Is NHS management a profession? Should managers be regulated?

Transcription

1 Is NHS management a profession? Should managers be regulated? Dr Judith Smith Head of Policy The Nuffield Trust Mid Staffordshire NHS Foundation Trust Public Inquiry seminar 18 October 2011

2 Agenda History and development of NHS management The nature and culture of NHS management A code of conduct The debate about regulation International experience Report of the advisory group led by Ian Dalton (2010) Arguments for and against regulation Responding to the exam questions...

3 History and development of NHS management Three main phases: Pre-1979 consensus management, the administrator general management, the general manager 1990 onwards NHS internal market, the chief executive Matched by phases of NHS management development: - national education centres - NHS Training Authority, National Accelerated Development Programme - NHS Training Directorate, NHS Leadership Centre, NHS Institute, National Leadership Council

4 Changes over time A focus on a more entrepreneurial management culture The development of a stronger chain of command The strengthening of individual managerial accountability for finance and, latterly, also quality The assumption of managerial and financial responsibility by clinicians A move to focus on leadership as well as management Acceptance that it is both and that matter, and the transactional is important alongside the transformational

5 The Institute of Health Services Management (IHSM) An Institute of Health Service Administrators that became the IHSM post-griffiths Inquiry The awarding body for the then recognised qualification for health service managers, the Diploma in Health Services Management Was then the mouthpiece of NHS managers, networking body, and professional body Lost influence over the years as management and NHS diversified, and managers looked elsewhere for support and networking

6 The nature and culture of NHS management Management and leadership regularly asserted as important to organisational performance (e.g. King s Fund Commission, Bristol Inquiry) Despite attempts to broaden the base of recruitment into NHS management, chief executive community remains relatively homogenous Approximately one quarter are women, almost all are white Five per cent are medically qualified Almost all chief executives are appointed from within the NHS

7 Bristol Inquiry criticised unhealthy club culture within that organisation and inadequate challenge of powerful individuals Called for a culture of quality and safety, with flexibility to respond to people s needs Called for support for chief executives, professional codes of conduct, continuing professional development, periodic appraisal, and revalidation NHS culture sometimes criticised in wider research and analysis for being centrally directed, top-down, and with a tendency to be punitive Cannot explore regulation and registration of managers without considering cultural context

8 A code of conduct IHSM carried out work on ethics and health management in the 1990s, and started work on a formal code of conduct Bristol Inquiry gave impetus to this, and Ken Jarrold chaired a DH group to develop a code Published in 2002, setting out core principles to underpin the work of NHS managers Was to be written into all senior management employment contracts It is unclear how far this happens, how much the code is ever used to reinforce or challenge behaviour, and if it is used in foundation trusts

9 Issues raised by uncertainty surrounding the Code The risks of leaving the operation of the Code to local discretion The risks of a code of conduct being the responsibility of a government department which may be preoccupied with other matters, and lack incentives to challenge/expose management failure The need to explore the possibility of an independent professional body that can act as guardian and champion of the code The need for the code to have public visibility and credibility, and to be regarded as fundamental to how the NHS works

10 The debate about regulation of managers Bristol Inquiry called for consideration of statutory regulation of NHS managers Whilst code of conduct was taken forward, work on regulation was not Darzi Review of 2008 called for more work to prevent cases of poor NHS management, review of operation of code of conduct, and of recruitment procedures Ian Dalton asked to chair an advisory group on assuring the quality of NHS senior managers The group commissioned independent research from Price Waterhouse Coopers, to develop an evidence base

11 Conclusions of the PWC research Generic managers rarely accredited in any sector Dept of Health, and local NHS boards, relied upon to monitor and develop managerial performance Some other countries have moved to develop professional associations that uphold ethics/code of conduct, accredit development, provide networking, etc. Main options going forward: - recruitment, vetting and employment - corporate governance - accreditation, licensing and regulation

12 International experience France very regulated approach with controlled entry to training and the profession, ongoing supervision and control of who works where Netherlands evolution of management as per NHS. Senior managers have formed professional body to organise education, set standards, uphold code of conduct, provide networking Canada and Australia national college of health executives, for professional standards, accreditation of education, CPD New Zealand statutory code of rights for the provision of health services to people, matched by duties of providers. Commissioner has wide-ranging powers of inspection, investigation, and action

13 Report of the advisory group Dalton Report (2010) Emphasised importance of examining regulation alongside development of managers Code of conduct to be replaced with statement of ethics, and embedded in contracts, operational framework, appraisals, etc Strengthening of standards of recruitment and vetting Improved appraisal of senior managers, including 360 degree Strengthen capability of boards and sub-committees re holding senior managers to account Consult widely on a system of professional accreditation and more formal regulation Dates set for this work, but unclear if enacted

14 The arguments for the regulation of managers NHS managers occupy significant positions of responsibility for public money and patient safety There needs to be a fit and proper person test, as with many other professions and appointments There is a need for a set of professional standards, and for these to underpin professional development and performance Accreditation would increase the standing of managers with public and with other professions Core standards would provide a baseline for private or public challenge of any perceived breach There would be protection for managers against undue pressure

15 The arguments against the regulation of managers There is not a consensus in the DH, management circles, and wider policy bodies about the benefits of formal accreditation or regulation The work of managers is generic, hard to codify, and difficult to test for competence in relation to a discrete body of knowledge The cost of setting up a professional body, developing standards, assessment of managers, and ongoing development would be prohibitive There is a move to reduce the number of quangos and to lower management costs There is a risk of exacerbating those elements of NHS management culture that are unhelpful

16 Responding to the exam questions... Is NHS management a profession? NHS management is not a profession in the same way as law, medicine and accountancy It does however require the highest standards of professional ethics, conducts and practice It can learn from education about how to codify standards, formalise development, move towards licensing, and live with external inspection International learning is instructive about the potential of a strong and meaningful professional body to uphold a code of conduct, guide and accredit development, and represent and speak for the professional group

17 Responding to the exam questions... Should NHS managers be regulated? They need a strong and formal code of ethics and conduct This needs to be implemented in a public, transparent and robust manner across providers This would need to be governed and implemented by boards, chairs, and regulators A professional body needs to be rediscovered and established for health managers, and international experience could help with this This is all necessary but not sufficient more focus on continuing support and development for CEOs is needed

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