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Judith Smith, Director of Policy, Nuffield Trust

In 1987, like generations of NHS graduate management trainees, I made my way to Harrogate for the 2-day assessment centre which determined which bright-eyed and bushy-tailed graduates were to be admitted to the national scheme.  I can still recall how surprised and impressed I was that the final appointments panel was chaired by a woman chief executive, and that she took time during the interview to talk to me about the NHS’ opportunities and support for women managers.  Bear in mind that a similar interview for the then British Rail scheme, I had been asked why ever a woman would be interested in trains, and at another for the electricity supply industry, I found myself completely surrounded by male engineers and aspirant trainees.

So do we still need to keep talking about gender and leadership almost 30 years later, or is this yesterday’s issue?  There seems to be more positive news for women where NHS management is concerned: between 60 and 70% of trainees entering the NHS graduate scheme in the past three years have been female[1], and 36%[2]of NHS Chief Executives are women.

But dig a little deeper and progress does not look so good.  Women still tend to migrate to chief executive posts in community health, children’s, women’s and mental health services.  And only two out of ten Chief Executives of the Shelford Group, containing the largest teaching hospitals, are female.  This mirrors my PhD research in 2006 which found that three quarters of trust/foundation trust chief executives were men, and women tended to lead organisations of smaller budget and headcount[3]. This reflects a well-evidenced phenomenon in research on gender and organisations that women will always tend to be found in greater numbers within what are perceived to be less powerful or attractive parts of a particular sector of work (e.g. primary rather than senior schools, family law rather than litigation, paediatrics rather than orthopaedics).

There is also a fundamental question to be asked about why the female majority at graduate trainee level has not yet translated into at least equal numbers of women securing chief executive posts in all parts of the NHS.  In my PhD research, women NHS chief executives highlighted profound dilemmas that suggest why gender equity is still proving elusive.  As well as the perhaps unsurprising tensions of trying to balance healthy home life and parenthood, women expressed serious concerns about a wider NHS culture, typically displayed by national oversight and performance bodies, that models ‘do as I tell you’ and unforgiving management behaviour, and expects a single ‘heroic’ leader for organisations.  In other words, one who will be married to the job and prepared to fall on their sword if and when their organisation struggles.

These issues may come from research with women chief executives, but I am convinced that many male chief executives encounter the same dilemmas, and feel similar dissonance about how they choose to craft the culture and ways of working in their own organisation, compared with how they experience performance management and regulation from above.  In our Francis One Year on work at the Nuffield Trust[4], we heard from chief executives of how they were strengthening means of staff engagement, taking a much more open and direct approach to dealing with comments and complaints from patients and families, encouraging staff to speak out about concerns, and using errors and complaints as part of wider organisational development and learning.

In an article for the HSJ in 2013[5], I argued that the culture of NHS management continues to be a cause for concern, especially after the Francis Inquiry and its conclusion that the NHS was too prone to prioritise ‘the system’s business’ above the needs of patients, families and staff.   In our Nuffield Trust research into the response made by hospitals to the Francis Report3we concluded that NHS executive teams are often the ‘shock absorber’ in the wider system, trying to shield their organisations from an unforgiving performance and regulatory culture.  What Francis was seeking was something more open, improvement-focused, and supportive, with proper respect shown to NHS leadership teams, albeit with accountability for quality and patient care above all else.

I never imagined in 1987 that I would still be concerned about the composition of the NHS leadership community some 30 years later.  So we do need to keep talking about gender in NHS leadership and management, for data on representation of women, together with analysis of the experiences of all leaders’ experiences of holding executive posts, act as a barometer of how successfully (or not) the NHS is creating a healthier and more supportive culture for its leaders.  

[1]NHS Leadership Academy, personal communication


[3]Smith Judith A (2009) The role and experience of women chief executives in the NHS in England: gendered stories of leadership in difficult times.  PhD thesis, the University of Birmingham

[4]Thorlby R, Smith JA, Williams S and Dayan M (2014) The Francis Report, One Year On: the responses of acute trusts in England