Would greater regulation put managers on a par with other professionals in the NHS, ask Peter Coles and Neil Goodwin

Management is one of the most powerful professions in the NHS, but it is also the least regulated. Indeed, some would say managers are such an unstructured, undeveloped and unregulated group that the term 'profession' is inappropriate.

Now that clinical governance makes NHS chief executives explicitly accountable for standards of clinical performance, we argue that they, too, should be part of a governance framework.

Most professions insist on a range of minimum skills or competencies before entry. According to a survey undertaken by the NHS leadership programme, 60 per cent of chief executives possess a first degree, with most also holding an Institute of Health Services Management qualification.

Stuart Marples, director of the IHSM's successor organisation, the Institute of Health Management, has also suggested that his organisation could develop a competency framework for senior managers based on either academic qualifications or work-based assessment.

This could form the basis of a system of self-regulation by the institute.

But there are problems with pursuing an evidence-based skills approach. First, management tasks are largely determined by employers rather than managers themselves, and managers do not control the selection or definition of work problems, which are largely outside their direct control.

Second, unlike other professions, managerial tasks are not readily standardised across organisations. And third, managerial skills are highly interdependent both on each other and on organisational structures and policies.

Managerial tasks cannot easily be isolated from their context.

So attempting to establish evidence-based management, which in the case of medicine and accountancy underpins their external regulation, is largely doomed to failure since 'managing' is not a standardised activity.

1Similarly, training for, and assessment of, leadership competencies has been the subject of much research and debate. It is difficult enough in trusts but much more complex in the new NHS with its emphasis on inter-organisational collaboration. No number of MBAs or formal development programmes can be guaranteed to produce effective leaders, although they can help individuals understand leadership theories and the personal skills required in practice.

Perhaps more importantly in the context of the NHS, these programmes can also explain the essential differences between the rational basis of management and the more intuitive approach required for leadership, which are so easily confused.

The performance of most healthcare professionals can be measured against a range of outcome criteria. But financial performance, waiting lists, recruitment and retention levels, external organisational accreditation reports and the quality and volume of patient activity are all subject to influence by external factors, which are often beyond managers' control. On the other hand, effective internal management of external issues is often contingent on the quality of corporate leadership.

So it should be no surprise that the NHS Executive developed the NHS leadership programme in an attempt to provide a national development framework. For the first time since the general management training schemes of the 1980s, the importance of good management for the delivery of good health services has been recognised centrally and supported with investment.

But a balance must be achieved between an overarching national framework and local frameworks for self managed learning. These should be not just for those in top leadership positions but also for the equally important, much larger group of managers. After all, organisational leaders come and go, but it is the ranks of clinical and general managers that actually get things done.

NHS regions have varied in their approach to leadership development and succession planning. What is important is that best practice is replicated across the whole health service. The NHS Executive should copy industry and develop a system to ensure that senior managers who are seen to have 'failed' in one place are not stigmatised but reemployed after appropriate re-training.

A final exemplar worth considering is the Institute of Directors' 'chartered director' initiative, which it claims is the world's first professional standard for company directors.

2Under this scheme, chartered directors will be recognised as having achieved standards of professional knowledge and experience, making a serious commitment to their profession and undertaking to act with probity and honesty.

The development of such a framework for the NHS would certainly help to assure 'management governance' in the complex and constantly changing world of the NHS and place managers on a par with their professional colleagues.


1 Whiteley R. The management sciences and managerial skills. Organisation Studies . 1988; 9(1): 47-68.

2 Institute of Directors. Chartered director. Director Development . 1999; August November: 2.

Peter Coles is chief executive, Forest Healthcare trust, and Neil Goodwin is chief executive, Manchester health authority.