As pressures on the NHS workforce intensify, the quality of management has become one of the most important determinants of patient safety, staff experience, and organisational performance.
At the heart of this is psychological safety: the belief that staff can feel safe to speak up, raise concerns, admit mistakes, ask questions and challenge decisions without fear of blame, humiliation, or negative consequences. If that sense of safety isn’t there, the risk is staff who fear questioning authority.
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That’s when worries go unspoken, early warning signs are missed, and concerns that should be resolved through normalised, professional discussions escalate into patient safety failures. We have seen the consequences of weak speaking-up cultures.
The Thirlwall Inquiry into events at the Countess of Chester Hospital showed how concerns raised by staff were not acted upon effectively, and how organisational cultures, management, and leadership behaviours can contribute to delayed responses to serious risks.
The quality of management is not peripheral to NHS success; it is fundamental. Research from my charity, the Chartered Management Institute (CMI), found that 82 per cent of managers across all sectors are promoted into the role without any formal training. These “accidental managers” are rewarded for technical competence yet are not prepared for the realities of managing others.
Crucially for the NHS, they are instead thrown into a leadership situation in which they are expected to build trust, handle conflict, lead difficult conversations, and create psychologically safe environments. But in what is already an undermanaged service, many are being asked to deliver without the benefit of an investment in their own development.
The NHS does not have, or need, “born leaders”. It needs to train all of its leaders – both clinical and non-clinical – to a common standard, giving them the tools to succeed. The price to be paid for inaction is not solely patient safety but also workforce retention. Our research found that one in three people have walked away from a job because of poor workplace culture or toxic bosses.
Given the NHS vacancy rate in critical roles, inaction is a dereliction of leadership. Some organisations, such as the Royal Berkshire Foundation Trust, have leaned into this challenge. More than 150 of their clinical and non-clinical staff have undertaken the CMI Chartered Manager accreditation process, with positive results for both patient outcomes and employee morale.
In contrast, the independent review of East Kent Hospitals University FT maternity and neonatal services found that weaknesses in management and leadership, culture, and teamworking contributed to avoidable patient harm. A lack of psychological safety left staff feeling unable to escalate concerns effectively or challenge poor practice.
Given the high-stakes risk, if we are serious about psychological safety in the NHS, then we must be serious about professionalising management. Psychological safety is built through everyday management practices: active listening, enabling fair challenge, creating trust, and the confidence that concerns will be heard and acted upon.
Investing in managers is not a frill or an optional extra but a critical investment in patient safety and organisational performance. Put simply, if we want a safer, higher-performing NHS, we need better-managed organisations and the safe, confident staff that they enable.
