The Messenger Review of health and social care leadership: what must it address?

Introduction

In October 2021 the government launched a review of leadership in health and social care, led by former Vice Chief of the Defence Staff General Sir Gordon Messenger. It is the latest in a long line of reviews dating back to the Griffiths review of NHS management in the 1980s. As set out in the latest review’s terms of reference, it will make recommendations on improvements to how health and social care is led and managed in England. The report is expected in April.

Since the announcement of the review, the NHS Confederation has engaged directly with NHS leaders through our member networks to understand how they believe leadership could be more supported and improved across health and care. This included five roundtables that were held with our members from across all parts of the health system, and Sir Gordon and his team. We are grateful to our members and Sir Gordon and his team for engaging so extensively ahead of the final report.

This short report sets out the key issues that our members would like to see feature in Sir Gordon’s final report. Our focus is on NHS leadership rather than social care leadership, which other organisations are better placed to address.  

The view from NHS leaders: improving leadership across health and care

The NHS Confederation has long been clear that developing effective leadership is a prerequisite for improvement across a range of areas, including operational performance and working culture. As the Care Quality Commission (CQC) has rightly highlighted, ‘the most important determinant of quality of care is leadership ¹ .’ 
While there is no one right way to lead organisations, there are certain core skills and behaviours that should apply in any leadership context. Our members believe that development of these skills and behaviours should be supported through a light-touch national framework that provides a consistent approach to developing leaders.

Sir Gordon’s report should cover the following priority issues, which will require greater attention from government and the national bodies, including NHS England and NHS Improvement (NHSEI).

System leadership

The Messenger Review should emphasise the new operating environment we are moving into through integrated care systems (ICSs) and place-based partnerships. The focus on integration, collaboration and more blurred organisational boundaries will require different leadership characteristics than those incentivised by a system driven by marketisation and competition. The review should address and begin to explore the new skills and systems-focused mindset that will need to be ‘hard-wired’ into those in leadership positions within the NHS – much of which is already in evidence across the country. 

Key to developing effective system leadership will be establishing a culture of learning and improvement, with less emphasis on top-down performance management. To support this, the NHS Confederation is working alongside the Local Government Association and NHS Providers to offer a programme of peer support and peer review to health and care leaders. 

The CQC, meanwhile, should move from overseeing an inspection (and often punitive) regime to one that encourages learning from errors. It should focus on improvement as well as sharing of best practice.  

Distributed leadership

Linked to the above point, we are moving towards a new health and care landscape in which leadership is likely to be dispersed throughout different levels of system working. For example, leaders of local authorities, place-based partnerships, trusts and provider collaboratives will all need to demonstrate leadership to deliver improvements for populations at place level. There is therefore scope here for the development of leadership models which reflect that leaders’ remit may cover, or have implications for, not one but several organisations. 

Lessons may be drawn here from multi-academy school trusts as an existing public sector collaborative model.

The role of the centre

The review should take the opportunity not just to examine leadership within the organisations that deliver frontline services, but also the role of the arm’s-length bodies, particularly with regards to NHSEI and its regional offices. There is a strong sense from our members that central leadership is needed on some issues and local leadership on others, supported by peer challenge and support and the use of information on comparative performance.

It will be a major omission if the review fails to examine the role of NHSEI in supporting effective leadership, which will be crucial over the coming years. This was highlighted in our recent report written by Professor Sir Chris Ham.

Diversity in leadership

The review should address the need to ensure greater diversity across NHS leadership. While progress has been made in some areas to improve levels of diversity across the NHS, there is still a long way to go. While there were encouraging early signs of increased diversity across a range of characteristics within ICS chair recruitment, this has not been reflected in the CEO appointments, with just one ICS CEO designate identified as coming from an ethnic minority background.

The importance of the 'tap on the shoulder' culture in role progression was raised by our mental health leaders, which often negatively impacts on supporting more diverse leadership within the NHS.

Given the importance of this agenda, the NHS Confederation has been working with NHSEI to provide recruitment support to the new ICSs to help achieve greater leadership diversity. Thought diversity across the range of experiences of our workforce must be actively sought and utilised. Research by our Health and Care Women’s Leaders Network, BME Leadership Network and Health and Care LGBTQ+ Leaders Network has detailed the damaging effects of the pandemic on women, people from LGBTQ+ communities and black, Asian and minority ethnic communities. 

The review presents an opportunity to invest in current diverse talent management and succession planning, as at present the NHS is effectively squandering talent through lack of inclusion.

Diverse efficient leadership must be supported by an NHS leadership centre and coded with a clear set of values and accompanying materials empowering frontline workers. We must take the opportunity to improve cultural intelligence, equality of opportunity and the realisation of potential with expectations of leadership in every role. The impact of structural change should help not hinder representative leadership and therefore the quality, effectiveness and efficiency of the delivery of work against inequalities.

Consistency of leadership development

The review should recognise that a new and consistent approach to leadership development across the NHS is required; one that is less centred on individual organisations with their own approaches. 

Primary care leaders have told us that they would like access to the same NHS leadership programmes as those in secondary care, but also face the challenge of lacking funded backfill for leaders to join such programmes. Our primary care engagement sessions also highlighted the neglect of managerial leadership development. Continuing to overlook managers in favour of clinicians will impact primary care's ability to plan strategically and engage at scale.

The NHS is one of the biggest employers in the world and it needs more robust infrastructure on leadership development. This should incorporate a more rigorous and proactive approach to talent management, as well as more effective sharing of talent across organisations and systems. 

Consideration should be given to the notion of an independent organisation with responsibility for leadership development. However, the review should note criticism of the NHS Leadership Academy (which moved to NHSEI in 2019). To our members, this has felt disconnected from the realities of local operating environments. There is therefore a need for leadership programmes developed at national level to be co-designed, where possible, with local leaders on a cross-sectoral basis. 

The inverse leadership law

The review should address the inverse leadership law ² that we often see across the NHS. This law stipulates that the quality of leadership is likely to be highest in NHS organisations that are already the most successful, and poorest in the least successful. 

Linked to this is an outdated assumption that the acute sector is where the ‘strong’ leaders are, which undervalues significant experience that exists in other sectors. 

Simply, we need to do much more to support leaders who take on the most challenging roles in the NHS. Too often, CEOs are not given the time, support and incentives they need to succeed in organisations that face the most severe systemic challenges. We are in danger of deterring leaders from taking on such roles or, worse still, damaging the careers of leaders who are criticised and dismissed if they are deemed to have failed, despite often facing challenges outside of their control. 

The education sector arguably provides a case study for better culture on this problem, with headteachers given time and support to turn around the most troubled schools and celebrated when they do. 

Diversifying pathways to NHS leadership

The review should acknowledge that the NHS must do more to simplify, increase and incentivise entry routes into the service for mid-career professionals, both to those from outside the sector and those already working in one part of the NHS but who want to broaden their experience in another. 

This will require, for example, facilitating more opportunities for staff working in primary care to enter secondary care roles and vice versa. Similarly, more must be done to break down the boundaries between clinicians and managers, with better support for clinicians to take on leadership roles. Primary care leaders have told us they would like to see more managers and front-of-house staff entering leadership positions to ease the burden on clinical leaders and diversify the types of roles represented.

Currently, emerging leaders often become stuck in career silos.

Allowing time to lead

Leaders from across the NHS Confederation’s members have told us that there is a significant lack of time, capacity and support to undertake some of the fundamental but longer-term strategic thinking for their organisations and systems. Immediate pressures on services, notably through the COVID-19 pandemic but now on elective recovery, have taken up much of leaders’ capacityThe review must address this and explore how we can begin to free up more time for leaders at all levels to lead.

NHS Confederation viewpoint

The announcement of General Sir Gordon Messenger’s review was accompanied with negative headlines about the quality of NHS management and leadership. This understandably led to concerns among NHS leaders that the review would get in the way of more pressing priorities for NHS leaders and their teams. In response to these headlines, the NHS Confederation has published ‘long reads’ on the valuable contribution that NHS managers and leaders make to patient outcomes and efficiency. In our view, investment in management and leadership is essential in securing productivity, quality and reform.

Following the extensive engagement we have had with Sir Gordon and his team, we believe they share this view and we are encouraged by the work they have undertaken. The review is an important opportunity to improve the ways in which the NHS supports those in leadership roles – both now and in the future – and we look forward to assessing the review’s recommendations against the points we have made in this report.

Understandably, the NHS’s approach to leadership development over the last few decades has been focused on individual organisations and has reflected the fragmented nature of our health system up until this point. With important changes on the way that will put collaboration and partnership working at the centre of the way the NHS operates, there is a timely opportunity to evolve and improve the way we support leaders and the way we approach talent management. Key to this change will be developing effective system leadership, backed up by a culture of learning and improvement that places much less emphasis on top-down performance management.

As we know, Sir Gordon’s review is the latest in a string of reports into NHS management and leadership. Many of these reports did not achieve the objectives they set out to and it’s crucial that Sir Gordon’s report avoids their fate and instead translates into lasting improvements. To stand the best chance of achieving that, NHS leaders will need to be actively involved in the implementation of the recommendations. Given the collaborative way in which the review has been undertaken, it would be a mistake to impose the recommendations from the top down.