The writer is chief executive of the NHS Confederation
The full ramifications from the case of serial child killer Lucy Letby won’t be known until the inquiry is complete.
In the immediate aftermath, however, questions have been raised as to why senior National Health Service managers are not regulated in the same way as doctors, nurses and other healthcare professionals. The government and NHS England, the arms-length body that oversees and regulates the service day-to-day, are at the early stages of considering, again, new powers to disbar senior managers where serious misconduct — such as ignoring warnings of danger to patients — is found. Labour has also pledged to overhaul NHS management regulation.
This debate is not new. Indeed, the Francis Inquiry into the failings at Mid Staffordshire NHS Foundation Trust a decade ago led to the 2019 Kark Review, which recommended Freedom to Speak Up champions across NHS organisations to protect and encourage whistleblowers.
Each individual case should be investigated, of course. But it is crucial that wider NHS systems are made as robust and transparent as possible.
When it comes to NHS board appointments, tests are already applied with the intention of ensuring that only “fit and proper persons” can take up prominent roles. These checks are designed to prevent senior managers who have been involved in or enabled serious misconduct or mismanagement from joining a different NHS organisation.
While introducing a stronger regulatory framework is sensible, care is needed to design a system that actually fixes the problem it sets out to address. It will be no good viewing this challenge through the lens of “clinicians as heroes and managers as villains”, as some of the early commentary has sought to do.
Managing risk — including risk to patient safety — is central to the work of both senior managers and clinicians. Whether providing services in crumbling hospitals, dealing with the impact of industrial action or simply meeting the day-to-day growing demand with constrained resources, health leaders often have to make difficult choices. Partly as a result of the existing regulatory regime, the turnover of senior leaders is high — nearly two-thirds of current NHS trust leaders are first-time CEOs. And while bureaucrat-bashing is a popular pastime, the weight of evidence suggests many of the NHS’s challenges reflect a lack of investment in management.
Of course, none of this absolves the need for hard accountability when serious misconduct is uncovered among NHS senior managers or anyone else — those who have failed must be prevented from taking up future NHS roles. Judgments about allegations must be made independently: a regulator would need to measure personal and professional behaviour against clear standards and codes of conduct. Such an approach would need legislation.
But despite more safeguards being needed, we should acknowledge that the NHS is already highly regulated. A Patient Safety Incident Response Framework published last year sets out the health service approach to developing and maintaining effective processes for responding to patient safety incidents. The Care Quality Commission already inspects and rates hospitals, GP practices and other providers — including looking at cases where clinicians and managers raise concerns at GP practices and other providers.
In designing any new regulatory framework for senior managers, our starting point should be developing a proportionate approach. The NHS, which treats tens of millions of patients every year, has to respond to many concerns and complaints. A key feature of any system must be to retain a commitment to learning from mistakes. Simply seeking to assign blame will only incentivise cover ups and buck passing rather than transparency and improvement.
