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Regulating hospital managers is not the silver bullet to a safer NHS

Following the Lucy Letby murders, professional regulation is only one step towards improving accountability in our health service.

By Jon Restell

The murder of seven infants by the neonatal nurse Lucy Letby, and the reports of how the Countess of Chester Hospital she worked in responded to suspicions against her, has left managers across the NHS feeling like they have ash in their mouths. As you would hope, it has also triggered widespread reflection as managers ask themselves: what would I do in the same situation? 

These events require an urgent, comprehensive and thoughtful response. The work of the independent inquiry into how Letby was able to commit her crimes will be vital to this, but several themes already seem clear – with the ability for clinicians and managers to raise concerns being the most important. We won’t need the outcome of an inquiry to know more needs to be done in this regard. Relationships between managers and clinicians, between doctors and nurses, and between individual colleagues are also relevant because, when they are poor, patients suffer. There are also major questions to ask about the actions and capacity of senior management and the system designed to hold managers to account.

It is on this last theme that many policymakers and commentators are focusing. NHS England is urgently reviewing the regulatory framework for NHS managers and, following the Letby case, the Labour Party announced that it would introduce statutory regulation if elected.

Many managers, including – when we last asked them – at least half of Managers in Partnership members, support the principle of professional regulation. But it is highly doubtful that professional regulation alone would prevent another Letby.

First, take the existing thicket of regulation, including of the type proposed by the Labour Party and others, around senior managers. Nurse directors and medical directors, key players in the events at the Countess of Chester, are covered by statutory regulation (by the Nursing and Midwifery Council and General Medical Council, or GMC, respectively) for their management as well as their clinical roles. Every NHS board member has to meet a statutory fit-and-proper-person test, on appointment and every year after that. This test was recently beefed up following the independent Kark Review.

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Also, the Care Quality Commission inspects hospital leadership and management, and damning reports normally dislodge senior managers. This is not to say that regulation has no value, but it is limited and remote from day-to-day activity in the NHS, where quality and safety depend far more on clinical professionalism, skilled management and an open culture, particularly with regard to raising concerns.

Second, there is a simple belief that everyone knows who the bad managers are, why they are bad and what must be done to disbar them. Think again. Professional regulation, GMC-style, would require a statutory framework that covers setting standards, registration and accreditation, revalidation and an independent body (emphatically not NHS England) to investigate and sanction professional managers who fall short. Those sanctions might include warnings and retraining as well as employment bars.

Who will decide what management standards to use? The GMC’s good medical practice 2024 offers an idea of the range and depth of professional regulation. What management activity will be regulated? Will all managers be regulated or – as now – just some? What happens when an individual manager is covered by more than one regulator? None of these questions are unanswerable, but they would need far more attention and resources than politicians and system leaders have so far been ready to give.

Third, professional regulation would expose under-powered managers in many contexts and chronic underinvestment in NHS management, now being identified in a slew of persuasive studies. Professional regulation might then lead to the change that the NHS needs. But don’t count on it being easy. Other NHS professionals, politicians and the system itself would need to adjust to a newly assertive group of managers discharging their regulated duties around safe and effective service provision. Are other wielders of power in the NHS ready for that? I would say not. Alongside a shift in the distribution of power and autonomy, managers will also need the capacity and resources to do a better job. Are politicians ready to find the missing 10,000 managers identified by the Institute for Public Policy Research’s health and care workforce assembly report? I suspect not.

Professional regulation is no silver bullet to solving problems of accountability around NHS managers. It would require far more change, in both the regulatory framework and the resources and power of managers, than policymakers are likely to want to make. Regulation must not be used to falsely assure an outraged public and grieving families. But if done properly and taken seriously, there is a major opportunity to improve the NHS by valuing its managers, recognising the importance of their role, and truly holding them to account.

[See also: How our health and social care systems keep hospital beds full]

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