Chartered Management Institute: In my opinion

Dr Peter Carter, chief executive and general secretary of the Royal College of Nursing and a CMI Companion, on leadership in the NHS.

by Dr Peter Carter
Last Updated: 23 Aug 2011

Last October, when we began to appreciate the scale of reform to which the NHS would be subjected, Nigel Edwards, the then acting head of the NHS Confederation, accused the Department of Health of 'anti-managerial rhetoric'. The Coalition, he stressed, was guilty of not recognising the 'modern face of health care (in which) managers would always be needed, be they employed by PCTs or in other guises'. I agree with him.

The NHS, like any other area of public service, needs to be led by people with expertise and skills relevant and appropriate to their area of activity. The recent assessment that 45% of NHS managers would be dismissed, largely as a result of the Government's axing of primary care trusts and strategic health authorities, requires further analysis; surely, efficiencies can be made by focusing not on the quantity but on the quality of NHS management?

The proposals set out in the Health and Social Care Bill aim to fundamentally change how the NHS works. The two main principles of the bill, which the Royal College of Nursing (RCN) supports, are about empowering patients and involving clinicians more closely in decision-making. The rigour with which these aims are being pursued is commendable, but the devil is in the detail.

The pace of change is too fast and too soon, and the piloting of proposals ought to be followed up with a formal evaluation. In order to maintain consistency, nurse leaders need to be recognised as being essential to all commissioning bodies, and good NHS managers necessary to leading the entire project. Disappointingly, these sentiments are either missing from the bill or not clearly expressed within it.

Whether in the NHS or the independent sector, leadership is the crucial element in maintaining and raising standards in all clinical settings. However, we have seen countless examples of wasted opportunities and non-existent leadership. You will have heard about the high-profile cases in which trusts failed their patients so badly, from understaffing to poor management; one reason for them was undoubtedly a lack of leadership, both at board and ward level.

In some cases, we know that the directors of nursing, along with the overall management, were completely disconnected from frontline staff. There appeared to be little evidence of leadership at board level or understanding of what good care should look like, and insufficient analysis of the standard of patient care being delivered.

Ultimately, in all the cases we know about, there has been a gulf in communications between board and ward. Leadership means ensuring a common purpose, a single vision, and a goal towards which everyone is working. The changing context of NHS provision means that leadership will require strengthened capabilities.

The RCN is the leader in establishing the competences for advanced nurse-practitioner practice, and we have developed national professional standards for practitioners and nurse leaders. Since 1997, 30,000 nurses have taken part in the RCN's own clinical leadership programme. But clearly there is more to be done. We must battle the still-present prejudice that nurses can't reach the very top of health service management and leadership, and we must continue to promote our belief that nurses are among the best-placed healthcare professionals to take on leadership roles.

But what of non-clinical NHS leadership? Despite the number of managers increasing from 14,112 in 1998 to 29,924 in 2009, and even after the Francis Inquiry and Lord Darzi's Next Stage Review (both of which recommended improving management performance at all levels of the NHS), there is still no national body to monitor and accredit NHS management performance. The Department of Health's advisory group report, Assuring the Quality of Senior NHS Managers (February 2010), recommended establishing an accreditation scheme for NHS managers that would report to the National Leadership Council.

The NHS needs good managers, now more than ever, so should I be concerned that this scheme has not been recommended as compulsory for all NHS managers? Should I also be concerned that the Health and Social Care Bill makes uncertain the future of valuable programmes such as the NHS Graduate Training Scheme, which is administered up and down the country though SHAs? Nobody is quite sure what will happen to the programme when SHAs have been axed.

The answer to both questions is yes. It's clear to me that we need to change how the NHS manages its managers. Clinical staff are made very aware of what is expected of them from the moment their training starts, and that expectation continues unabated throughout their careers. Why is this not the case with managers?

The NHS prides itself on delivering high-quality care. We must ensure, therefore, that those involved in leading that care are working under and monitored by the same high standards.


Dr Peter Carter is chief executive and general secretary of the Royal College of Nursing. He holds a doctorate from the University of Birmingham, was awarded an OBE for services to the NHS, and is a visiting professor at the Florence Nightingale School of Nursing and Midwifery at King's College London

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