Doctor Sandy Bradbrook’s Health Service leadership career followed 15 years in Industry. Now, nearly twenty-five years on as Chief Executive of Heart of Birmingham Teaching PCT, Sandy has a valuable perspective on the job of leading in the NHS, which he shares with Catalyst Editor Lesley Griffiths.

Lack of leadership is one of the biggest threats to the NHS in meeting its future goals. This was the observation of NHS Head David Nicholson at a recent NHS Employers’ conference. What makes this environment so particularly challenging? What characterises leadership excellence in health and how do we get more of it?

How would you define excellent leadership in the Health Service?

It’s the ability to manage both internal and external relationships well in order to deliver on very sharp government targets and keen customer expectations - these, of course, are very personal because of the nature of the services we are dealing with. Leadership in the NHS is quite distinct from other types of business - in Industry, for example, you have a defined chain of command and if there is a product fault, the customer-facing retailer can pass it back to the manufacturer. In the NHS we’re responsible for both the front-end client who experiences the problem and the people who have created it.

What skills do you look for in future leaders?

Relationship management is key. Leading in the NHS is more about corralling people to a common purpose than it is telling them that they have to follow a particular line, as it often is in other types of organisation. Then, in the external world, we’re working jointly with local authorities and the Third Sector, so another challenge is how to draw those partners together to follow that purpose.
Leaders also need to be able to see the bigger picture and take some risks but also have the ability to get into sufficient detail when necessary.
You also need people with a strong sense of integrity and a strong value set because you can’t survive in the public sector without it – that, in particular, sets leadership in this sector apart from commercial leadership.  

What lessons from your own life and leadership career would you pass on to a leader-in-waiting?

Be true to yourself and know yourself; be prepared to rely on others; and make sure you select good people. Remember you’re a servant, not a king. 

Why do you think there is such a lack of good leaders in Health?

The politicisation of the NHS means that it’s been under huge pressure and those accountable are the managers, directors, and chief executives, rather than the doctors, nurses and clinicians. That level of pressure can create ‘yes people’ - those who want to tick boxes - and because the political system often has the characteristic of seeking scapegoats, that can mitigate against good leaders putting themselves forward.
But we’re beginning to shift from that. The challenge from the politicians is still there, but now they recognise the need to build up capabilities locally for bringing about that leadership. We now have NHS Foundation Trusts to develop excellence in the provision, with local accountability, and the World Class Commissioning movement to foster local leadership needing quality in both teams and individuals. However, all of that could easily fail if too much control is assumed by the centre.

One observation of the NHS is that a lack of commercial imperative puts a greater focus on process and slows decision making. How would you respond to that?

Certainly, the focus on process is true. Over the years the NHS has become sort of risk averse and every time there’s an issue someone imposes another system of controls on it, which never actually solves the problem - you’ve only got to look at child protection cases over the last 30 years. But, as to slow decision making, you can’t take rapid decisions in the Health Service because the sheer scale - and the process in which you have to engineer that change - takes time. The idea of Foundation Trusts is to try and bring some of that speed of movement from the commercial sector on the basis that people’s futures are wrapped up in the success of that enterprise, and if you get clinicians really switched on you can achieve quite rapid change.

Do you feel leaders in the sector are unfairly perceived?

It’s a popular political or media football to kick the management, but the NHS has got amongst the lowest management cost for any organisation of its size in the world and I think the quality of leadership in the NHS is very good. The job of a leaders in the NHS is becoming increasingly complex and challenging and there are people in the sector who say “I don’t want to be a Chief Executive, because it’s too risky a job”. Therefore, we have to foster the talent that can cope with the stresses and strains that exist in this very complex and publicly exposed role.

What are the biggest frustrations of working in the culture of the NHS?

Currently, it’s finding the way to engage effectively with the public. If we could do that better we could do three things:

• get them to take more responsibility for their own health
• understand better what it is they feel they need so that we can respond to that
• they would understand and better appreciate what the Health Service does for them, what it could do in the future, and how best they can use its services.

What do you find most rewarding?

Two best things: the people we work with are terrific and very committed and passionate about what they’re doing. The other thing is not necessarily immediate unless you’re a clinician, but in so far as every individual employee contributes to improvements in that healthcare system, you know that you’re actually putting something better in place that a lot of people will ultimately benefit from - that’s very satisfying.

What would you like your legacy in this role to be?

To leave behind a vibrant organisation that’s confident in itself and set in place some irrevocable change that will deliver far better health to the local population. I can’t finish the job because it’s never-ending, but we can set quite a few things in place.

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