Leading the NHS: Proposals to regulate NHS managers

In fulfilment of a manifesto promise, the Labour Government is planning to regulate NHS managers, and their proposals were out for consultation until Tuesday, 18 February 2025.

the proposal

The aims of this regulation, as stated in the consultation, are to make sure that managers and leaders have the right skills and values to support their colleagues to improve and deliver services and to have access to the right learning and training opportunities throughout their careers. In addition, managers and leaders should engender a culture of openness and honesty so that patients and staff are confident that leadership in the NHS is effective and accountable.

To do this, NHS England proposes developing a leadership and management framework, introducing a code of practice and a set of core standards and planning to develop a curriculum for managers. It is intended that the standards will cover values, behaviours, and competencies and that there will be formal training with specific qualifications.

There have been several public inquiries that have commented on the role of NHS managers and leaders with a sense that leaders have often failed to act appropriately and when this has happened the individuals concerned have not been held to account for their actions. The Francis Report (2013) introduced the ‘fit and proper person test’ for directors. Despite this, cultural issues continue to be a problem, and people who raise legitimate concerns are not always heard. Consequently, managerial regulation is proposed to provide public protection and professional accountability. Regulation would also provide a publicly searchable register, defined and protected titles, and increase public esteem. It would also facilitate fair treatment, career development, and punishment if appropriate. Potential unintended consequences are also noted, with regulation potentially causing a barrier to entry, providing a chilling ‘big brother’ type’ effect leading to cautious decision-making, which may increase risk aversion or lead to vexatious complaints.

It is proposed that this will apply (as a minimum) to all board-level directors in NHS organisations in England, arm’s length body board-level directors and integrated care board members.

An individual duty of candour is also recommended. This has been in place for organisations since the 2013 mid-Staffordshire Inquiry, but the infected blood inquiry’s final report (May 2024) has recommended extending this to individual NHS senior leaders.

is this a good proposal?

training

At its heart, these proposals recognise that the role of healthcare leadership is both important and makes a difference, and in the same way that there is for medicine and nursing (or any other job), there is a knowledge base to learn and a skill set to acquire – training is required, and training and support could be improved and is needed.

This is very welcome and runs contrary to much public and political discourse. Our NHS leaders at a senior level are leading very large organisations with turnovers in excess of a billion pounds and with many thousands of employees. This is a proper job; the CEO position in an NHS organisation is a highly complex job requiring exceptional skills and management experience and is as demanding as any equivalent-sized job in the private sector.

However, it seems that the government is being unambitious in applying this to only the most senior managers. There is an opportunity to set up good quality training and a strong career path from much earlier in the career pathway, similar to that offered to doctors and nurses who are regulated at qualification and undergo further training and sub-specialisation. Care is needed to ensure that this does not act as a barrier to entry, and new regulation should not be used maliciously to concentrate power in a small number of hands or (perhaps unintentionally) prevent those busy clinicians who might make very good clinical leaders from ‘dipping their toe in the water’ and starting their leadership journey.

regulation

There remains a view that when problems occur, NHS leaders and managers do not always do the right thing but instead act in their own interests and those of the institution, protecting from reputational damage, and not being held to account.

Therefore, regulation is required to hold NHS managers and leaders to account.

However, it is important to consider why this happens despite the recommendations of multiple public inquiries and excellent guidance (eg the Nolan Principles).

One might argue that the task our NHS managers are set is often impossible to achieve in the resource envelope provided (consider the A&E treatment delays and chronic inappropriate corridor care). But within a highly politicised NHS where results must be achieved at all costs, it is not always possible to say this. Pressure is applied to CEOs to avoid reputational damage with their jobs at risk. A culture has come from the very top that eats policy for lunch (dinner and tea!).

Historically, there was a managerial qualification awarded by the Institute of Health Service Management, which also acted as a voice against inappropriate political pressure and interference. However, this is a voice that has now been lost.

In this context, regulation could provide helpful protection against inappropriate political interference and lead to fairer treatment.

Establishing an Academy of Healthcare Management to oversee the professional training of those wishing to embark on a career in healthcare management or take up a senior position in leadership in the NHS would be welcome. This would establish and enforce standards and fulfil some of the regulatory functions envisaged in the Consultation document.

duty of candour

A mandatory individual duty of candour might be one of the greatest benefits of this proposal and help to protect NHS leaders and managers from unreasonable political pressure. It may also be of benefit within organisations where subtle dishonesty and lack of candour about what can and cannot be achieved and its consequences often exist. This lack of candour is not without consequences; it is very often the junior and powerless in the organisation who are left trying to provide good care in impossible circumstances and suffer the resulting moral distress that contributes to the huge staff turnover, particularly amongst nurses and junior doctors. Candour from above sets the scene for support in these difficult circumstances rather than blame for not meeting unreasonable expectations.

There remain questions regarding the practical outworking. For example, to whom should our managers be candid? The Chair of the Trust Board? The Integrated Care Board? NHS England? The Health Secretary? Patients? There is a very long list. And what happens when you keep being candid but nothing changes? (Think again about delays in A&E treatment times and chronic, normalised corridor care).

However, at the very least candour recognises reality, allows support of hard-pressed clinical staff instead of blame, and allows patients and relatives to make informed choices where that is possible.

Will NHS England and the Department of Health be mandated to share publicly the candid comments of their managers and leaders?

Christian views

What should we think as Christians?

We are all made in God’s image, so we value our clinical and non-clinical managerial colleagues who are working hard and doing a difficult job in difficult circumstances. It is too easy to slip into ‘manager bashing’, and so we welcome the further training and support, and training proposed in this proposal. We believe that well-trained, competent managers and leaders make a positive difference.

As Christians, we welcome accountability; we are accountable first and foremost to God and then to our employer. But as public servants, our duty is primarily to serve the public.

And these proposals strengthen that accountability, encouraging managers and leaders to do the right thing.

These principles of servant leadership are clearly embodied in the seven Nolan Principles, which already apply to public and civil servants and politicians. However, there remain issues with inappropriate culture in the NHS, so the proposed training, regulation, and duty of candour are all welcome to encourage the needed culture change.

The mandatory duty of candour is welcome. Truth is a fundamental Christian value and is one of the ten commandments; ‘no lies against your neighbour’ Exodus.20:16 (The Message), and we support and encourage candour, although we recognise that the truth is not to be used maliciously as a weapon but that we are to ‘tell the truth in love’ Eph 4;15..

As the government develop and puts in place core standards, a code of practice, and a curriculum, we are aware that these all come from a value system and an underlying worldview that has its roots in the Christian faith. As these proposals are developed, Christians have a huge opportunity to input into that development.

conclusion

So overall, we welcome this proposal, which could markedly and very helpfully support NHS managers and leaders doing very difficult jobs. The implementation is, however, all important to ensure that the training and support are embedded, and this is not just used as another stick with which to beat hard-pressed staff.

Chris Holcombe and Howard Lyons on behalf of CHLN

February 2025