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Francis: Status of management needs to be enhanced

The status of healthcare management as a profession needs to be enhanced in order to bridge the gap between managers and clinicians, according to Robert Francis QC.

In his report into care failings at Mid Staffordshire Foundation Trust, Mr Francis notes that the “tenure” of trust chief executives is “shockingly short” and the pool of candidates for such posts is “often small”. He also says clinicians are reluctant to put themselves forward for senior leadership roles.

He says: “There is little doubt that enhancement of the status of healthcare management and leadership as a profession is sorely needed. The gulf that still exists between some managers and some clinicians would be more bridgeable if there were a mutual perception of grounding as members of a profession, with all the ethical background that entails.

“It would be easier to develop a shared culture and harder for barriers between ‘them’ and ‘us’ to develop.”

He proposes the creation of a “physical” staff college that would enable all aspiring leaders to attend training and go through a “common and shared experience” that could lead to some form of accreditation.

This could “enhance the eligibility of candidates for leadership roles”, he suggests.

Mr Francis stopped short of proposing regulation of all NHS managers in his report, instead proposing Monitor has the power to disqualify board level directors if they fall below a fit and proper persons test, in line with a shared code of conduct.

However, he says the creation of an independent professional regulator should be kept under consideration if it is thought appropriate in future to extend a regulatory system to a “wider range of managers and leaders”.

“The proportionality of such a step could be better assessed after reviewing the experience of a licensing provision for directors,” Mr Francis adds.

He says the experience in Stafford shows “there is no system of accountability for leaders or managers of healthcare providers that is uniformly fair to the individuals concerned and that satisfies the public”.

Former Mid Staffordshire trust chief executive Martin Yeates left under a compromise agreement after the scale of the problems emerged in 2009.

Mr Francis said: “While the compromise arrangements made with Mr Yeates may have satisfied the interest of the trust in ‘moving on’, neither the individual nor the public were given an opportunity to have it established whether Mr Yeates had acted in a manner rendering him unfit to hold the post of an executive officer.”

Readers' comments (18)

  • "He proposes the creation of a “physical” staff college that would enable all aspiring leaders to attend training and go through a “common and shared experience” that could lead to some form of accreditation."

    Close off the NHS to anyone who hasn't come up through the system? Just what we need when being asked to think and act differently.

    We have enough reluctance to involving "outsiders" without making things worse. Much better would be effective recruitment and NEDs with teeth.

    Equally depressing to again see the apparent assumption that clinicans make good leaders. Some can and do, but for many their skillset is no more relevant to management than a senior manager's would be in theatre.

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  • Maybe the status of NHS management would be enhanced if NHS managers showed more courage, individually and collectively, to take a stand against action or directives that adversely affect patient care. Or refused to provide pointless exception reports to SHAs.0r supported whistleblowers, listened to patients, learnt from complaints. Managers have a bad name because few openly act in a principled way, or support others that do. Status needs to be earned.

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  • I think Heather's comments are unhelpful.they could just as easily be directed towards anyone clinical and managerial administrative or layperson in an NHS organisation. The reality is that NHS managers are unfairly vilified bullied and left unsupported. The NHS is dominated by professions, including the financial profession. And yet for some reason it is always the general manager who is lambasted when anything goes wrong. I have worked at every level of the NHS from clinical front line to board. We need to start talking openly about the real problem of the NHS: It is managerially and professionally toxic; competitive, divided, and at worst in open conflict. And the new system is appallingly poor in terms of governance.How can we be seven weeks away from handing responsibility over to clinical groups that have no concept of how to run an effective business where patient safety is properly prioritised? The new NHS is already a train wreck; overlay Francis and you have no prospect of addressing the real issue for commissioners: how do you know that your suppliers aren't killing people?

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  • Why does the NHS when anything goes wrong, simply pass the buck to lack of adequate leadership, training, supervision blah blah blah? Why does no one ever take responsibility?
    What we really need is to make people accountable and have clear consequences for inappropriate action or inaction. That is how the private sector works! If you do not perform, you are sacked. But in NHS if you fail, you find a better paid job elsewhere!
    Secondly, if people in the NHS cannot and do not have the ability/culture/mindset to care for their patients, they should not be doing their job at all! Let us not forget, that the NHS is there for the patients, the taxpayor. Not for CQC/Monitor/NHSCB/BMA/RCN etc etc.

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  • this is what is called taking advantage of a crisis to enhance your position.
    instead of putting managers at the same status as clinicians we should be making the clinicians more accountable.
    where are the clinicians responsible for events in mid staffs and what is happening to them?

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  • Steven Burnell

    The Board was clearly weak & / or misguided but it was doctors & nurses on the front line that did not do the right thing for the Patients who were harmed or died.
    Rightly, Directors should be held to account & if they are found to be "unfit" then they should be sacked & disqualified from Executive roles in the NHS.
    Similarly, we expect Nurses to be caring & doctors to be experts, both acting in the best interests of their Patients. And, bad ones need to be routed out.
    If Managers are guilty of intimidating clinicians & of preventing them from doing their jobs properly then we have got to wonder if the Royal Colleges & BMA could not have got involved & done something to protect their members & their patients & also deal with any poor performance too.
    To my mind, the Francis Report contains far too many recommendations. I would rather it focused on just a few big things that have GOT to be done.
    For example:
    1. Every person (back office or front line or otherwise) in the DH & NHS must have a written job specification that clearly describes how their responsibilities & personal objectives are designed to directly or indirectly improve Patient Health & Care.
    2. The right for any member of a hospital's staff / or Patient [advocate] to access in confidence designated Public Governors who must then take up issues they think might be prejudicing Patient Care with the Chairman & get them resolved to their satisfaction.
    3. Professional bodies to ensure that their members are held to account & proper system of consequences applied.
    4. Misleading or deceiving a Regulator to be a criminal offence.
    5. Prominent publication of key measures of Quality with full and frank explanations + Quality Statement in the Annual Accounts by both the Chairman & the Chief Executive. Any misrepresentation or neglectful statements being a criminal offence.
    6. Every Project Initiation Document concerned with sigificant Cost Improvement / Process Change / Target Achievement to include an assessment of how it will most likely impact the quality / timeliness of Patient Care.
    7. Vicarious Liability of Chief Nurse & Medical Director

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  • Heather's comments are very astute. Status needs to be earned. Couldn't agree more.

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  • Heather,

    I agree with your comments and always acted in accordance with the principles you extol when I was a CEO. That is why I gained a reputation for being 'difficult' i.e. not a political pawn and also why I am now unemployed.

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  • the relationship between clinicians and managers in a partnership is evidence based and proven time after time where this exists. Where it does not exists more often than not the opposite is observed. Being a clinician and a senior manager are both a privilege but leadership is so much more. a leader can not be created with a bag of tools and a certificate, it's a way of life. Anything less is not good enough and being held account for the way it's done vital!

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  • A good summary thanks Sarah.

    No professional group comes out of Francis well - doctor, nurse or manager. But NHS managers have allowed themselves to become associated in the minds of staff and pubic with an agenda that is not seen as being part of quality care delivery. Targets, budget management and reconfiguration are examples, despite the fact that most managers I work with are very definitely trying hard to continually improve patient care.

    Secondly, we have somehow come to see a focus on whole system of care, rather than on individual patients, as a less worthy aim. For example, a doctor focuses on the patient in the clinic room, and is rarely criticised, while the manager organises the whole clinic, the booking, the car parking etc and is often criticised. Both are worthy roles, but there is an imbalance in how the two roles are perceived.

    Respect for managers won't increase through regulation or formalised training, or a blacklist. We will have to earn it, through having, and being seen to have, the right values and motivations. And yes, having the courage to reject any pressures that drive us away from these too.

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  • Heather Wood is - as on numerous occasions recently -spot on.

    Difficult to see why the public and staff would have full confidence in more effective leadership styles developing within the NHS when at least one of those now directly responsible for developing leaders appear to have a less than glorious track record in their treatment of whistleblowers in their own previous organisation.

    We all get things wrong but surely we have to put our hands up and admit so before we show others what to do?

    And I am not referring to David Nicholson on this occasion

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  • Mark 11.26 - well put as always. Not enough like you in CEO positions.

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  • It may be helpful to consider why other European countries have achieved better outcomes/ mortality rates and higher levels of patient satisfaction, and without to my knowledge similar scandals.

    The behaviour of hospital executives in these countries is different. They are driven to attract good patients and doctors in competitive markets (choice is much more embedded) and public hospitals are often accountable to local government and hence locally elected politicians.

    NHS managers are forced to look upwards and keep their political masters happy by achieving arbitrary targets (Can anyone name another system that uses targets in the way the NHS does?) rather than looking outwards to patients and local communities. Governors and NEDs are little more than a fig leaf to cover naked centralism.

    Clinicians, who should have the most intrinsically rewarding job in the world, often have lower job satisfaction rates than staff working on the floor in John Lewis.

    Until we create a system which shifts accountability in this way, any investment in Don Berwick and leadership training will be largely wasted

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  • Francis is a wakeup call for everyone. As Mark says no one profession comes out well. We got to move away from 'them and us' culture, blame culture and bullying culture. We are all in this together.

    NHS needs 'Fair and Open' culture, supportive and learning culture and an accountability for all including the Trust Board members. Patient safety is everyone's business and everyone's duty. Leaders should walk the floor, mix with their staff, listen to them and their concerns, see what goes on at the level of patients in the beds, A&E, theatres and talk to both patients and staff regularly. Sadly most leaders sit in their ivory tower and expect things to run smoothly at the level of patients.

    Most staff come to work to do a good job and it is our systems which make them what they become. Organisational culture, leadership and energy are the key to the success or failure of any organisation.

    If the culture, leadership, governance systems are good and robust then poor behaviours and poorly performing staff are identified early and they can be helped and supported and if not removed. Sadly, NHS always looks for scapegoats and individuals rather than looking at the whole system. In a poor system and poor culture and poor leadership, bad behaviours are tolerated, sub-standard treatment is accepted and even simple basic humanity and dignity is forgotten and patients simply become targets and numbers.

    The most important thing is to look at the organisational culture, leadership, governance, quality assurance systems and patients and staff feedback survey. Every leader must be performance managed and should have feedback
    from those who are affected by their leadership.

    Leaders must have the courage to challenge those who provide sub-standard care and poor behaviours.

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  • @Insiderperspective

    "Driven to attract good patients"?

    Who are the bad patients? And what happens to them?

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  • Insiderperspective - I believe there are indeed other countries which use targets as a legitimate lever to improve access and quality, however in countries like Sweden, for instance, how they are managed is different. The expectations of hitting the target are less absolute. The punishment for missing them less punatitive. The reason for doing it more laudable.

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  • It is extremely difficult to speak out as an individual senior manager when tied to corporate decsion making which is often just to rubber stamp central directives. Anyone remember the days spent on PCTs assuring the top that they were ready for commissioning that could have been spent actually monitoring the contracts we already had. Constant change and interference does not lend itself to good management. Good managers are constantly stymied in their attempts to impose regulation by the 'excellent leaders' we are supposed to need.

    As a clinician turned manager I echo that this is not a role that many would want or be suited to. However clinicians do have to advise and inform managers what would seem to be best for their patients so that in partnership informed decsions may be made.

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  • David Poynton

    Some good points form many who care, otherwise they would not be in the jobs that they are. The trouble is so many are blaming everyone else. The challenge is "what am I doing about improving patient care?". My quality standard has always been "Is it good enough for my mum?" Having worked as a director in the NHS for 30+ years and with some of the present key decision makers I have seen various management styles. rarely have i seen bullying. Yes I have seen hard decision makers who set stretching goals and don't except poor performance. Isn't that what you want in any high performing, customer focussed organisation? As a management consultant and advisor nowadays I often see mangers, including clinicians, who need to seek permissions to do things. A healthy organisation encourages their future leaders to take risks, to seek new opportunities and to deliver the plan. Too many managers seek an excuse for poor performance blaming the system or bureaucracy or targets. "Leaders think and talk about the solutions. Followers think and talk about the problems." —Brian Tracy

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