I am unconvinced by the arguments for the regulation of healthcare managers for three broad reasons.
First, the many technical, practical and legal problems might be overcome, but we are unlikely to get the skill, resources and good faith needed to do the job properly.
‘Regulation will lead to respect for managers.’ Oh, my giddy aunt!
Second, need for regulation is offered to the public as an answer to why standards of care can collapse catastrophically. But regulation of managers would not have prevented the Mid Staffordshire Foundation Trust care scandal, just as the existence of the General Medical Council did not prevent the crimes of Harold Shipman. And the “bad apple” analysis of the problem is so weak and cowardly it makes it certain regulation would fail to change anything important.
Finally, the gains regulation might bring managers - higher professional standards, protection and public respect - are being talked up too much by enthusiasts. We could spend our energies on better and faster ways to deliver such gains.
The Department of Health has also identified these other ways, and sensibly decided against simply announcing regulation and instead set some time for debate. Managers should seize the chance to broaden the discussion.
The practical problems are best described as a list of loaded questions. Is healthcare management a profession you can regulate? As you don’t need specific healthcare management qualifications, is it even a profession? Why has no one attempted such regulation before anywhere in the world? Is there a commonly agreed set of professional knowledge and skills? What other profession would only regulate its senior members? Why exclude managers in the private and voluntary healthcare sectors, especially those delivering NHS services? Will we put up barriers to managers from other sectors? Will we narrow access to clinical staff or, worse, even stop non-clinical staff moving up the ranks? Who is going to pay for regulation? What about managers already covered by a professional regulator? Can you legally deprive someone of their livelihood without a full statutory procedure? Got answers? Got more questions (there are hundreds)? Post them below as comments to this column.
With hard work we could address all these problems but most managers know in their gut that regulation would not be done properly. Before the ink was dry it would be perverted by the low politics, ritualised reporting and organisational chicanery that come with the departures of chief executives and other directors. To persuade very senior managers that it could be otherwise would require a complete about turn both in the culture at board level and in the relationship with politicians.
What exactly are we trying to fix? The analysis often gets no further than the idea that we have “a few bad apples”. But in the NHS anyone who falls from the tree is labelled bad. People fail in some jobs and succeed in others - circumstances, personalities and even luck matter. Others are over-promoted, some are inexperienced. Some are very capable but doing very difficult jobs. Would you strike them all off?
Critically, the “bad apple” analysis ignores other factors at play in accountability. Managers work in an NHS system closely linked to government and other organisations through performance management and regulation. Hundreds of thousands of healthcare professionals share responsibility for standards. What about the board? The chief executive might carry the lion’s share of personal accountability, but does he or she carry the can for everything? No. This is why I describe talk of management regulation being a guard against another Mid Staffs as selling the public a pup. The incompetence of one manager and the failure of a whole organisation are not one thing.
Finally, we can get the benefits by other means. “Regulation will lead to respect for managers.” Oh, my giddy aunt! Many things might address our low standing, but wishful thinking ain’t one of them. Open, brave and visible management will gain respect.
Better recruitment practice, fair disciplinary procedures, tougher board attitudes to holding executives to account, codes of conduct, supportive board to board culture, voluntary accreditation, leadership development: all these actions would be preferable to regulation and should be tried first - for the simple reason that they might work.
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