the NHS is going to be extremely difficult, but it is essential that we support our NHS leaders without reverting to the easy throwaway approach of the past of blaming those who care to lead.
