Written evidence from the Chartered Management
Institute (REV 27)
EXECUTIVE SUMMARY
- This is a submission from the Chartered Management
Institute (CMI), the only Chartered professional body dedicated
to raising standards of management and leadership across all regions
and sectors of the UK. We work closely with many different employers
in the NHS to raise their teams' management and leadership skills,
resulting in better performance for staff and better care for
patients.
- Our focus in responding is how the Government
can take this opportunity, in reforming the NHS, to champion and
improve management and leadership skills throughout the health
service, in order to achieve its stated aim of better health outcomes,
centred on the patient rather than the process.
- While instances of poor leadership and management
practices in the NHS are relatively rare, bad managers and leaders
can lead to serious incidents and, in the worst cases, cost lives.
We have evidence from some of our members that a lack of national,
quality assured management and leadership training in the NHS
leads to inconsistent management performance, resulting in time
and money wasted as problems are investigated and resolved. The
recent events at the Mid-Staffordshire NHS Trust are a dramatic
example of what can happen when poor management goes unaddressed.
- It is therefore essential that the Government
puts the conditions in place for the NHS to improve leadership
and management skills, starting with senior leaders and managers
but eventually helping all managers within the NHS - after
all, today's middle manager may well be tomorrow's leader.
- Some good work is already being done in some
areas of the NHS to improve leadership and management. For example,
the NHS Institute for Innovation and Improvement (NHSIII) has
developed and implemented its Leadership Qualities Framework (LQF)
which describes the qualities expected of existing and aspiring
leaders. But we urge Government to take this development work
much further. We believe that all managers should be accredited
to a national, professional management and leadership framework.
In time we would like to see all senior NHS managers (i.e. board
level) holding a management and leadership qualification. In this
way, NHS managers would become professionally qualified to practice,
just as clinical staff must be medically qualified.
- In our response we have set out our proposals
for implementing a national accreditation framework, based on
the recommendations made in the Department of Health's report,
Assuring the quality of senior NHS managers (February 2010),
and outline how we can help to deliver higher management and leadership
skills for NHS managers, which will in turn contribute to better
health outcomes for patients. We have also commented on how our
proposals tie into the new structure and goals being proposed
by Government in the consultation document.
1. OVERVIEW OF
CMI
1.1 The Chartered Management Institute (CMI)
is the only chartered professional body dedicated to management
and leadership, with some 88,000 individual members across the
UK. Our members are employed at all levels of management within
business and public sector organisations. We are well represented
in the health sector, with over 3,000 members employed in the
NHS and associated organisations (including military medical managers),
and almost 100 holding our prestigious Chartered Manager award.
1.2 We have helped many NHS employers around
the country to improve the management and leadership skills of
their employees over the years. Some examples of our work with
the NHS are included in section 6 of this report. Our health sector
members agree that in using a professional body with years of
experience of improving management and leadership skills at all
levels, they benefit from our skills and knowledge of management
as a profession, which are tailored to meet the particular needs
of the public health sector.
2. PUTTING MANAGEMENT
AND LEADERSHIP
SKILLS AT
THE HEART
OF NHS REFORM—THE
BUSINESS CASE
2.1 The CMI welcomes the Government's ambition
to put patients at the heart of the National Health System, and
to ensure that the focus is on patient outcome, rather than the
treatment process. We do not wish to comment on the structural
and clinical changes which are proposed in the consultation document,
as this is outside the scope of our expertise. However, we believe
that, far from viewing managers as an expensive burden on the
NHS, managers and their teams must be viewed as the drivers of
change. If the Government is to achieve its stated aim of bringing
about a "change in the culture and focus of the NHS, driven
by staff who are empowered, engaged and well supported" (p 3),
it must ensure that all NHS managers, whether clinical or administrative,
high level or junior, are offered the opportunity to become accredited
to professional, nationally recognised management and leadership
standards.
2.2 At a time when there are multiple demands
on resources, and public expenditure must be wisely spent, the
business case for improving management and leadership skills in
the NHS is clear. Indeed, the Department of Health itself acknowledges
the importance of the link between management and leadership skills
and improving the quality of care in its recent report, Assuring
the quality of senior NHS managers.[25]
It states: "Studies such as West and Johnson (2002)[26]
and Jiang et al (2009)[27]
have shown that good management and board practices can reduce
mortality rates in hospitals by improving the interactions between
all the members of the community that comprise a hospital."
(p 10).
2.3 It is therefore disappointing that both the
White Paper and the consultation document fail to recognise the
importance of leadership and management skills in improving patient
outcomes. It is surprising that the consultation document makes
no reference to the findings of previous Government reports on
improving the performance of the NHS, for example Lord Darzi's
report, High Quality Care for all, NHS Next Stage Review.[28]
This report notes that a small number of managers are deemed to
have significant performance issues, and makes recommendations
for improving staff performance across the NHS. The Francis Inquiry
into problems at the Mid-Staffordshire NHS Trust hospital also
underlined fundamental problems with leadership and management,
which resulted in 400 avoidable deaths at the hospital. Both these
reports highlight a key theme - that management and leadership
skills in the NHS are essential to improving patient outcomes.
2.4 We also know from our members working in
the NHS, some of whom are senior managers and leaders, that a
lack of systematic, national, quality-assured management and leadership
training for all NHS managers leads to performance problems
which sometimes take a great deal of resources to resolve. One
of our Trustees reports that good clinical staff are often promoted
to management without receiving management training, which leaves
them to develop their management and leadership skills based on
their own experience, rather than professional standards. He describes
a case he has been involved in which has lasted seven years, which
resulted from poor leadership skills by one head of department,
and a consequent lack of timely remedial action. These cases take
up valuable time and resources which should be directed towards
patient care, rather than administration costs. Where staff do
receive training, it is sometimes unaccredited and there is no
quality assurance scheme to ensure that training is effective.
3. A NATIONAL,
PROFESSIONAL ACCREDITATION
FRAMEWORK FOR
HEALTH MANAGERS
3.1 We therefore urge Government to introduce
measures to help improve the management and leadership skills
of managers at all levels of the NHS, as part of its commitment
to making the health service more patient-centred.
3.2 As a first step, we urge the Department to
act on the recommendations made by the Advisory Group on Assuring
the Quality of Senior NHS Managers in its recent report.[29]
The report made a recommendation that, in order to strengthen
the performance of individual hospital Trusts and to ensure that
senior staff with performance issues do not simply leave and join
NHS organisations elsewhere, the National Leadership Council introduces
a professional accreditation scheme for all senior managers. It
recommends that the scheme is developed and administered by an
independent organisation with expertise in setting and accrediting
standards of professional managerial practise, overseen by a board
reporting to the National Leadership Council. The Chartered Management
Institute is uniquely placed to implement such a scheme and we
are discussing this with the National Leadership Council.
3.3 However, we believe it is essential that
the Department also acts on another recommendation from the Advisory
Committee, to raise the skills level of all NHS managers,
not just those at the very top. There is a pressing need to ensure
that all managers receive the same high standard of skills training,
particularly since under the new structure more and more decisions
will be taken at local and sub-regional level. The Advisory Committee
report states: "It [is] recognised that the principles
that apply to senior managers should apply equally to managers
and leaders at every level in the NHS…The National Leadership
Council, in due course, will want to consider how the principles
that the group wants to apply to senior leaders should extend
to the leaders of tomorrow in more junior (but still important)
managerial roles within the NHS." (p 15)
3.4 CMI therefore urges Government to introduce
a nationally-accredited management and leadership skills training
system for all NHS managers, concentrating on senior managers
first. By using national accreditation services, all NHS employers
will ensure that the training they purchase has been quality-assured
and sets a national standard for managers. In this way the Government
can ensure that management and leadership skills are professionally
and nationally benchmarked and form the basis of the customer-focused
standards set out in the White Paper.
3.5 In order to achieve parity between clinicians
and non-clinician managers, in time we would like to see all senior
managers to have professional accreditation, which would give
them a license to manage in the NHS, similar to their clinical
colleagues' medical license to practice. This would give patients
and their families reassurance that those who are in charge of
overseeing NHS services within their area are fully equipped to
do so, using professionally recognised management and leadership
skills.
4. HOW TO
DELIVER THE
ACCREDITATION FRAMEWORK
4.1 There are many different routes by which
a national accreditation framework for management and leadership
could be introduced into the NHS throughout England - through
NHS employers becoming approved centres; by direct delivery of
accredited qualification programmes, and via direct delivery by
recognised partners and quality assured providers. Employers may
choose to have their in-house management and leadership programmes
validated, which would not lead to a qualification but would be
mapped to the framework and would assure them that national standards
are being met. In this way, employers would be offered a flexible
system which caters to their needs and budgets, but nevertheless
ensures that national standards are met.
5. HOW BETTER
MANAGEMENT AND
LEADERSHIP SKILLS
CAN HELP
DELIVER THE
GOVERNMENT'S
AGENDA FOR
CHANGE IN
THE NHS
5.1 We would like to comment on how improving
management and leadership skills are essential to the proposed
reforms in the consultation document. The consultation paper proposes
an outcomes framework which is made up of a set of goals. The
Chartered Management Institute believes that a set of national,
professionally accredited management and leadership standards,
delivered using accredited training, will help achieve these goals
in all five domains set out in the consultation document. However,
we believe that management and leadership skills have a particularly
important role to play in delivering the goals set out in domains
4 and 5:
Domain 4: ensuring people have a positive experience
of care
5.2 This section, together with domain 5, is
most dependent on the quality of management and leadership in
the NHS. As the consultation document states, "quality
of care includes the quality of caring" (p 30).
The domain emphasises the importance of the patient experience,
and capturing how patients feel about the care they receive. Good
management and leadership are essential to improving patient feedback.
Mistakes and poor care are often the subject of patient complaints,
and incidents such as the case of the Mid-Staffordshire NHS Foundation
Trust are an example of how poor management, low morale and a
disengagement between clinicians and management staff result in
tragic outcomes for patients.
5.3 We are aware that the NHSIII has developed
the Leadership Qualities Framework to promote world-class leadership
qualities and identify how NHS leaders can improve their skills.
This is a very valuable tool and is widely recognised in the NHS.
However, more needs to be done to develop and implement a national,
quality assurance framework which all NHS managers, not just those
at the top, can use. This is why we recommend the alignment of
the Leadership Qualities Framework with the National Occupational
Standards, which can then map clear progression routes across
the frameworks. This work could be done relatively quickly and
cost-effectively.
5.4 The CMI's quality assurance framework for
management and leadership is based on the National Occupational
Standards (NOS) for Management and Leadership,[30]
which have been developed in consultation with a wide range of
practising managers, as well as academic and policy experts. The
Standards set out constructive ways in which managers can improve
their performance in six areas: managing self and personal skills,
providing direction, facilitating change, working with people,
using resources and achieving results. In following the NOS, employers
can ensure that managers are trained to high standards which are
nationally recognised as being proven benchmarks of best practice.
Domain 5: Treating and caring for people in a
safe environment and protecting them from avoidable harm
5.5 Again, the quality of management and leadership
in the NHS is central to achieving the goals in this domain. The
three underlying principles of Domain 5, protecting people from
further harm; an open and honest culture; and learning from mistakes,
are all dependent on factors such as communication, team work,
positive leadership and helping staff address problems with their
performance. The Francis Inquiry into the Mid-Staffordshire NHS
Foundation Trust found that problems in the hospital included
bullying, low staff morale, disengagement by consultants from
management, an uncaring attitude by staff, and frequent changes
in management, which led to a sense of lack of leadership and
support. All these problems, which ultimately resulted in 400
avoidable deaths, could have been solved by better management
and leadership by hospital staff, and the report made a specific
recommendation that a system of "professional accreditation"
should be introduced for senior NHS managers.
6. EVIDENCE THAT
CMI CAN DELIVER
IN THE
NHS
6.1 CMI has developed numerous case studies showing
how NHS clients have used our products and services to achieve
their development aims. Three such examples are set out briefly
below:
Kingston Hospital
6.2 Kingston Hospital is a district general hospital
which supports approximately 320,000 residents. It has recently
appointed a new Chief Executive who has implemented a number of
organisational changes. With these changes going on, and given
the more challenging financial operating environment, it is important
that Kingston hospital's managers are well equipped to handle
change and to disseminate information to staff where and when
appropriate. Members of the management team have varying levels
of experience and qualifications.
6.3 A key aim of the hospital's training strategy
is to equip managers with the skills and knowledge to manage all
the changes taking place effectively. The hospital works with
Kingston College, a local FE establishment, to provide a choice
of four CMI courses for its staff, including the Introductory
Certificate in Management and the Introductory Diploma in Team
Leading. To date more than 40 staff, predominantly at the junior
level, have taken up the courses. As a result, the hospital has
witnessed an improvement in the skills level of its staff, and
some have been promoted as a direct result of the training.
6.4 Kingston Hospital Training Manager Marie
Mackenzie says: "The type of skills we need our staff
to have include good communication, a well rounded understanding
of the organisation and its goals, the ability to form strong
relationships with fellow team members and an understanding of
the importance of trust and transparency when managing change.
We have seen a definite improvement in all these areas following
CMI course participation…Our belief is that if you have good
managers, who manage their teams effectively, this translates
into better service provision and improved customer satisfaction
as a result."
Nottingham NHS University Hospital
6.5 Nottingham University Hospitals NHS Trust
(NUH) is one of the largest acute teaching trusts in the country,
providing acute and specialist services to 2.5 million people
within the Nottingham area. NUH employs over 13,000 staff, making
it one of the city's largest employers. During 2009-10 the Trust
cared for around 100,000 people. It has set itself ambitious targets
for the future; by 2016 it aims to become the best acute teaching
Trust in the country. Following the publication of two NHS reports
which highlighted the importance of strong leadership ("Inspiring
Leaders of the Future" and "High Quality of Care for
All") the Trust decided to embark on a management development
programme that would play an integral part in achieving its ambitious
goal.
6.6 Fitting training into managers' daily workload
was always going to be a challenge in itself, and the Trust wanted
a programme that would ensure managers received real value for
time spent, with learning they use immediately and pro-actively
within their different teams, ranging from finance to physiotherapy.
It was also important that NUH design and deliver the programme
themselves whilst allowing the accreditation to come from a credible
external organisation. Responding to the needs of the Trust, CMI
took NUH's learning requirements and proposed a bespoke management
development programme for Level 7 managers. Extremely flexible,
the course could be segmented into weekly chunks to make it easier
for as many managers as possible to devote time to attend. The
training was called "Building Essential Leadership Skills"
(BELS) and launched in 2009 and that year was delivered to 132
managers, the highest voluntary attendance rate achieved at NUH.
6.7 Having received the training, managers reported
that they feel more empowered to make a difference to the patient
experience and, according to the training team, staff appear more
satisfied in their jobs. The programme has given managers more
confidence to make decisions, and has challenged the way they
approach situations. "The course is really helping support
the application of the elements needed to achieve our Trust's
vision and is helping the Trust re-define its leadership roles.
Things are continually changing, so it's important to keep it
fresh for the fourth tranche. Managers' needs don't stay the same
and neither will the course - but the CMI's input into the BELS
progamme allows us to adapt it as we grow and move the Trust forward
towards the future."
Royal Free Hospital NHS Trust
6.8 The Royal Free is a large hospital and medical
school employing approximately 5,000 staff across multiple sites
and disciplines. Its Staff Education and Development Centre provides
a wide variety of course programmes for all staff, at all levels.
In April 1996 the senior management of the Trust recognised the
need to have programmes in management approved by an external
organisation. As a result, the Centre was given approval in 1997
to deliver various CMI qualifications and training. The Hospital's
management board developed a "management by objective"
strategy, in partnership with CMI's External Verifiers. Staff
were offered the most appropriate level training according to
their needs, including at Level 3, Level 5 and Level 7.
Staff Education & Development Centre Manager,
Joe Serra, believes that the variety offered was key to its long-term
success. He said: "To have a true impact, the development
programme had to be made available to staff at all levels. Anything
less would have diluted buy-in, created a two-tier system of staff
development and would not have had the desired effect on the Trust's
performance. The application of management theory to practice
was also critical, as all relevant management knowledge needed
to be applied by participants within their respective clinical
areas." Following the training, surveys showed that satisfaction
amongst patients increased as a result of the training programme
and the Trust earned a five star rating for excellence - the highest
that could be awarded. Some staff then went on to study for Chartered
Manager award, and staff from other external organisations have
also received management training at the hospital under the scheme,
enabling the hospital to become a de facto centre of excellence
for leadership and management training.
7. CONCLUSION
7.1 The Chartered Management Institute is strongly
placed to help deliver the Government's desire to improve patient
outcomes by creating a more patient-centred approach within the
NHS. To achieve this outcome, the Government needs to build on
the numerous reports into specific performance issues within the
NHS, and to implement recommendations to improve management and
leadership skills at all levels. In this way managers will be
better equipped to reach the standards set by the consultation
document, resulting in better performance for staff and better
care for patients.
October 2010
25 Assuring the quality of senior NHS managers:
Report of the Advisory Group on assuring the quality of senior
NHS managers. Department of Health, February 2010. Back
26
Ibid. Back
27
Ibid. Back
28
Department of Health, 2008.
Back
29
Assuring the quality of senior NHS managers: Report of the
Advisory Group on assuring the quality of senior NHS managers.
Department of Health, February 2010. Back
30
The National Occupational Standards for Management and Leadership.
Management Standards Centre (2009). Back
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