4.50. Great quality care needs great leadership at all levels. Evidence shows that the quality of care and organisational performance are directly affected by the quality of leadership and the improvement cultures leaders create [168, 169, 170]. While some parts of the NHS have created and sustained the leadership cultures necessary for outstanding performance and the big service changes set out in this Long Term Plan, this is not yet commonplace. We also do not currently have a sufficient pipeline of highly skilled and readily deployable senior leaders – a 2018 survey by The King’s Fund and NHS Providers found 8% of Executive Director roles were filled by an interim or vacant, while 37% of trusts had at least one vacant Executive Director post .
4.51. There will be a new compact with our most senior leaders. We will better support them, particularly those undertaking the most challenging roles; ensuring they have both the time and space to make a difference, and appropriate ‘air cover’ when taking difficult decisions. NHS England and NHS Improvement are already aligning our operating models, and we will continue to work closely with other regulatory bodies to ensure our expectations are clear and consistent, and to keep our assurance and oversight proportionate. We will consistently model the behaviours we expect to see from leaders in our interactions with them. These commitments will be enshrined in a new ‘NHS leadership code’ which will set out the cultural values and leadership behaviours of the NHS and will be used to underpin everything from our recruitment practices to development programmes.
4.52. We will also do more to nurture the next generation of leaders by more systematically identifying, developing and supporting those with the capability and ambition to reach the most senior levels of the service. The national workforce group will look at options for improving the NHS leadership pipeline. This will build on the recent Kerr  and Kark  reviews. It will include:
- a systematic regional and local approach for identifying, assessing, developing, deploying and supporting talent, to be in place from early 2019;
- proposals to ensure that more senior clinicians take on executive leadership roles building on the recent Faculty of Medical Leadership and Management report on clinical leadership;
- expansion of the NHS graduate management training scheme, and support for graduates from the scheme, while also identifying high-potential clinicians and others to receive career support to enable progression to the most senior levels of the service;
- a consideration of the potential benefits and operation of a professional registration scheme for senior NHS leaders, similar to those used in other sectors of the economy and amongst other NHS professionals, which would recognise the role of NHS management and help the NHS attract and retain the best people for the most challenging jobs;
- measures to support transitions from other sectors into senior leadership positions in the NHS.
4.53. We will do more to develop and embed cultures of compassion, inclusion, and collaboration across the NHS. Building on the ambitions of Developing People: Improving Care we will work to support all parts of the NHS to create an inclusive and just culture that leads to outstanding staff engagement and patient care, including:
- programmes and interventions to ensure a more diverse leadership cadre, and more inclusive cultures, to improve the experience and representation of all staff and the population they serve;
- leadership development offers available to staff at all levels, and the establishment of a faculty of coaches and mentors available to support senior leaders;
- developing the knowledge of improvement skills and how to apply them for all levels of leadership in the NHS.
For cancer, we need to recruit an additional 1,500 new clinical and diagnostic staff across seven priority specialisms between 2018 and 2021. Since 2017, there has been a net increase of 833 FTE staff across the seven priority specialisms.
168. West, M., Topakas, A. & Dawson, J. (2014) Climate and culture for health care performance. The Oxford handbook of organizational climate and culture. 335-359. Available from: https://doi.org/10.1093/oxfordhb/9780199860715.013.0018
169. Care Quality Commission (2017) Driving improvement: Case studies from eight trusts. Available from: https://www.cqc.org.uk/sites/default/files/20170614_drivingimprovement.pdf
170. Faculty of Medical Leadership and Management, Centre for Creative Leadership & The King’s Fund (2015) Leadership and leadership development in healthcare: The evidence base. Available from: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/leadership-leadership- development-health-care-feb-2015.pdf
171. Anandaciva, S., Ward, D., Randhawa, M. & Edge, R. (2018) Leadership in today’s NHS: Delivering the impossible. The King’s Fund & NHS Providers. Available from: https://www.kingsfund.org.uk/sites/default/files/2018-07/Leadership_in_todays_NHS.pdf
172. Department of Health and Social Care (2018) Empowering NHS leaders to lead – Sir Ron Available from: https://www.gov.uk/government/publications/sir-ron-kerr-review-empowering-nhs-leaders-to-lead
173. Department of Health and Social Care (2018) Kark Review of the Fit and Proper Persons Requirement: Terms of reference and protocol. Available from: https://www.gov.uk/government/publications/kark-review-terms-of-reference