Revalidation of Doctors - Health Committee Contents

Written evidence from the Chartered Management Institute (REV 27)


  • 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.


1.1  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.


2.1  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.


3.1  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.


4.1  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.


5.1  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.


6.1  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.


7.1  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   IbidBack

27   IbidBack

28   Department of Health, 2008.


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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Prepared 8 February 2011