Leading the NHS: proposals to regulate NHS managers
Updated 28 November 2024
Applies to England
There has been a minor change to the wording of one question. Survey responses given before 28 November will still be considered in the government response.
Introduction
Delivering the new 10 Year Health Plan for the NHS requires the best leadership talent. The NHS requires people who are trained and supported to lead the changes needed to fix a broken NHS and drive the excellent performance in a world-class healthcare system, which patients and the public rightly expect.
The vast majority of NHS managers and leaders across the country work hard every day to enhance performance, support staff and nurture a positive culture in the NHS. As the September 2024 Lord Darzi review of the NHS states:
For the NHS to have more and better leaders, it needs to continue to invest in them.
This is why we are improving how we support managers and leaders to reach their full potential.
Developing a leadership and management framework
We want to make sure that our current and future managers and leaders have the right skills and values to support colleagues to improve and deliver services, engendering a culture of openness and honesty in which all NHS staff are encouraged and supported to raise concerns. Managers and leaders need access to the right learning and training opportunities throughout their careers and patients and staff alike need to be confident that leadership in the NHS is effective and accountable.
That is why NHS England is developing a leadership and management framework, which will introduce a code of practice, a set of core standards and a development curriculum for managers. This will support managers and leaders to undertake further training to improve their effectiveness and to progress in their careers.
Acting on the outcomes of public reviews
These positive changes are much needed for all NHS managers and leaders but at the same time several high-profile public reviews over the last 2 decades have identified serious failures in NHS leadership and the impact this can have on care and patient experience. Too often in these tragic cases there has been a sense that leaders who have failed to act appropriately have not been held to account for their actions.
A substantial amount of work has already taken place in response to these reviews. Following the Francis inquiry into the failings at the Mid Staffordshire Foundation Trust (2013), the NHS introduced a fit and proper person test (FPPT) for directors, to provide a mechanism to help ensure that only suitable individuals are appointed to leadership roles.
Tom Kark KC undertook a review of the FPPT in 2019, which identified a perception that poor managers were moving around the system from high-profile job to high-profile job. To address this, the test was extended to board level leaders across all integrated care systems and to appropriate Department of Health and Social Care (DHSC) arm’s length bodies. Resources were also put in place to help employing organisations ensure that the right conduct, values and competencies are demonstrated by their senior leaders.
As part of the first annual FPPT recording and reporting this year, a small number of board members have been identified as not being fit and proper, and in other cases action is underway to support development and improvement.
Improving organisational culture
We also know that culture issues continue to be a problem. The 2022 Messenger Review highlighted successful leadership as an important driver for improving organisational culture, setting out a series of recommendations that would further support and develop leaders to engender a positive culture more widely in the NHS. All 7 Messenger Review recommendations were accepted by the government at that time and work continues to implement these in the NHS and social care.
In response to the Messenger recommendations, NHS England has developed a roadmap of initiatives to identify appropriate standards, underpin quality-assured development opportunities and support talent and career management for NHS managers and leaders at all levels.
Taking further action to strengthen accountability
Despite these measures to improve NHS leadership and leadership accountability, those affected when things go wrong have been left feeling that NHS managers and leaders are not properly held to account for their actions or that people raising legitimate concerns are not always heard. The ongoing Thirlwall Inquiry into events at the Countess of Chester hospital continues to highlight these concerns. The Infected Blood Inquiry further highlighted the devastating impacts a lack of senior leadership accountability can have and emphasised the need for candour to apply across the NHS, regardless of position.
It is therefore vital that we take further action to strengthen the accountability of managers, with the overarching aim of ensuring patient safety. That is why this government committed, in its 2024 election manifesto, to providing managers with the support and accountability they need by implementing professional standards and regulating NHS managers. This will ensure those who commit serious misconduct can never do so again.
Regulatory oversight of NHS managers will provide an opportunity to further professionalise the NHS management and leadership workforce by setting clear and consistent standards that all managers and leaders in the NHS must meet. It will also strengthen their professional accountability by providing a consistent and fair means of addressing concerns about their conduct or performance and, in the most serious cases, will mean that an individual can be prevented from working in any NHS managerial or leadership role.
Objectives of this consultation
This consultation seeks views from all stakeholders, including health and care organisations, regulators, professional bodies, health and care managers and senior leaders, the public, patients and other health and care staff on the most effective way to strengthen oversight and accountability of NHS managers.
We are seeking views from stakeholders on:
- the type of regulatory system that would be most appropriate for managers
- which managers should be in scope for any future regulatory system
- what kind of body should exercise such a regulatory function
- what types of standards managers should be required to demonstrate as part of a future system of regulation
This consultation also asks questions on the sequencing of the introduction of a regulatory mechanism for NHS managers, alongside the NHS England work that is already underway to develop professional standards. The territorial extent of this policy proposal is England only.
All references to the introduction of a regulatory system for NHS managers and/or leaders refers to NHS managers and leaders in all NHS organisations (including primary and secondary care) in England only, hereafter referred to as ‘NHS managers’. This is with the exception of the sections ‘Duty of candour for NHS leaders’ and ‘NHS leaders’ duty to respond to safety incidents’, which refer to NHS leaders.
Any legislation brought forward to implement a statutory regulatory regime for NHS managers will be subject to further consultation.
Policy proposal for consultation
Regulation can take many forms, and it’s vital that any regulatory system for NHS managers is proportionate to the risk to the public, enabling action to be taken in response to concerns.
The Professional Standards Authority for Health and Social Care’s (PSA) paper on Right-touch regulation (revised in 2015) highlights the need to balance risk against regulatory force by ‘understanding the problem before jumping to the solution’.
This section of the consultation introduces the main types of regulation and sets out the functions, benefits and risks of bringing a profession into regulation. It highlights, where relevant, what this could mean in practice for regulating NHS managers.
Considering these options against the risks posed by NHS managers will help inform an evidence-based decision on the best type of regulatory oversight for NHS managers. We know, for example, that NHS managers come from a range of backgrounds, undertake a broad scope of divergent roles and do not currently have a single common entry qualification in the same way that doctors, nurses and dentists do. The regulatory system must therefore be designed around the specific risks and requirements of NHS managers.
Overall approach to the regulatory model
There are several different approaches that can be taken to regulate NHS managers. These range from non-statutory mechanisms such as a voluntary accreditation register, to statutory barring functions through to full statutory registration and revalidation mechanisms. Depending on the regulatory model chosen there will be different requirements, processes and constituent parts to the regime.
Types of regulation
Statutory barring system
A statutory barring mechanism is a list of people who have committed offences, or who have been found to be unsuitable to practise a particular profession. The lists are enforced through legal obligations on employers not to appoint barred individuals. In practice this means that a professional who has been included in a barring list as a result of poor conduct is prevented from practising in their profession. Examples include the Teaching Regulation Agency (the barring list for teachers) and the Companies House list of disqualified directors.
An individual may be disbarred for ‘serious misconduct’, which includes behaviour such as criminal convictions or offences, deliberate bullying and harassment or dishonesty (as outlined in the Kark review of the fit and proper persons test). A barring list prevents an individual from practising in that profession for as long as they remain on the list.
A statutory barring mechanism does not usually include a register of individuals who are ‘fit to practise’ in the same way that a full statutory regulation system does. Rather, it holds a list of those who have been found unsuitable to practise.
If a statutory barring system is introduced for NHS managers, it would mean the introduction of a national code of conduct for managers or leaders and a body would be given legal responsibility to consider serious complaints made about individual professionals.
If managers or leaders demonstrated serious misconduct this would be investigated and, if upheld, managers or leaders would be placed on a ‘barred list’ of individuals deemed unfit to practise in the profession. Any decisions to uphold a complaint would be made public, as would the resulting sanction and a register would be maintained of those found unfit to practise.
Setting up a barring system would involve an initial cost to government and subsequent annual running costs, which would also fall to government.
A professional register
Full statutory regulation or a voluntary accreditation route would involve the use of a professional register and is another type of regulation. In the case of voluntary accreditation, managers would have the option of joining the register, but with statutory regulation, managers would be required to join the register to be able to practise as a manager in the NHS.
Professional registers are held by some healthcare regulators, such as the General Medical Council (GMC), which regulates doctors, and the Nursing and Midwifery Council (NMC), which regulates nurses, midwives and nursing associates (in England only). The regulators assure the capability of registrants by maintaining registers of people who are fit to practise in the profession. Applicants may have to demonstrate that they hold an approved qualification from an approved domestic educational institution, or a recognised international institution or country, to achieve registration. In the case of managers, individuals would likely be required to meet the standards of competence set out by the regulator, including standards of training, professional skills and education.
The cost of bringing managers into regulation (and the costs of any new regulatory body established to take on this function) would fall to the taxpayer. There would normally also be a fee for registration, which individual registrants would be required to pay (usually annually).
Full statutory regulation
Full statutory regulation requires professionals to register with a regulator, which publishes a list of people who hold an approved qualification for entry on the register and are therefore deemed fit to practise a particular profession. This would put managers on a similar regulatory footing as medical and nursing colleagues. For healthcare professionals, the regulators’ standards set out what is expected of an individual working in that profession and the individual is required to evidence that they have the skills, knowledge and experience required to work in their profession and that they are fit to practise.
Full statutory regulation normally requires periodic revalidation to assess whether a registrant continues to be eligible to maintain their registration by demonstrating that they have kept their skills up to date and that there are no matters of misconduct which would call their continued registration into question. Individuals whose conduct or performance falls below the regulator’s expected standards can have conditions attached to their registration if their fitness to practise is found to be impaired. In the most serious cases they can be ‘struck off’ a regulator’s register, which legally prevents them from practising a particular profession. If managers are brought into full statutory regulation, standards of proficiency, conduct, formal entry qualifications and educational courses to deliver them, and continuing professional development standards and mechanisms will need to be developed to underpin registration requirements.
If full statutory regulation is introduced for NHS managers, it would mean the introduction of a set of professional standards which managers are required to meet in order to join the register. Joining such a register would be a statutory requirement in order to practise as an NHS manager. Such a register may involve periodic revalidation (periodic assessment that the registrant continues to meet the required standards to remain on the register).
Setting up such a register would involve an initial cost to government (further cost estimates are set out later in the consultation) and annual fees for registrants to join and remain on the register. It would also mean that managers or leaders could be struck off the register or have sanctions imposed on their registration if they fail to meet the professional standards required of them. There would also need to be support offered to managers in meeting requirements and transitional arrangements put in place for moving existing managers onto a register.
Accredited voluntary register
An accredited voluntary register is one way of enhancing professional accountability and can provide many of the same benefits as a statutory register. This is an independently quality assured and publicly searchable list of individuals who have demonstrated they have the skills and competencies to practise a certain profession.
A voluntary register may be accredited, akin to those already held and quality assured by the PSA for a range of professions in health and social care. This provides assurance that the organisation holding the register has a focus on public protection and robust processes in place for handling complaints against registrants. The independent PSA quality assures accredited voluntary registers that include more than 100,000 accredited practitioners across a range of professions. The PSA gives assurance to the public that the organisation holding the register has a focus on public protection and robust processes for handling complaints against practitioners.
By definition, it is not a legal requirement for all individuals to join a voluntary register to practise in their profession. However, employers and those accessing services may favour those on a voluntary register as it provides a competitive advantage and may be all that a practitioner needs to practise in certain roles.
If a voluntary accredited register is introduced for NHS managers, it would mean the introduction of a set of professional standards which managers are required to meet in order to join the register. Joining such a register would not be a statutory requirement in order to practise as an NHS manager but may be made mandatory in practice through employers choosing only to appoint people to leadership or management roles who are members of the register. Such a register may involve periodic revalidation (periodic assessment that the registrant continues to meet the required standards to remain on the register).
Setting up such a register would likely involve an initial cost to government (further cost estimates are set out later in the consultation) and annual fees for registrants to join and remain on the register. It would also mean that managers or leaders could be struck off the register if they fail to meet the professional standards required of them.
The purpose of regulating a profession
Regulation of specific workforces can serve several functions, some intentional and others a by-product of its intended primary purpose, which in the case of regulating health professions is to enhance and protect patient safety. The main functions of regulation are set out below and we encourage respondents to consider these when responding to the questions in this consultation.
Maintaining registers
The healthcare professional regulators (which are independent of government), such as the GMC and the NMC, maintain registers (lists) of people who have demonstrated that they are suitably qualified and meet the necessary professional standards (usually standards of behaviour, conduct and competency) to safely practise.
Regulators set standards that individuals must attain and maintain to be on the regulator’s register. The standards establish the required body of knowledge and a code of practice for registrants to follow, acting as the basis against which competence and conduct is assessed when considering whether the professional’s fitness to practise is impaired. If registrants fail to meet the professional standards expected of them and their fitness to practise is found to be impaired, they can:
- have conditions placed on their registration
- have their registration suspended
- in the most serious cases, be removed from the regulator’s register
These registers can be statutory, which makes it a legal requirement for an individual to be a member of that register in order to practise in their chosen profession. This type of regulation is referred to throughout this consultation as ‘full statutory regulation’.
Alternatively, a register can be voluntary, where a professional can choose to join the register, but it is not a legal requirement to practise in their profession. This type of regulation is referred to throughout this consultation as ‘a voluntary accredited register’.
Barring mechanisms
Barring mechanisms, such as the Companies House list of disqualified directors and the Teaching Regulation Agency barring list, maintain lists of unsuitable staff who have committed offences or who have been found to be unfit, enforced through legal obligations on employers not to appoint barred individuals. This type of regulation is referred to throughout this consultation as ‘a statutory barring system’.
Adjudication processes
Both full statutory regulation and barring system approaches require systems to triage complaints and then investigate, adjudicate and impose sanctions on professionals when concerns about their conduct are upheld. As removal from a statutory register or inclusion on a statutory barring list cuts across the European Court of Human Rights (ECHR) protection of the right to a chosen livelihood, both also require an independent legal appeal mechanism, generally the High Court.
Periodic revalidation (for full statutory and voluntary accredited regulation)
Some regulators, such as GMC and NMC, periodically assess whether a registrant should maintain their registration (known as revalidation), irrespective of whether concerns about a registrant’s conduct have been raised. This is done through a review of any continuous professional development undertaken, practice hours, employer appraisals and recommendations from supervising or senior colleagues. Failure to revalidate can result in removal from the register.
Benefits of regulating a profession
A regulatory system can serve several functions as set out below. Some of these are intentional, while others are a by-product of its intended primary purpose.
Public protection
This is at the heart of regulation and is at the core of any decision to regulate a profession. Regulation provides assurance to the public that those working in a regulated profession meet accepted standards and are suitably trained and experienced for the work that they are undertaking. Likewise, regulation can provide a means of restricting the registration or removing the right to practise of someone whose conduct or performance falls below the required levels.
Professional accountability
Regulation provides a means of ensuring individual professional accountability, so that an individual is required to demonstrate that they meet the required standards of practise, and that they are held accountable should they fail to meet those standards. In the most serious cases, this can mean that an individual may be barred from working in a profession or have their right to practise restricted.
Protected titles
A statutorily regulated profession will often have protected titles (for example paramedic, midwife or registered nurse) which can only be used by those that are on the regulator’s register. Use of that title by someone not appropriately registered is a criminal offence. This can have both protectionist (policing demarcation lines) and protective impacts (preventing impersonation of clinical professionals). We recognise that managers and leaders hold a wide variety of responsibilities at different levels of management and are not a single profession in the same way that some other registered clinical professions are. Any standards or assessment of proficiencies for manager regulation must recognise these differences.
Publicly searchable registers
Many regulatory regimes have publicly searchable registers, providing a simple means for employers, other professionals and the public to check if an individual is legally able to practise in a given profession, and whether or not they have any restrictions on their registration.
Public esteem
Some professions see regulation as a route to higher social esteem for their profession, and as a means of increasing professional pride.
Punishment
Those who are deeply affected by professional failings can perceive a professional being ‘struck off’ a statutory register or added to a barring list as punishment for harms. While imposition of sanctions can be punitive, their primary purpose is to protect the public in future.
Fair treatment
Some see the due process of statutory adjudication panels as an assurance that concerns about professionals’ conduct will be investigated fairly and properly.
Career development
Some see regulating managers as supporting a better career structure. Consideration must also be given to managers who do not currently work as NHS senior managers or board members but who may wish to become registered with a view to progressing their career in the near future.
Implementation considerations
While regulation aims to have a positive effect on public protection, there are often other consequences of statutory regulation. These consequences are set out below and we encourage respondents to consider these factors, alongside the purpose of regulation set out above, when responding to the questions in this consultation.
Barriers to entry
The formalisation of training requirements and standards for professions can act as a barrier to entry to the profession for some individuals. This could make recruitment from other sectors much more difficult and deter external talent from joining management and leadership roles in the NHS. It could also potentially be a barrier and/or have implications for ongoing employment of existing NHS managers.
Chilling effect
The introduction of an additional system of oversight and standards attainment may increase the fear of sanctions and individuals from both within and outside the sector may be deterred from taking up already challenging board roles.
Decision making
NHS managers monitor risks and face challenging decisions to balance patient safety, operational performance and financial sustainability. Additional regulation may change the framing for the difficult judgements that frontline, system and national NHS managers make on a daily basis, by increasing their aversion to risk.
Weakening local responsibility
The introduction of regulation could unintentionally feed a sense that centralised regulation of individuals provides a safety net that reduces the need for local board oversight and intervention. It may in places feed a tendency to refer difficult disciplinary issues rather than resolve them locally.
Vexatious complaints
Regulation provides a route for spurious complaints to be made against managers, rather than as a genuine route to address safety concerns. This could result in a high quantity of vexatious concerns being raised and increase the regulator’s caseload. This will also in turn increase the regulator’s operational costs (which will either fall to registrants or to taxpayers in the case of a barring system).
Other considerations
Scope of managers to be included
Our starting position is that the regulatory scheme should, as a minimum apply to:
- all board level directors in NHS organisations in England
- arm’s length body board level directors
- integrated care board members
However, the appropriate scope may vary based on the type of regulation being considered and indeed may flex over time, for example, starting with more senior grades and then expanding.
Any managers that come in scope for the regulatory system will be required to meet a set of professional expectations (usually a national code of conduct for a barring register, and professional standards of behaviour, conduct and sometimes training and education for a professional register system).
In the case of full statutory regulation those in scope for regulation will also be required to pay annual registration fees to join the statutory register in order to practise in their profession. The number of managers that come within the scope of a regulatory system (either those in the scope of a barring system or the number of registrants on a statutory register) will also have an impact on the cost of running and maintaining the regulatory system. The higher the number of managers in scope and, in turn, the greater the caseload of a regulator, the greater will be cost to run the regulatory system.
The responsible body
Depending on the type of regulatory approach adopted, there will likely be a need for one or more new or existing bodies to take responsibility for all or part of a regulatory system. These roles may include:
- setting standards of conduct and competency against which NHS managers are assessed
- holding a register of NHS managers who are registered to practise
- running a disbarring or fitness to practise scheme for NHS managers
There are various types of organisations that could exercise these functions including:
- an independent regulatory body (like the bodies that regulate other health professions such as the Health and Care Professions Council (HCPC), which regulates various other health professionals including paramedics, dieticians and 13 other healthcare professions)
- the Care Quality Commission (CQC), which runs the existing fit and proper persons test
- an executive agency or arm’s length body (a unit that is part of a government department but administratively separate from that department. An example is the Teaching Regulation Agency, which is an executive body of the Department for Education that operates the regulatory system for all teacher misconduct)
- a professional membership body (an organisation that oversees the professional practise of its members)
For full statutory regulation, there would usually need to be an independent body funded by registrants similar to the existing health professions regulators such as HCPC. This would involve either creating a new body or housing this function within an existing body.
For a statutory barring system, this function could be held by an existing body such as a professional regulator or CQC, or could be conferred to a newly established body. It would play a similar role to the Teaching Regulation Agency which operates the regulatory system for teacher misconduct.
A voluntary register could be held by a range of bodies, such as an existing or newly established professional body for managers, but it may be less appropriate to house this within a current body with statutory regulatory functions.
Costs
Barring systems are generally taxpayer funded and one consequence of implementing a barring system for NHS managers would include the cost of setting up and running the barring system falling to taxpayers. For example, the Teaching Regulation Agency, which operates the barring list for teachers in England, costs approximately £12 million per year to run (based on just under 500,000 teachers in the country within scope of the system). If a barring system was introduced for NHS managers, we would expect the numbers of managers and leaders within scope of the barring system to be smaller than that of teachers, but we would still expect the costs per year of running the system to be between £2 million and £10 million, in addition to the cost of initial set up of the system.
For a full statutory system of regulation, or a voluntary accredited register initiated by government, the initial set up cost is usually taxpayer funded and then registrants are required to pay for registration, which funds the regulator to perform its functions. This mechanism is intended to give regulators financial independence from government as an underpinning for the overall independence of their operations.
For example, the cost to bring Nursing Associates into regulation in England under NMC (an existing regulator) was approximately £6 million. The cost to the taxpayer to establish a new regulatory body, Social Work England, to take on the regulation of social workers in England was approximately £12 million. We would expect the cost to the taxpayer of bringing NHS managers into a full statutory system of regulation under an existing regulator to be in the region of £5 million to £10 million. If a new regulatory body was also established to take on the function of regulating NHS managers, we estimate this will cost the taxpayer in the region of an additional £10 million.
Costs (registration fees) for registrants to join a regulator’s register are usually dependent on the number of registrants and the case load of the regulator (the number of concerns about conduct that are raised and investigated by the regulator). Regulators with a high case load and a low number of registrants tend to have higher fees, and vice versa. Registrants pay a registration fee to join a register and thereafter an annual fee to remain on that register. Registration costs vary by profession and by regulator caseload. For example, fees are:
- £750 to £800 per year for the General Chiropractic Council
- £455 per year for GMC
- £116 for HCPC
Given the costs and consequences associated with bringing a profession into regulation, it’s important that the development of any regulatory system carefully considers the most effective and proportionate way to enhance professional accountability for managers and leaders in the NHS.
Standards for managers and leaders
Our current policy position is that any standards put in place for NHS managers will cover, as a minimum, the values, behaviours and competencies that managers will be expected to demonstrate.
While there is not currently an agreed set of recognised professional standards for NHS managers, further work is being undertaken by NHS England to develop professional standards for managers, which could form the foundations for future regulatory standards for managers. For other regulated healthcare professions, regulation comes with an approved qualification to meet the requirements of registration. If full statutory regulation is taken forwards for NHS managers, all future registrants may have to complete formal training and gain specific qualifications before joining a statutory register and practising in the profession. If a formal qualification is made part of the standards for the statutory regulation of NHS managers this would also necessitate developing a mechanism to inspect and verify qualifications and providers.
Attaining a formal qualification to join a register (in the same way that other regulated health professions are required to do) could create a significant new barrier to entry to the profession for some and potentially a barrier for some of those already in the profession who do not undertake to gain the qualifications required for registration with the regulator. In this event there would also be a need to put in place ‘grandparenting’ arrangements to provide processes and arrangements to transition those who are already working in the profession to meet the requirements of registration. If regulation were intended to include non-executive and executive leaders, which are distinct roles with different skills sets and competencies, then careful thought would be needed in defining the method through which non-executives demonstrate their suitability for joining the register. While a qualification may be appropriate for executive leaders, it would be a significant barrier to entry for non-executives.
Revalidation
Certain types of regulation, such as being part of a statutory professional register, can involve a revalidation process - this is a periodic check that someone remains fit and competent to remain on a professional register. It can include confirming or providing evidence that an individual has kept their skills up to date and continues to meet the standards.
For example, the revalidation process for health professionals registered with HCPC includes making a professional declaration confirming that they have:
- continued to practise their profession since their last registration or have met the regulator’s returning to practise requirements
- continued to meet the regulator’s standards of proficiency for the safe and effective practice of their profession
- not had any change relating to their good character or had any change relating to their health which may affect the ability to practise safely and effectively
- continued to meet the regulator’s standards for continuing professional development
- ensured that professional indemnity arrangements are in place providing appropriate cover
GMC requires that doctors revalidate their registration by taking part in annual appraisals and collating a portfolio of evidence to show they meet the necessary standards set by the regulator, which is then assessed by a responsible officer.
If NHS managers were to be brought into a regulatory system that involved revalidation, the revalidation process may include some or all of the processes and assessment listed in the examples above. For non-clinical practitioners, replicating this process could be harder, as defining the evolving body of knowledge for safe practice of their profession may be less clear, given the wide range of clinical and non-clinical backgrounds NHS managers come from. Existing regulated health professionals are required to revalidate their registration periodically and the period of time between revalidation varies by profession. For example, doctors are required to revalidate every 5 years, nurses every 3 years and HCPC registrants are required to renew their registration every 2 years.
Clinical managers and dual registration
Many individuals who hold management and leadership positions in the NHS will also be clinically registered professionals who are already regulated as part of their clinical profession. For example, a medical director in the NHS holds a leadership position but will also be regulated to practise as a doctor by GMC. As part of this individual’s clinical registration, they will be required to meet the professional standards set by GMC. There are other types of non-clinical NHS managers who may hold a separate professional registration such as finance directors. There will also be many managers who do not hold a separate professional registration of any sort.
If NHS managers become a regulated profession, arrangements will need to be put in place to deal with registration for those clinical managers who already hold registrations with other regulators to avoid situations where professionals are held to account to differing standards for the same sort of competencies, or concerns about professional conduct being investigated in different ways by more than one regulator at a time.
There are 3 main options for dealing with regulating managers who also hold another clinical professional registration. These are:
- dual registration, where managers are required to register as a regulated manager, in addition to holding registration as a regulated healthcare professional. This would require assessment against the standards set by each of the regulators they are registered with
- broadening existing regulatory frameworks (for healthcare professionals) to include management competencies. In this scenario, managers who are already registered with a clinical regulator as part of their professional practice would not be required to register with a manager regulator, but their healthcare professional regulator would expand their existing standards to include a new set of management or leadership standards
- developing a set of mutually agreed standards between existing clinical regulators and the body responsible for regulating managers. All regulators would assess managers against those standards, while accepting that regulators are independent and have the statutory competence to set specific standards that are relevant for the professions that they regulate
Phasing of a regulatory scheme
The implementation process for any regulatory regime for NHS managers will be important and there are options for how to deliver it. For example, it would be possible to move straight to a chosen regulatory scheme or to take a phased approach, beginning with implementation of a voluntary register or a barring mechanism, with a view to transitioning to a full system of regulation in the longer term.
Duty of candour for NHS leaders
In regulating NHS managers, it will be important to consider the types of duties and standards that managers should be required to demonstrate.
A statutory duty of candour on providers (organisations rather than individuals) was recommended by the 2013 Mid Staffordshire Inquiry. The inquiry found at the heart of the failure a lack of openness, transparency and candour. The statutory duty was implemented from 2014 for all providers registered with the CQC (including NHS trusts and social care providers). The statutory duty is set out in regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and is regulated by CQC. The aim of the statutory duty was to incentivise providers to commit to a learning culture. It requires providers to be open and honest with patients or service users (including an apology) where avoidable moderate harm or worse happens during the provision of treatment or care.
The Infected Blood Inquiry’s final report (May 2024) makes a recommendation to extend the statutory duty of candour to apply to NHS senior leaders. The report states:
The statutory duties of candour in England, Scotland, Wales (and Northern Ireland, when introduced) should be extended to cover those individuals in leadership positions in the National Health Service, in particular executive positions and board members.
This recommendation refers to the existing statutory (that is, organisational) duty of candour. This consultation asks whether NHS leaders should have a duty to ensure that that statutory duty of candour is correctly followed in their organisation and if they should be held accountable for this.
In parallel to the introduction of a statutory duty of candour for CQC-registered providers from 2014, professional regulators (such as GMC, NMC and HCPC) introduced a professional duty of candour as part of the professional standards for their registered members to encourage open behaviour. This consultation asks whether a professional duty of candour, similar to that which forms part of the professional standards for regulated health and care professions to encourage open behaviour, is one of the standards that should be introduced for NHS leaders.
NHS leaders’ duty to respond to safety incidents
The Infected Blood Inquiry’s final report makes a recommendation that NHS leaders should have a legal duty to record, consider and respond to any concerns raised about healthcare being provided. The recommendation states that:
Individuals in leadership positions should be required by the terms of their appointment and by secondary legislation to record, consider and respond to any concern about the healthcare being provided, or the way it is being provided, where there reasonably appears to be a risk that a patient might suffer harm, or has done so. Any person in authority to whom such a report is made should be personally accountable for a failure to consider it adequately.
Such a duty could be introduced for NHS leaders and this consultation asks about what duties NHS leaders should have in relation to recording, considering and responding to safety incidents.
Consultation questions
Overall approach to the regulatory model
There are a number of different approaches that can be taken to regulate NHS managers. These range from non-statutory mechanisms such as a voluntary accreditation register, to statutory barring functions through to full statutory registration and revalidation mechanisms.
This section of the consultation asks questions about the most effective approach to the overall model of regulation for NHS managers.
Question
Do you agree or disagree that NHS managers should be regulated?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
Question
Do you agree or disagree that there should be a process to ensure that managers who have committed serious misconduct can never hold a management role in the NHS in the future?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
Statutory regulatory schemes for healthcare professionals such as doctors and nurses allow for:
- conditions to be placed on their registration
- their registration to be suspended if their fitness to practise is found to be impaired
Question
If there was a disbarring process, do you agree or disagree that the organisation responsible should also have these sanctions available to use against managers who do not meet the required standards?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
A professional register
A professional register is a list held by a regulatory body of individuals who are fit to practise in a given profession. A professional register can be mandatory or voluntary. With voluntary accreditation, managers would have the option of joining the register, but with statutory regulation, managers would be required to join the register to be able to practise as a manager in the NHS.
Question
Do you agree or disagree that there should be a professional register of NHS managers (either statutory or voluntary)?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
If you agreed, do you agree or disagree that joining a register of NHS managers should be a mandatory requirement?
This could be either a statutory requirement or made mandatory through NHS organisations choosing only to appoint individuals to management positions who are members of a voluntary register.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
Scope of managers to be included
This considers the seniority and roles of managers that a regulatory system should apply to and whether there are other organisations it should apply to. Our starting position is that the regulatory scheme should, as a minimum apply to:
- all board level directors in NHS organisations in England
- arm’s length body board level directors
- integrated care board members
Question
Which, if any, of the following categories of managers within NHS organisations do you think a system of regulation should apply to? (Select all that apply)
- Chairpersons
- Non-executive directors
- Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)
- All NHS staff aspiring to be board level directors
- Senior managers and leaders (approximately bands 8d to 9, for example service manager, clinical lead, nurse consultant, deputy director or director - usually band 9 - and head of department)
- Mid-level managers and leaders (approximately bands 8a to 8c, for example operations manager, programme manager, senior clinician and matron, up to head of service, for example head of nursing, head of performance and delivery)
- First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)
- Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)
- Don’t know
- Not applicable - managers should not be regulated
Please explain your answer. (Maximum 300 words)
Question
Which, if any, of the following categories of managers in equivalent organisations do you think a system of regulation should apply to? (Select all that apply)
- Appropriate arm’s length body board members (for example, NHS England)
- Board level members in all Care Quality Commission (CQC) registered settings
- Managers in the independent sector delivering NHS contracts
- Managers in social care settings
- Don’t know
- None of these
Please explain your answer. (Maximum 300 words)
The responsible body
The responsible body refers to the organisation that should be responsible for regulating managers. A responsible body may:
- set standards of conduct and competency against which managers are assessed
- hold a register of NHS managers who are registered to practise
- run a disbarring or fitness to practise scheme for NHS managers
Question
If managers are brought into regulation through the introduction of a statutory barring system, which type of organisation do you think should exercise the core regulatory functions outlined above?
- Executive agency of DHSC
- Professional membership body
- Don’t know
- Other type of body
- Not applicable - managers should not be regulated through a barring system
Please explain your answer. (Maximum 300 words)
Question
If managers are brought into regulation through the introduction of a professional register (either a voluntary accredited register or full statutory regulation), which type of organisation do you think should exercise the core regulatory functions outlined above?
- Independent regulatory body
- Executive agency of DHSC
- Professional membership body
- Don’t know
- Other type of body
- Not applicable - managers should not be regulated through a professional register system
Please explain your answer. (Maximum 300 words)
Question
If managers are brought into some form of regulation, do you have an organisation in mind that should operate the regulatory system? (Select all that apply)
- An existing regulator
- An existing membership body
- An existing arm’s length body (for example, an executive agency)
- Establish a new independent regulatory body
- Establish a new membership body
- Establish a new arm’s length body (for example, an executive agency)
- Don’t know
- Other
- Not applicable - managers should not be regulated
Please explain your answer - if you said an existing regulator, membership body or arm’s length body, please specify which. (Maximum 300 words)
Other considerations: professional standards for managers
Professional standards include as a minimum, the values, behaviours and competencies that managers will be expected to demonstrate. There is currently not a set of recognised professional standards for NHS managers. Further work is being undertaken by NHS England to develop professional standards for managers, which could form the foundations for future regulatory standards for managers.
Question
Do you agree or disagree that there should be education or qualification standards that NHS managers are required to demonstrate and are assessed against?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
If you agreed, which categories of NHS managers should this apply to? (Select all that apply)
- Chairpersons
- Non-executive directors
- Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)
- All NHS staff aspiring to be board level directors
- Senior managers and leaders (approximately bands 8d to 9, for example service manager, clinical lead, nurse consultant, deputy director or director - usually band 9 - and head of department)
- Mid-level managers and leaders (approximately bands 8a to 8c, for example operations manager, programme manager, senior clinician and matron, up to head of service, for example head of nursing, head of performance and delivery)
- First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)
- Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)
- Don’t know
Please explain your answer. (Maximum 300 words)
Other considerations: revalidation
Revalidation is a periodic check that someone remains fit and competent to remain on a professional register. Certain types of regulation, such as being part of a statutory professional register, can involve a revalidation process. It can include confirming or providing evidence that an individual has kept their skills up to date and continues to meet the standards.
Question
If a professional register is implemented for NHS managers, do you agree or disagree that managers should be required to periodically revalidate their professional registration?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
If you agreed, how frequently should managers be required to revalidate their professional registration?
- Annually
- Every 2 years
- Every 3 years
- Every 5 years
- Less frequently than every 5 years
- Don’t know
Please explain your answer. (Maximum 300 words)
What skills and competencies do you think managers would need to keep up to date in order to revalidate? (Maximum 300 words)
Other considerations: clinical managers and dual registration
Dual registration is where individuals are required to register with more than one professional regulatory body at a time. Many individuals who hold management and leadership positions in the NHS will also be registered clinicians, who are already regulated as part of their clinical profession.
Question
Do you agree or disagree that clinical managers should be required to meet the same management and leadership standards as non-clinical managers?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
If you agreed, how should clinical managers be assessed against leadership or management standards?
- They should hold dual registration with both their existing healthcare professional regulator and the regulator of managers
- They should only be required to hold registration with their existing healthcare professional regulator who will hold them to account to the same leadership competencies as non-clinical managers
- They should only hold registration with an existing healthcare professional regulator that will determine any leadership and managerial competencies
- Don’t know
- Other
Please explain your answer. (Maximum 300 words)
Other considerations: phasing of a regulatory scheme
A phased approach may begin with the implementation of a voluntary register or a barring mechanism, with a view to transitioning to a full system of regulation in the longer term.
Question
Do you agree or disagree that a phased approach should be taken to regulate NHS managers?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
Duty of candour for NHS leaders
The professional duty of candour forms part of the professional standards for regulated professions, overseen by professional regulators such as the GMC, NMC and HCPC to encourage open behaviour. There is also a statutory (organisational) duty of candour.
Question
If managers are brought into a statutory system of regulation, do you agree or disagree that individuals in NHS leadership positions should have a professional duty of candour as part of the standards they are required to meet?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
If you agreed, which categories of NHS managers should a professional duty of candour apply to? (Select all that apply)
- Chairpersons
- Non-executive directors
- Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)
- All NHS staff aspiring to be board level directors
- Senior managers and leaders (approximately bands 8d to 9, for example service manager, clinical lead, nurse consultant, deputy director or director - usually band 9 - and head of department)
- Mid-level managers and leaders (approximately bands 8a to 8c, for example operations manager, programme manager, senior clinician and matron, up to head of service, for example head of nursing, head of performance and delivery)
- First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)
- Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)
- Don’t know
Please explain your answer. (Maximum 300 words)
There is an existing organisational statutory duty of candour that already applies to providers.
Question
Do you agree or disagree that NHS leaders should have a duty to ensure that the existing statutory (organisational) duty of candour is correctly followed in their organisation and be held accountable for this?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
If you agreed, which categories of NHS managers should the statutory duty of candour apply to? (Select all that apply)
- Chairpersons
- Non-executive directors
- Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)
- All NHS staff aspiring to be board level directors
- Senior managers and leaders (approximately bands 8d to 9, for example service manager, clinical lead, nurse consultant, deputy director or director - usually band 9 - and head of department)
- Mid-level managers and leaders (approximately bands 8a to 8c, for example operations manager, programme manager, senior clinician and matron, up to head of service, for example head of nursing, head of performance and delivery)
- First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)
- Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)
- Don’t know
Please explain your answer. (Maximum 300 words)
NHS leaders’ duty to respond to safety incidents
This considers if a duty should be applied to NHS leaders in relation to recording, considering and responding to any concerns about the provision of healthcare that might be brought to their attention.
Question
Do you agree or disagree that individuals in NHS leadership positions should have a statutory duty to record, consider and respond to any concern raised about healthcare being provided, or the way it is being provided?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
If you agreed, which categories of NHS managers should this apply to? (Select all that apply)
- Chairpersons
- Non-executive directors
- Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)
- All NHS staff aspiring to be board level directors
- Senior managers and leaders (approximately bands 8d to 9, for example service manager, clinical lead, nurse consultant, deputy director or director - usually band 9 - and head of department)
- Mid-level managers and leaders (approximately bands 8a to 8c, for example operations manager, programme manager, senior clinician and matron, up to head of service, for example head of nursing, head of performance and delivery)
- First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)
- Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)
- Don’t know
Please explain your answer. (Maximum 300 words)
Question
Do you agree or disagree that individuals in NHS leadership positions should have a statutory duty to ensure that existing processes in place for recording, considering and responding to concerns about healthcare provision are being correctly followed?
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
- Don’t know
Please explain your answer. (Maximum 300 words)
If you agreed, which categories of NHS managers should this apply to? (Select all that apply)
- Chairpersons
- Non-executive directors
- Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)
- All NHS staff aspiring to be board level directors
- Senior managers and leaders (approximately bands 8d to 9, for example service manager, clinical lead, nurse consultant, deputy director or director - usually band 9 - and head of department)
- Mid-level managers and leaders (approximately bands 8a to 8c, for example operations manager, programme manager, senior clinician and matron, up to head of service, for example head of nursing, head of performance and delivery)
- First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)
- Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)
- Don’t know
Please explain your answer. (Maximum 300 words)
How to respond
You can respond using the online survey. The consultation runs for 12 weeks and closes at 11:59pm on 18 February 2025.
You can email DHSC with any questions on the consultation at nhsleadership@dhsc.gov.uk.
Next steps
DHSC will consider all information submitted as part of this consultation in future policy decisions on regulating NHS managers. Any legislation brought forward to implement a statutory regulatory regime for NHS managers will be subject to further consultation.
Annex A: public sector equalities duty
The matters considered in this consultation do not raise any significant issues in relation to the public sector equality duty under section 149(1) of the Equality Act 2010. Following consideration of the potential equalities impacts, it is anticipated that any impact will be minimal and if there is any, it will likely be a positive impact for certain groups of individuals.
It is anticipated that the matters considered in this consultation will not adversely impact on the duty to eliminate unlawful discrimination under the Equality Act. If patient safety is improved through enhancing consistency in the standards NHS managers are expected to meet, it is envisaged that all NHS patients will benefit.
It is anticipated that the matters considered in this consultation will not produce an adverse impact on the duty to advance equality of opportunity or foster good relations between different groups, as the policy is intended to apply to all of the NHS in England.
The matters concerned in this consultation could have a positive effect on certain groups with protected characteristics. Patients and service users will benefit if NHS manager and leadership skills, competencies and experience are enhanced as part of meeting the required standards set by a regulatory system, which will mean that management and leadership in the NHS becomes more proficient and more accountable. This, in turn will mean that leaders are able to become more effective at driving up innovation and efficiencies, which in turn supports other staff to provide the best quality care for patients, many of whom are elderly or disabled. The intention of this policy is to improve patient safety, which may increase public confidence in NHS management and leadership, as patients, service users and the public will be assured that there is greater oversight and accountability of NHS managers.
This policy consultation is intended to inform further decision making on the introduction of a regulatory system for NHS managers. We will continue to carefully consider the equalities impact of any potential future policy interventions arising from the outcome of this consultation, including carrying out further work to ensure any policy decisions arising from this consultation are compliant with employment law.
Annex B: environmental principles duty
It is anticipated that the matters considered in this consultation will not produce an adverse impact on the duty to protect the environment. If management and leadership efficacy is improved through introducing a system of regulation for NHS managers, those managers will be better equipped to help drive NHS performance and innovation. This could lead to positive effects on the environmental impacts of NHS organisations through improved delivery of green plans developed by trusts or integrated care systems, which meet the duty set out in the Health and Care Act 2022 to contribute towards statutory emissions and environmental target and address the net zero emissions targets.
This policy consultation is intended to inform further decision making on the introduction of a regulatory system for NHS managers, and we will continue to carefully consider the environmental impact of any potential future policy interventions arising from the outcome of this consultation.
Privacy notice
Summary of initiative or policy
This public consultation seeks views from all stakeholders, including health and care organisations, regulators, professional bodies, health and care managers and senior leaders, the public, patients and other health and care staff on the most effective way to strengthen oversight and accountability of NHS managers.
Data controller
DHSC is the data controller.
What personal data we collect
We will collect data on whether respondents are responding on behalf of an organisation or as an individual sharing either their personal or professional opinion.
If responding on behalf of an organisation, we will collect data on the name of the organisation, the sector it operates in, and whether the organisation operates within England.
If responding to share professional views, we will collect data on the person’s profession, the level of managerial category the person falls within, and the type of organisation they work for.
If responding to share professional or personal views, we will collect data on age, ethnicity and gender.
How we use your data (purposes)
We will collect the above listed data for the purpose of analysing consultation responses to understand whether any future policy interventions arising from the outcome of this consultation, will impact certain types of organisations, social groups, or professional groups adversely.
Legal basis for processing personal data
Under Article 6 of the United Kingdom General Data Protection Regulation (UK GDPR), the lawful basis we rely on for processing personal data is:
(f) We have a legitimate interest
In addition, we are also processing special category data under the following condition as per article 9 of the UK GDPR:
(a) Explicit consent
Data processors and other recipients of personal data
Responses to the online consultation may be seen by DHSC’s third-party supplier (SocialOptic), who is responsible for running and hosting the online survey.
International data transfers and storage locations
Storage of data by DHSC is provided via secure computing infrastructure on servers located in the European Economic Area (EEA). Our platforms are subject to extensive security protections and encryption measures.
Storage of data by SocialOptic is provided via secure servers located in the UK.
Retention and disposal policy
Your data will be retained for a period of 12 months from the closing date of the consultation following which all data will be securely disposed of according to departmental procedures.
How we keep your data secure
Your data will be stored on secure DHSC servers and password protected, it will only be accessed by policy and analytical team members responsible for analysing consultation responses.
SocialOptic is Cyber Essentials certified.
Your rights as a data subject
By law, data subjects have a number of rights, and this processing does not take away or reduce these rights under the EU General Data Protection Regulation (2016/679) and the UK Data Protection Act 2018 applies.
These rights are:
- the right to get copies of information - individuals have the right to ask for a copy of any information about them that is used.
- the right to get information corrected - individuals have the right to ask for any information held about them that they think is inaccurate, to be corrected
- the right to limit how the information is used - individuals have the right to ask for any of the information held about them to be restricted, for example, if they think inaccurate information is being used.
- the right to object to the information being used - individuals can ask for any information held about them to not be used. However, this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case.
- the right to get information deleted - this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case.
Comments or complaints
Anyone unhappy or wishing to complain about how personal data is used as part of this programme, should contact data_protection@dhsc.gov.uk in the first instance or write to:
Data Protection Officer
1st Floor North
39 Victoria Street
London
SW1H 0EU
Anyone who is still not satisfied can complain to the Information Commissioner’s Office.
Their postal address is:
Information Commissioner’s Office
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF
Automated decision making or profiling
No decision will be made about individuals solely based on automated decision making (where a decision is taken about them using an electronic system without human involvement) which has a significant impact on them.
Changes to this policy
This privacy notice is kept under regular review. This privacy notice was last updated on 26 November 2024.