We welcome our CCG colleagues just as we need a new leadership approach in the NHS. In a recent HSJ article Susan Hodgetts of the Institute of Healthcare Management says our new breed of senior leaders must be less ‘heroic’ and more ‘brave, inspirational, engaging, collaborative and inclusive’ as well as having ‘commercial understanding and acumen’. Quite an ask!

In the same issue Chris Hopson, the new CEO of the FTN, points out that some CEO posts are proving difficult to fill. I believe over 20 posts are currently vacant.

If I were a new GP leader entering the fray I might be perturbed by this, and wonder what the reasons are? After all, in the old days there didn’t seem to be any shortage of ‘pace-setting’ CEOs stepping forward, so why are the ‘new collaborators’ hanging back?

One explanation is that some Trusts, a growing number, have fundamental structural issues for which a wider solution is needed, but not yet possible or agreed.  A legacy financial deficit, an unaffordable PFI, or insufficient scale to be sustainable. These jobs present an interesting challenge to some, but a negative agenda to others. After all, isn’t it more rewarding to implement a safety culture, or work on care quality, or get to grips with outcomes, than to struggle with the system in an effort to resolve structural issues? Particularly if you come from a clinical background?

A second reason is that the culture in the NHS is not, currently, a comfortable one for the ‘new’ leader to work in. From day one there will be pressure to hit targets from ‘tomorrow’, even though it will require a year of engaging, relationship building, and system influencing to make real progress. Headroom to do this is hard to come by, and so it drives a ‘pace-setting’ approach from CEOs.  I was afforded it when I first became a CEO and it was crucial. Others have not been so lucky, and it does seem as if ‘fighting the system’ is often necessary?

A personal example. This year, we agreed with our Commissioners a risk sharing fixed contract, backed by a System Plan and behavioural compact signed by all parties. At a stroke, we could no longer be accused of driving income growth through tariff, or of not being a ‘system player’. And we can invest in clinical schemes to keep people well and reduce the need for hospital admission – fantastic!

The reaction? Concern that the commissioners had ‘colluded’ with us, and were now unable to use ‘contractual levers and penalties’, plus the need for us to reassure our regulator that we had not put the organisation at financial risk (from over-activity).

I guess we have ‘colluded’, or collaborated, but with constructive intention?  We aren’t now spending many man hours arguing over coding, or penalties – instead we are working together on managing demand. It is true we have taken a risk on activity. But if we hadn’t, we would have been unable to move forward in the way we must. We will press on, I hope, but isn’t it daft that we need to stretch the rules to do what is right?

Large bureaucracies are unwieldy things, especially when they are as politically and universally important as the NHS. I understand that and I remain optimistic. In these challenging times, here are my three ‘must do’s’ for all senior leaders:

1. Always do the right thing, even if it might create short term difficulties for you. At the same time, make the case again and again, and trust that ‘right will out’ in the end. And if it doesn’t, well, you did the right thing?

2. Support our CCG colleagues to be different, and to stay different, from their predecessors. They must remember always that their clinician and patient perspective is their raison d’etre, and they must stand firm whenever the forces of inertia are acting in favour of ‘business as usual’.

3. Keep stressing the need for culture change, and work together to drive it. We all know what is needed – system not organisation, collaboration not competition, listening not telling, dealing with concerns not hiding them, agreed solutions not sticking plasters, and so on and so on

Will the new leadership succeed? Of course, so long as we follow our instincts, work together, and fight the good fight!