In the NHS, as for all human enterprises, leadership is the thread running through everything. For any system to survive and thrive, someone needs to take a lead and motivate people to follow. With every major issue in health and care, leadership is crucial to changing the way things are done.
Given this, outsiders might expect leadership to be one of the highest national priorities in health and care. But they would be wrong. For all their fine words, when the time for action arrives, politicians and policymakers often fail to thread the needle. This failure to invest attention and resources in leadership has been so persistent and damaging that the many achievements of the NHS workforce, particularly in recent years, seem even more remarkable.
Politicians and policymakers fail for two reasons. First, they don’t properly value the ‘support’ staff of the NHS, who, despite making up 45% of the total, have been accurately described as the “invisible workforce”. Second, they suffer from a deep-rooted aversion to management, a feature of both left and right in British politics.
We pay a high price for those failings. How many young people think of the NHS, one of our largest employers of IT professionals and accountants, as a great place to pursue a non-clinical career? Endless re-organisations and job cuts have robbed services of experienced, specialist managers, and the absence of management from workforce strategy means we won’t attract the next generation of skilled managers. Bluntly, if it doesn’t say Nurse or Doctor, it doesn’t matter.
Nowhere can you see this aversion more clearly than with pay. The proposed three-year pay deal for Agenda for Change staff finally ends the pay cap and has good features for everyone, including managers. But it unfairly singles out staff at the top of Bands 8D and 9 for smaller pay rises, and denies those in Bands 8 and 9 the investment offered to all other staff in reducing the time it takes to progress through their pay bands. As our national committee identified early in the talks, it’s already hard to attract clinicians to 8A management jobs: the extra responsibility and unpaid hours aren’t worth the candle. And the strategy for very senior managers seems to be little more than a series of transient tactical judgements based on the likely attitude of the Daily Mail. In other words, it’s not a strategy at all.
The situation is not without hope. Local employers and staff are much better at valuing and supporting managers than politicians (with the odd honourable exception, like Philip Dunne). There are signs of good intentions from national bodies, with NHS Improvement’s leadership framework, the programmes of the NHS Leadership Academy, and encouraging noises from new NHS Improvement chair Dido Harding about a more nuanced approach to senior management accountability.
Politicians are the key
But good intentions burn up in the heat of media and political controversy, and single initiatives can never replace the need for a comprehensive workforce strategy for managers. Politicians are the key.
Our submission on the draft workforce strategy for England made three key suggestions to help thread the needle:
- Support staff are as important as clinical staff in delivering the services patients need, and deserve the same strategic focus. Just as there are safe staffing levels for clinicians, we need indicators for the required level of other staff in relation to clinical and patient activity.
- Recognise the complexity of managers as a staff group. There is no single supply line – management is populated in fundamentally different ways. Some manage full-time, while others do it alongside hands-on clinical work; some are managers throughout their careers, while others take on managerial responsibilities after substantial careers in other roles.
- Invest attention and resources in management careers and ensure that managers are more representative of the population they serve – this requires a supportive and realistic approach to accountability, and proportionate spending on pay and training.
Politicians face a choice about leadership and managers: invest, or continue to ignore. None of our suggestions will happen without their sustained support. The long term funding settlement proposed by the Prime Minister is the opportunity to make that choice.
Jon Restell is chief executive of Managers in Partnership