Wednesday 14 December 2022
Speaking at MiP’s Summit last month, the Labour MP and former NHS manager Karin Smyth quipped that “if it all goes wrong, I’m going to become an estate agent to complete the triplet of most unpopular professions”.
Most MiP members have a thick skin. Seasoned against the stereotypes, lies and abuse, you’re used to a bad press and being scapegoated for every NHS problem. But the denigration and devaluing of NHS management does real damage. It deters good managers from joining the NHS and existing staff from taking management jobs. It demoralises and demotivates, damages relationships and undermines collaborative working. And it deters politicians and system leaders from investing in the management skills we need. In any other industry, the case for good management is taken as read. But not in the NHS.
If MiP doesn’t make that case, who will? Smyth was speaking at a Summit debate, provocatively entitled ‘No Managers, No NHS!’, exploring the negative perceptions of NHS managers and the opportunities we have to change them.
The message is simple enough. “Great care doesn’t happen without great clinicians and great teams and that requires great management,” explains MiP chief executive Jon Restell. “If you ignore management, attack it, or treat it as a cost rather than a resource, you get poor results for patients and staff. That’s why it’s important we do this.”
But getting that message across demands more than just going after manager-bashing politicians and commentators. “Whingeing about our lot won’t do,” Restell warns. “We need to give NHS managers a more positive personality.”
One of the damaging perceptions of NHS managers is that they’re not accountable to anyone, or are accountable to the wrong people.
This is partly because the NHS is a national service delivering largely local care. At the Summit, Smyth argued that it remains “far too centralised”, with managers looking upwards to NHS England and national politicians rather than outwards to local communities.
She sees Integrated Care Systems (ICSs) as a “massive opportunity” for managers to build “a more responsive system” that’s accountable to local people. “People can then understand the priorities and trade-offs about funding and care that managers face,” she said.
Sam Allen, chief executive of the North-East and North Cumbria ICS, disputed the perception of managers as servants of the centre. “Of course, we have to meet national standards, but I’m in service to my community; that’s my day-to-day responsibility and where my priorities lie,” she said.
NHS managers need “to see themselves as part of the wider community” and spend time “building and nurturing relationships”, said Suzie Bailey, director of leadership at the King’s Fund. “The more you invite people into the conversation, the more likely you are to find the right solution.”
But having “one foot in the community and one foot in making sure things are delivered operationally is a big challenge, with the backlog and everything else managers are dealing with,” she admitted.
The ICS reforms should mean managers in England focus more on community health outcomes and inequality than central targets, Allen explained. “We need to value the time needed to build those relationships with housing, local business, with community and voluntary groups,” she said. “But when do you get the time to step out and have those conversations?”
While an effective centre is still essential for setting national standards and tackling things, like workforce planning, that can’t be done locally, a lack of clarity over accountability and relationships pulls managers in different directions. “We do need a discussion about what national direction and local autonomy actually means, rather than this destructive pendulum swing from one to the other,” Restell said.
NHS managers also suffer from not being seen as professionally accountable like doctors and nurses. The idea of accredited professional standards gained strong support from members at the Summit, and has been given some impetus by the recent Messenger review. Allen suggested it could boost public confidence in NHS managers by helping to tackle variations in practice and the “vacuum in accountability”.
Allen, who joined the NHS as a receptionist, said the lack of clear professional standards meant “accidental managers” often got no support with learning and career development. Questioning the NHS’s need for bespoke standards, she felt that becoming accredited through the Chartered Management Institute (CMI) had raised her professional standing by requiring her “to do CPD and abide by a code of conduct, just as my clinical colleagues are expected to”.
With many detractors and few defenders, it’s no surprise many NHS managers want to keep their heads down. But Karin Smyth urged managers to be more vocal in debates about the NHS. Local NHS leaders had “become almost frightened of meeting with MPs and telling people what’s going on,” she said.
A poll of managers attending the Summit showed that, while most engaged regularly with community groups, few spoke regularly to local MPs about their jobs or the NHS.
“This is not about annual formal meetings with the chief executive,” Smyth explained. “My surgeries give me lots of useful intelligence that helps me understand things better… If we want professionalisation and better status for managers, we need better political awareness of what you do.”
The vital role managers play in improving patient care by enabling staff, teams and organisations to work effectively together is not widely understood. “Managers are seen as something imposed on the NHS, preventing clinicians from working, rather than something that supports them,” said MiP’s Jon Restell. “People don’t think that way about head teachers or senior civil servants.”
“Managers are critical to the delivery of high-quality care,” Suzie Bailey told the audience. It was managers, who “ensure staff can be at their very best at work”, she said, and who deal with staff shortages, excessive workloads, discrimination, bullying, and the health and wellbeing of their colleagues.
With “the huge backlog and pressure on services right across the system”, it was also managers who “focus resources on where they’re most needed” and who tackle health inequalities and clinical variation, she added.
Trust is critical to the public standing of any profession. The first thing many people say about politicians, journalists and estate agents is, “I don’t trust them.” Managers need to be trusted by the public to run NHS services, and trusted by politicians and system leaders to do their jobs.
Allen argued that the sense of a “united purpose” was crucial to the “high-trust environment” in which clinicians and managers worked during the Covid crisis. “People were trusted to do their jobs… We need to learn from those results and resist the strong undertow to go back to how we worked before,” she said.
Such support and autonomy is vital, but so is honesty, added Bailey: “It’s really critical that managers are honest with politicians, local communities and staff about what is possible.”
Telling better stories
NHS managers may indeed be accountable, engaged, professional, visible, empowering and trusted, but the public won’t notice unless managers and their allies tell better stories about their work.
Taking up the challenge, MiP’s Jon Restell identifies five ways the union can fight back: by “developing a habit of challenge” when politicians or commentators are “untruthful, unreasonable or unfair”; by being ready with evidence “to bust the myths and counter lies”; by talking “relentlessly” about what managers are doing to make the NHS better; by supporting members to talk publicly about their work; and by “striving for professionalism” – challenging bad behaviour by some managers and organisations, and supporting accredited standards.
The Covid backlog, staff shortages, funding cuts, strikes, major reorganisations in England and Scotland – the list of challenges facing health and care managers is daunting. But it’s also an opportunity to show what good management can do. Telling your story has never been more important.