What Q3 told us about evolving leadership profiles in Specialist Care

Commissioners are asking providers to justify every line of the bed price

One of the most consistent themes in my conversations this quarter has been the changing tone of discussions with local authorities and commissioners. The business development director of a large specialist care provider described commissioners using pricing software that generates an expected bed price based on the care being delivered. Where the provider’s price differs from the output, they are expected to explain why, in detail, including wages, overheads and bed numbers.

Her frustration was that the conversation had drifted away from what she would rather be discussing: an outstanding rated service, a strong track record and the care actually being delivered. It is a little like a client asking a recruiter to break down how they arrived at their fee, down to the desk cost and the wages behind it. Every conversation becomes a justification of cost rather than a discussion of value.

The pressure is not evenly spread either as some local authorities have a reputation for being particularly restrictive, and I know providers who will not open services in those areas because the economics do not justify the effort.

The link to hiring is relationships. A leader with established commissioner relationships and a credible track record changes the nature of the conversation, from bartering to trust in the care being delivered and an understanding of the pricing behind it. It also speeds up growth. Those relationships make it easier to secure a property, open a service and reach admissions, which shortens the time it takes for a service to move from loss making to P&L positive.

This is most visible in adult social care and complex care, although the same dynamics apply in elderly care. The policy direction towards community-based care is also increasing acuity in the community, and higher acuity carries higher cost and, usually, a better margin. One MD search I am running is at final stage with a candidate who brings exactly these relationships. The client’s plan is to open homes supporting two adults with very complex needs, where the margin is significantly higher, and the relationships make it far easier to get the property secured and the admissions in.

Every leadership role now carries a commercial lens

Of course commercial acumen has always mattered in care leadership, but it has been exacerbated by cost pressures that providers cannot ignore. Increased employer National Insurance, a higher cost of living and rises in the minimum wage are squeezing margins, and the response has been to assess every role as a return on investment.

That now extends well beyond the roles you might expect. I am seeing operations directors being asked about their P&L understanding and whether they have been involved in commercial pricing strategy, something that would once have sat firmly with a commercial director. Even a people and culture director search I recently completed was framed through cost. The client wanted strong employee relations to avoid tribunals, a robust sickness management process to reduce absence, and good learning and development and onboarding to protect hiring and retention.

A director of quality role I am working on came from the same place. The business was securing investment, and the equity house asked what it was doing to manage quality as it grew. Despite good and outstanding services, it had no one owning quality at a senior level. That is a quality hire, but it is also a commercial one.

The one area where I see less of this is therapy. Heads of therapy will typically hold a team budget, but their focus is on delivering high quality care, and the wider cost decisions are handled by the operational and regional directors around them.

Leadership candidates now need clinical credibility alongside commercial acumen

The hardest profile to find right now is the clinical leader who also has commercial acumen. There are plenty of business development professionals with decent commissioner relationships. The very best are hard to attract because they are tied in by commission, KPIs and sometimes equity, but the pool exists. A clinician who can resonate with a clinical workforce, lead strategically and operationally, and run a P&L is a much smaller pool. Nine times out of ten, a clinician is excellent at clinical leadership and quality, and the stereotype, which usually exists for a reason, is that commercial awareness is not where their strengths lie.

I am currently running a confidential search for an MD of a large portfolio undertaking significant capex redesign. The current leader is clinical, and the COO is clear that quality is strong. The concern is that priorities are sometimes misplaced, and some sites are losing money without that being recognised. Yet the client cannot simply switch to a non-clinician, because these teams need clinical leadership to get site-by-site buy-in, to connect with staff and, in some cases, to engage commissioners.

As a theme, providers want it all. Whether the combined profile genuinely exists in enough numbers is a different question. The scarcity is greatest where clinical complexity meets commercial responsibility, such as mental health and ABI, and it is a very small pool. For candidates, that is a strong position to be in. For clients, it means the best of them will be weighing whether a role is right for them, and that a search of this kind is unlikely to succeed without specialist support.

Internal promotion is not always the easy answer

The suggestion that providers lack the internal pipeline to promote is one I agree with, although the picture varies from business to business. Where a business has strong leaders coming through and a genuine pipeline, promotion happens. Where it does not, promoting can create a bigger problem than it solves.

Take children’s care, where registered managers are so hard to find that they can cost up to £80,000. If you promote a registered manager, you have a serious problem refilling that role. In adult social care, the same chain reaction applies. Without a pipeline behind them, a promotion can leave a service with no registered manager, agency usage rises, quality dips and local authority confidence is lost, which brings us straight back to the commissioner pressure described above.

One problem is solved and another is created. In children’s care in particular, the more junior and middle management roles are also difficult to secure, which compounds the issue. Adult social care is less affected, but if a provider is looking to grow, open services or sell, it needs a registered manager in every service to do so successfully.

A senior leadership team drawn entirely from one background, say six people from complex care, may decide that what it needs is diversity of thought, someone who brings different expertise rather than the same ideas it already has. If the choice is between a gap that is hard to refill and a recruiter fee of £20,000 to bring in a different perspective, many providers are choosing to go external.

This also shapes candidate mobility. I recently spoke to a leader who had spent six years as an MD at one of the sector’s largest groups. The next step up was COO, a seismic jump, with the incumbent long established, and the next tier had effectively been removed. To progress, he moved to a smaller business as a CEO or COO, despite arguably overseeing more scale in his previous role. Movement in the sector has not slowed. People are still looking to improve costs and grow, and that continues to create demand for those who can deliver it.

Growth is broad, and occupancy is recovering in acute mental health

The past two to three months have been the busiest of my career. I am seeing a lot of roles which are linked to growth or development: providers pushing for more private admissions, businesses that have secured investment or equity and want to open new services, and operators who cannot embed new services into their portfolios or fill beds quickly enough.

The growth is broad too. Supported living has overtaken residential care in the latest sector statistics, and it is still growing. Children’s care continues to expand. ADHD services are growing strongly as NHS capacity constraints push demand elsewhere, and EAP is growing on the back of employers wanting fit and healthy employees.

Acute mental health is a particularly interesting story. Occupancy dropped away over the last one to two years, and the market looked quiet as a result. It is now recovering. A hospital director I placed recently at one of the country’s largest acute mental health hospitals told me that occupancy had fallen at its lowest point to around 70 of 150 beds and is now back up to between 110 and 120. Referral volumes and replenished local authority budgets are behind the improvement, and for hiring it means a market that felt dead is coming back to life.

On the question of supply, there are always plenty of candidates. What is finite is the number of very good ones, and those are inevitably the ones every client wants. Some specialisms are tighter still, with speech and language therapists notoriously difficult to find. If you want a home manager, you can find one. If you want a really good one – that is a different challenge.

Consolidation and reform as we await the Casey Commission

Adult social care is now heavily equity-backed and dominated by larger groups and big charities. I would estimate that private equity accounts for around 30 to 40% of the industry.

That scale is one reason the sector is watching the work of Baroness Casey’s independent commission into adult social care so closely. Its first phase is due to report in 2026 and is tasked with setting out how a National Care Service could be implemented referenced again by Andy Burnham at the Labour conference.

From what I hear, most providers are waiting rather than planning around it. What comes out of a review and what can actually be delivered are two very different things. My own view is that any national model will have to work with the independent sector, given how few of these services the NHS operates directly. Businesses also need to make a return to keep investing, while remaining accountable for quality, and there is real innovation happening. AI is now being used in a sector that has historically been paper-based.

What is making senior candidates stand out?

When I am advising clients on the external senior leaders who stand out, the same attributes come up again and again:

• Successfully opening or mobilising new services
• Managing multiple sites
• Genuine P&L responsibility
• Experience of working with commissioners
• A strong governance track record
• Managing significant growth without compromising quality
• Salary and package pressure is competitive across the board.

Beyond base salary, candidates are focusing on bonus, pension, flexibility, holiday, travel requirements, autonomy, and the scope and development of the role. As roles become more multifaceted, candidates naturally expect to be paid for that.

Looking ahead, clients are telling me their hiring plans for the next six to 12 months centre on service openings, acquisitions and succession planning. Some of the leadership roles I am working on exist because owner-founders are stepping back to secure funding, open services or pursue acquisitions, and want an operator to take the reins of the business or integrate what has been acquired.

What advice am I giving to hiring managers within specialist care?

Build the commercial case for your pricing before the commissioner asks for it

If commissioners are going to interrogate cost, providers need leaders who can articulate the story behind their numbers: quality ratings, track record, outcomes and the real cost of delivering the service. The strongest position is one where the price is evidenced before the conversation starts.

Decide whether you need a hybrid leader or two roles, and be honest about the trade-off

A single hire who combines clinical leadership with commercial ownership is attractive on paper, but the pool is small and the reporting lines matter. Be clear about which capability is non-negotiable, and where the wider team can cover the gap, rather than writing a brief for a candidate who may not exist.

Plan the backfill before you promote

Before promoting a registered manager or senior leader, look honestly at what happens if that role is empty for three months: agency spend, quality, and local authority confidence. Building the pipeline first is almost always cheaper than recovering from the gap.

Test commissioner relationships and track record properly

Relationships are only valuable if they are real and recent. Ask candidates which services they have opened, how long each took to reach occupancy, and which commissioners they worked with, and test those answers in the interview process.

Review packages for the scope of the role, not just the base salary

As roles absorb more responsibility, expectations on pay and package follow. Autonomy, flexibility and the shape of the role matter alongside salary, and the best candidates will be weighing all of it. Providers who benchmark against the role they are actually asking someone to do, rather than the one they used to hire for, will be better placed.