Consultation outcome

Leading the NHS: proposals to regulate NHS managers consultation response

Updated 21 July 2025

Summary

Strengthening NHS leadership and management is a key element of the 10 Year Health Plan, recognising the central role of leadership in delivering high-quality care and driving system-wide improvement. Managers and leaders across the NHS work tirelessly, making difficult decisions on a daily basis - and in challenging circumstances - to ensure patients receive the safe, high-quality care they deserve. The actions and conduct of these managers and leaders, both clinical and non-clinical, are what helps to nurture a compassionate, open and positive culture in our health service. The jobs they do will be critical in delivering the transformation that the government’s health mission and 10 Year Health Plan require - and for this the NHS needs the very best leadership. Regulating managers and leaders will help to professionalise NHS leadership and will ensure that NHS managers and leaders are professionally accountable, while improving patient safety and driving up performance.

There are a number of ways in which managers and leaders could be regulated and we know the importance of getting this right. A good or right-touch regulatory system is one that fairly and consistently holds managers and leaders to account for their actions against a just set of professional standards, in a way that is proportionate to the risks to individuals and the public.

In response to the Leading the NHS: proposals to regulate NHS managers consultation, we will develop a proportionate regulatory system that focuses where need is greatest to ensure that those who have committed serious misconduct are no longer able to work in senior NHS management positions, preventing unacceptable behaviour and improving patient safety.

Consulting on key options formed the first step towards delivery of the government’s manifesto commitment to introduce professional standards for, and regulation of, NHS managers.

We are grateful for the 4,924 detailed and thoughtful responses we received to the consultation. We have taken on board your feedback which will help shape future policy decisions on how NHS managers and leaders will be regulated and inform wider support for managers and leaders. Legislation brought forward to implement a statutory barring regime for NHS managers and leaders will be subject to further statutory consultation.

The feedback received through the consultation demonstrates widespread support for a statutory regulatory system, focusing on senior leaders. Having taken account of the feedback, the government’s view is that a statutory barring system for board-level directors and their direct reports within NHS bodies is the most proportionate and effective regulatory approach for NHS managers and leaders and that the Health and Care Professions Council (HCPC) is best placed to take on this role. We will therefore be taking forward legislative work that will provide the HCPC with the statutory powers to disbar NHS leaders in senior roles who have committed serious misconduct from holding such roles.

The consultation demonstrated that there is appetite to go further in extending the scope of regulation to more parts of the system (including primary care and the private sector), and to include further levels of management (for managers in NHS Agenda for Change pay scales bands 8d and above). As such, we are committing to keep this policy under review to ensure that it continues to best serve the interests of patients and the public, recognising the novel and transformational impact that a future regulatory regime will have across the NHS and beyond. We will continue to engage system stakeholders throughout the development and subsequent review of the regulatory system.

Introduction

Background

Great leadership is at the heart of the transformation plans to build an NHS fit for the future. While the vast majority of NHS managers and leaders across the country work hard every day to support patient care, too often tragic cases and high-profile reviews have shown repeated instances where leaders have failed to act appropriately and have not been held to account for their actions. 

The Infected Blood Inquiry showed 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, while the ongoing Thirlwall Inquiry into events at the Countess of Chester hospital continues to highlight similar concerns

General Sir Gordon Messenger and Dame Linda Pollard’s findings, report and subsequent recommendations into the state of management and leadership in the health and care sector recognised the real difference that good management and leadership can make in health and social care, contributing directly to better staff retention and patient care.   

The government is clear that we need to support, develop and reward our best managers and leaders, sanction those whose conduct or performance is unacceptable, and work to nurture the next generation of excellent NHS managers and leaders.

On the issue of candour, the government recognises the importance of strong and accountable leadership in encouraging an open and compassionate culture in the NHS and across the public sector more widely. This is recognised in the full government response to the Infected Blood Inquiry’s May 2024 report published in May 2025 - which recognised the importance of individuals in NHS leadership positions being accountable for compliance with the statutory (organisational) duty of candour - and proposals being developed by the government to establish a Hillsborough Law that would establish a duty of candour on all public servants and officials across the public sector.

The government is also clear that a culture of accountability in the NHS requires those in leadership positions to ensure that systems and processes are correctly engaged for responding to patient safety concerns and that this supports organisational learning.

Developing excellent leadership

As reflected in the 10 Year Health Plan, strengthening NHS management and leadership means holding those in senior positions accountable for their actions when things go wrong. It also means developing and supporting those in senior positions of responsibility to deliver excellent leadership. This includes giving them the opportunities to develop the competencies that will be required to lead our future NHS. It is therefore important that a statutory system of regulation is established alongside clear standards, expectations and development opportunities for managers and leaders (referred to here as ‘managers’, unless specified).

NHS England has been working with a consortium of partners to develop a management and leadership framework, which is due to be completed in summer 2025. This includes a set of consistent, professional standards across all levels of NHS management, as well as a single, national code of practice. This will provide clarity and consistency nationally in setting the expectations of NHS managers and will act as a common thread running through regulation, career development, talent identification and performance.

We have committed to establishing a college of executive and clinical leadership, to support and professionalise managers across the NHS. The college will play an important role in ensuring that managers can access the development they need, building on the core curricula being developed by NHS England as part of their leadership and management framework. As well as holding responsibility for the NHS management standards, the college will also play a role in setting clear career pathways, so that managers at different levels know what is expected of them to succeed and progress in their leadership career in the NHS. As part of our work to develop the college we will work with stakeholders to consider whether there are forms of accreditation that could be implemented to recognise the professionalism of NHS managers and leaders.

It is critical that the development of a system of regulation is aligned with the development of NHS management standards and other legislative frameworks and responsibilities which govern the work of NHS managers (such as the fit and proper person test). The government recognises that development of the regulatory system for managers will need to be carefully sequenced to align with the broader programme of work underway to develop and strengthen NHS leadership. 

Strengthening NHS leadership means developing, supporting and professionalising our existing leadership, but it must also be about attracting and developing future generations of leadership talent within the NHS. Recently published changes to the very senior manager pay framework provide incentives to encourage talent into challenged parts of the system and drive improved leadership, but there is scope to go further in developing a plan for talent management. The Secretary of State announced in November 2024 that Sir Gordon Messenger had been asked to provide advice to the department, building on the recommendations from his 2022 review, considering how we can go further on developing a strategic approach to NHS talent management and encourage talent into challenged parts of the system. As set out in the 10 Year Health Plan, we will establish new national and regional talent management systems to identify and develop those with great potential. 

The consultation

The NHS needs managers with the right skills to take it forward into the future. That is why the government committed, in its 2024 General Election manifesto, to introduce professional standards for and regulate NHS managers.

As a first step towards delivering the commitment to introduce regulation of NHS managers, the Department of Health and Social Care (DHSC) launched a public consultation on 26 November 2024. The consultation closed on 18 February 2025 and received strong engagement across the sector and wider public, with just under 5,000 responses in total. The consultation sought views from all stakeholders on the most effective way to strengthen oversight and accountability of NHS managers, alongside posing questions on the sequencing of the introduction of a regulatory mechanism for NHS managers, to complement the wider work already underway by NHS England to develop professional standards. 

The consultation also sought views on matters relating to candour, including on the possibility of delivering a professional duty of candour for NHS leaders, and on making leaders accountable for responding to concerns about the provision of healthcare patient safety.

This consultation explored options for regulating NHS managers in England only. Although health is devolved, the regulation of healthcare professions is reserved in Wales, devolved in Northern Ireland and devolved for Scotland for professions brought into regulation post 1999. We will work with administration officials to ensure any cross-border implications of regulating NHS managers in England are carefully managed.

Timetable for the future of manager regulation

The publication of this response marks the next phase in delivering on our commitment to improve leadership accountability. While this consultation response is an important step, there are a number of further actions that will need to be taken to bring managers into regulation, which are as follows:

• a statutory 3-month consultation will be carried out on the draft legislation to confer on HCPC the powers to bring managers into regulation dependent on the legislative vehicle
• following this legislative consultation, any responses will be analysed and, subject to further amendments, the draft order will be finalised
• the finalised order will then be laid before both houses of Parliament alongside a report on the outcome of this consultation. This gives Parliamentarians the opportunity to consider the legislation and to debate it. We anticipate that this will take place in the second half of 2026 (subject to Parliamentary time)
• once debated, the legislation will either be approved or rejected
• if approved, His Majesty in Council may then make the order
• the HCPC will then develop, consult on, make its rules and put in place the processes needed to hold a barring list for NHS managers with a view to commencing regulation within 12 months of the legislation being made

This consultation response

This consultation response provides a summary of the responses that have been provided following the consultation. Our consultation asked for stakeholder views on proposals to regulate NHS managers. It also sought views on leadership candour and making leaders accountable for responding to concerns about the provision of healthcare patient safety.

We have carefully considered the responses and recognise the concerns arising from multi-faceted issues such as dual regulation, phasing and professional development that need to be factored into regulating managers.

We analysed all responses to the online consultation, and further detailed feedback from employers, trade unions, charities and other representative groups received in writing.

We received a total of 4,907 responses to the online consultation, where:

• 2,815 respondents said they were a non-managerial member of health or care workforce sharing their professional views
• 1,344 respondents said they were an NHS manager or leader sharing their professional views
• 638 respondents said they were responding as an individual sharing their personal views and experiences (such as a patient or carer, or member of the public)
• 110 respondents responded on behalf of an organisation
• when answering the survey questions, respondents used survey free-text boxes to make comments 24,897 times

We heard:

• the vast majority of respondents (92%) agreed that NHS managers should be regulated. Responses largely cited improving accountability and trust in management decision making as reasons for this
• consensus for this was highest among non-managerial members of the health or care workforce, however, 79% senior managers and leaders also agreed
• the main areas of concern participants expressed around regulating managers was that it is the wrong solution to improve NHS leadership, and that regulation would cost too much money and/or staff time
• participants were also concerned about duplication for already regulated clinical staff and the need for learning and development opportunities for NHS managers

Methodology

The survey published comprised closed (quantitative) and open-ended (qualitative) questions. We also received several off-platform responses by email which, unless they specifically referred to any of the closed-format consultation questions, were analysed alongside the open-ended responses.

The consultation ran from 26 November 2024 to 18 February 2025. Shortly after launch, a minor change was made to the survey; the wording of one question was altered for clarity. There were a small number of responses submitted prior to the survey being amended - these were analysed alongside subsequently received responses.

Descriptive statistics of the quantitative responses were produced, which are used to describe and summarise the characteristics of the consultation responses, not to make inference or prediction, or assess the interaction between variables. For each question, distributions of responses were calculated as percentages of those who provided an answer to that question. We have provided a breakdown of all agreement questions by respondent type (for example, NHS managers, non-managerial members of the health and care workforce, members of the public and on behalf of an organisation).

Responses to the consultation are not representative of the groups referenced, but only of those who chose to respond to the consultation. Where particular groups are referred to or compared - for example, “members of the public are most likely to say…”, this refers only to members of the public responding to the consultation and cannot be taken to represent the views of the public more generally. As such, statistical significance testing has not been used to analyse results. We used our judgement to highlight differences between responding groups.

We have assumed in analysis that respondents submitted responses in good faith which, if given, accurately represent their characteristics and their view. For example, we take at face value that those selecting ‘An NHS manager or leader’ are indeed from this group, as verification was not sought.

For ease of reading, we have aggregated positive or negative responses. For example, if 28% agreed and 5% strongly agreed, we have written this as ‘33% agreed’. These aggregated figures are derived from the frequencies rather than the rounded percentages. In most cases, this would result in the same figure but may in some cases result in a 1 or 2 percentage point difference from adding together rounded percentages. Results are reported as a percentage of those that responded to the question (for example, “75% of public respondents agreed with…” should be understood as “75% of public respondents that responded to this question agreed with”). This is omitted for ease of reading, but results should be read this way throughout.

This consultation response presents a full breakdown for each quantitative question, in accordance with statistical disclosure controls to protect anonymity, and provide the data used in the analysis section. The number of respondents in each of the categories is also provided.

The consultation included 26 open-ended questions. In total, these questions gathered 24,987 individual free text answers. This was in addition to ‘Other (please specify)’ responses which were given to add to pre-defined options shown to respondents.

Responses from key organisations were identified for manual review in their entirety (including those submitted by email) using thematic analysis. This consisted of an iterative process of coding responses into themes by a team of 2 analysts. These organisations are referred to in the analysis as ‘stakeholders’ or ‘stakeholder organisations’.

A sample of respondents’ free text responses for each of the open format questions were also reviewed by the same approach to identify any themes raised in the responses. A random stratified sample was taken to saturation for each open text question, to ensure the views of a variety of response types were analysed. Where free text questions followed a quantitative question (for example, “please explain your answer [to the previous question]”), these responses were understood and analysed in context of their preceding quantitative response.

While qualitative analysis is not intended to show exactly how many people held a certain view, we have tried to provide an indication of the weight of opinion in responses, using words such as ‘many’, ‘some’, ‘several’ or ‘a few’. However, we caution against overinterpreting these terms as we received a relatively low number of responses to this consultation.

Government response

The following sections provide the government’s response to the issues noted in the consultation. We have grouped the comments we received from participants in the analysis section and responded thematically to address each overarching policy question.

System of regulation

As outlined in the consultation, a number of different approaches 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. The consultation asks questions on the most effective approach to the overall model of regulation for NHS managers.

The consultation responses showed that overall, stakeholders are highly supportive of regulating managers, with differing views on the appropriate type of regulation to take forward. Organisational responses to the consultation also show a lack of clear consensus on the regulatory approach; however, slightly more organisations were in favour of a comprehensive professional register over a barring mechanism. In developing policy on manager regulation, we have also engaged with a number of leadership groups, networks and managerial professional bodies, whose views reflected those shown in the consultation responses. Overall, stakeholders responding to the online consultation showed a slight preference for implementing a barring system over a full system of statutory regulation, arguing that this provides an effective and proportionate means of achieving the primary aim of regulation, enabling the removal of unsuitable managers who have committed offences or who have been found to be unfit. This preference is reflected in the decision that the government has made to introduce a barring system for NHS managers. While there are merits to introducing full statutory regulation (as outlined in the detailed government response and analysis sections), the primary reason that stakeholders put forward as a reason for regulation is to ensure unfit managers are held to account and cannot hold a role as an NHS manager. This objective is delivered in a barring system.

Some stakeholders in favour of a barring system also regard it as a first step towards a more comprehensive form of regulation. Stakeholders also highlight concerns that the implementation of a mandatory register in a full statutory system, would create an administrative burden and be disproportionate. The feedback received supports the government’s aim of introducing a proportionate form of regulation that enables decisive action in response to poor manager practice and therefore aligns with the decision to introduce a barring system. The government’s approach will therefore be a statutory one, which, through legislation, will give HCPC legal powers to take action in relation to the managers in scope.

While both full statutory regulation and a disbarring system are supported, there are fundamental differences in the complexities, benefits and risks of each.

Full statutory regulation

Full statutory regulation requires qualified professionals to register with a regulator, which publishes a list of people who hold an approved qualification for entry on the register and are otherwise 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 is viewed by some as a more rounded proposition, in which managers are required to demonstrate they meet required standards to practise in a role and are legally required to join a register to do so. This form of regulation would require implementation of a resource intensive process to assess whether each manager in scope meets the required professional standards for registration. For all other registered health professionals this also includes the development of specific education standards and approved qualifications.

However, full statutory regulation has drawbacks. The implementation of education standards and qualifications would be a major challenge for such a diverse profession and would require significant additional regulator time and resource to vet and approve new qualifications and require additional regulatory oversight of education providers. Full statutory regulation would also require implementing ‘grandparenting’ arrangements to transition existing managers onto the register (who do not possess an approved qualification). If educational standards are not included within registration requirements, we risk creating a regulatory system for managers that is weaker than other health profession regulation. Full statutory regulation would also present challenges in determining how to deal with (existing) registered clinicians who are also managers, to mitigate ‘double jeopardy’ risks.  

Statutory barring system

A statutory barring mechanism is a list of people who have been found to be unsuitable to practise a particular profession, which places a prohibition on the individual from practising in that profession. Examples include the Teaching Regulation Agency (the barring list for teachers - which also places an obligation on employers not to appoint) 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 person 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.

A barring system avoids some of the challenges inherent in full statutory regulation, such as revalidation and complex transitioning arrangements, and reduces the complexity of ‘double jeopardy’ risks. Dual registration issues concern the risk of dual authorities overseeing clinicians in managerial roles, which may disincentivise clinicians from moving into leadership positions. Statutory barring is also a more appropriate form of regulation for non-executive leaders - full regulation is not easily applicable to non-executive leaders, where registration requirements, which could include a common set of educational standards, are unlikely to be workable and may deter individuals from applying. A power to disbar for serious misconduct was one of the recommendations of the Kark review of the fit and proper person test, although this was not accepted by the government at the time. 

A barring system could also be coupled with additional training and development opportunities, such as those afforded by a college of executive and clinical leadership, which would help to raise the standards of the profession, without full statutory regulation​. Furthermore, a lighter touch approach by barring individuals who are unfit to practise, does not restrict entry into a role (beyond those barred). In a profession where attraction of talent to senior manager roles is already a challenge, this supports the government’s ambition of ensuring a strong future pipeline of managers.

However, some organisations view barring schemes as too limited, while others see them as a proportionate first step that can be built upon. A binary choice of either disbarring an individual or taking no action at all is seen to lack nuance, and there are also some instances where it would be deemed as disproportionate to disbar an individual. Organisations often highlight the need for less punitive sanctions such as conditions, suspensions and warnings.

Government position

The government’s aim is to ensure that a regulatory system is proportionate, and that the regulation of NHS managers focuses on its principal role of protecting the public. While good regulation can support improved professionalism, the government’s view is that the regulator’s primary focus should be on public protection and should not become diluted to consider matters such as career development, which better sits with the role of a professional body (and may be a more appropriate role for the forthcoming college of NHS clinical and executive leadership to adopt).

The government is therefore taking forward a statutory barring system, as a proportionate regulatory solution for removing unfit managers from the profession. To avoid the potential misuse of barring powers, the government plans to set out a clear definition of the criteria for disbarment. It is also important that there should be safeguards to ensure that barring is not used too punitively or for scapegoating, and that decisions will be made by HCPC, as the appointed, independent regulator to ensure objectivity. The safeguards aim to ensure the barring system is not replacing those matters which would otherwise be dealt with through performance management, appraisals or employment contract.

We also note that consultation respondents highlighted the need for existing frameworks that govern the responsibilities of NHS managers to be reviewed to ensure suitability. As part of the process of developing a barring system for managers we will continue to consider how frameworks such as the fit and proper person test should interact with the new regulatory system.

Sanctions

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. The sanctions that will be used against managers who are found to have fallen short of the required standard will reflect this aim of protecting the public.

Under a barring system, managers can be investigated for serious concerns about their conduct and, if the allegations are upheld, managers will be added to a ‘barred list’ of individuals deemed unfit to practise in the profession. Any decisions to uphold a complaint could be made public, as will the resulting sanction, and a register will be maintained of those found unfit to practise.

Adjudication processes

A barring mechanism also requires systems to triage complaints and then investigate, adjudicate and impose sanctions on professionals when concerns about their conduct are upheld. As inclusion on a statutory barring list cuts across the European Court of Human Rights protection of the right to a chosen livelihood, this also requires an independent legal appeal mechanism, generally the High Court.

Government position

The government supports a barring system as the most proportionate mechanism to regulate NHS managers. ​The consultation showed that of those that support a barring list, the majority of respondents support the use of sanctions on managers who do not meet the standards.

Any concerns regarding remediation and being removed from the barring list will be the responsibility of the regulator and subject to thorough fitness to practise investigation processes. There is some appetite for the regulator to also have the powers to implement sanctions short of permanent barring, and implement interim measures while an investigation is ongoing should the public interest test be met. We will continue to consider this alongside the threshold for barring and whether decisions on barring are made public, as the legislation is developed.

Scope of managers

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
• DHSC arm’s length body board-level directors
• integrated care board (ICB) members

The consultation asked 2 questions on scope of managers.

This first question focused on the categories of managers within NHS organisations that a system of regulation should apply to. The second focused on whether the scope of managers included within regulation should be extended to equivalent organisations outside the NHS (for example, primary care, social care and independent organisations providing NHS contracts).

The consultation shows strong support for bringing a narrower cohort of managers into regulation, starting with senior NHS managers, and then rolling out to further levels of management over time (and to arm’s length bodies and ICBs), to ensure feasibility and quality of delivery. For a barring system, precise cost will depend on caseload. A barring system would be expected to cost £5 to 10 million to set up (estimate based on the cost of bringing other health professions into regulation and set-up of the Teaching Regulation Agency), with an ongoing cost to government to fund the system. With a cohort of approximately 25,000 managers at band 8d and above (including within ICBs), the maximum estimated cost of running a barring system would be £2.75 million per year with HCPC as the regulator. Should the barring system include powers for the regulator to impose sanctions short of barring, or interim measures, costs may be higher, and further work is required to define detailed costings.

The number of managers that come within the scope of a barring system will impact on the cost of running and maintaining the regulatory system. If the scope was extended to include ICBs and arm’s length body managers, the higher end cost estimate would be £3.5 million per year in addition to set-up costs. The higher the number of managers in scope and, in turn, the greater the caseload of a regulator, the higher the cost of running the regulatory system. There is also the risk that large numbers of vexatious complaints may put additional cost pressure on a new regulatory function.

There is merit and support for extending the breadth of scope to include other organisations, however, this presents its own delivery challenges such as interactions with performer’s list and other regulatory frameworks. Extending the regulatory regime to any group outside of NHS bodies will need to be considered on a case-by-case basis and will require further policy work and engagement with stakeholders.

Government position

The government will initially introduce regulation only for NHS bodies. The new legislation will set out a clear definition of which NHS bodies are in scope, but we expect this to include NHS trusts, foundation trusts and ICBs. We are committed to reviewing the regulatory system once fully embedded, with a view to considering whether the regime should be extended beyond NHS bodies. In March 2025, the Prime Minister announced his decision to abolish NHS England and integrate its functions into DHSC. As a result of this, managers that work within NHS England will no longer come into scope when regulation takes effect.

Regulation will be implemented for NHS board-level leaders and their direct reports. Following thorough review of the regulatory system once embedded, we will consider whether to extend scope of regulation to other senior managers. This achieves the overarching objective of preventing unfit NHS managers from occupying senior leadership roles and enables initial implementation to focus on the parts of the NHS that are most ready for this new regulation.

The responsible body

There is strong support in the consultation responses for establishing a new regulatory body to operate a barring list. The most frequent reason given for establishing a new independent body to hold a barring list referenced independence from government and DHSC, and negative experiences of existing regulatory bodies.

However, this was balanced with views that supported a pragmatic approach to choosing a responsible body; one which is cost-effective and timely to implement. Establishing a new body also goes against the emerging government view regarding rationalisation of regulators, and the wider reform agenda, to deliver efficiencies and avoid duplication. If a new regulatory body was established, it could add in excess of an additional £10 million to initial investment required, alongside the early running costs that come with a new regulator. ​

Government position

The government’s preferred solution is for HCPC, as an existing multi-professional regulator, to operate a barring system. HCPC already regulates various other health professionals. A disbarring system will prevent NHS managers who have committed serious misconduct from holding or continuing in management roles in the NHS. This recommendation is the most cost-effective option.

The government has committed to reforming the legislative framework of HCPC within this Parliament as part of our programme to modernise the regulation of healthcare professionals in the UK. We will work to ensure alignment between plans for manager regulation and wider regulatory reform. Our expectation is that the legislation to regulate NHS managers will have completed its passage through Parliament prior to bringing forward the legislation to modernise HCPC’s broader legislative framework for the 15 professions that it currently regulates (which is due in the second half of this Parliament).

The government has begun discussions with HCPC to determine how an effective barring system for NHS managers could operate. We will continue to work closely with HCPC to refine the proposal for a system of regulation for managers that will most effectively and proportionately achieve the aim of improving accountability and improving professional standards. Careful consideration is also being given to ensuring a HCPC barring system is operated so as to mitigate any risk of cross-subsidy between a manager barring list and the registration of other fee-paying health professionals already regulated by HCPC.

Secondary considerations (professional standards for managers, phasing, revalidation, dual regulation, standards and interplay with NHS England framework)

Stakeholder views and consultation analysis suggests support for the idea of revalidation, education standards and the need to carefully work through dual regulation considerations. Many of these issues were dependent on a full system of regulation being implemented. However, with the decision to implement a barring system, issues such as revalidation and education arrangements no longer directly factor into the new system of regulation. However, other standards will still need to be considered.

Dual regulation

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. The introduction of a barring system introduces complexity with dual regulation and raises questions about whether a clinician’s professional register should investigate their conduct, or whether the barring system should do so, to avoid double jeopardy.

A number of organisations are strongly opposed to any regulatory scheme that required dual regulation. They highlighted the burdens of having 2 sets of fees, standards, processes for revalidation and duplication of effort.

One option to resolve this issue within a barring system is to let the barring mechanism apply solely to non-clinical managers, with clinical professional regulators adopting common management standards against which clinical managers’ conduct is assessed through existing fitness to practise mechanisms. However, this would remain complex to administer, as the systems would still interact with each other. It is feasible to have a scenario where a senior clinician has been working in an executive role on a trust board, and is disbarred from being a manager, but is still regulated as a medical professional, and therefore able to continue working in the NHS as a clinician.

Alternatively, HCPC could consider all cases with other professional regulators and adopt a policy of referring primarily managerial cases to the barring system. This distinction may in some cases be quite difficult to separate out and further detailed work is needed to consider this and the position of other directors - notably finance directors - who have other forms of individual regulation.

Government position

The government acknowledges that there are dual regulation considerations that need to be worked through. As such, any decisions on dual regulation will be tested with system stakeholders.

The government will finalise details on the secondary considerations, such as dual regulation, in due course.

Duty of candour

Health and social care providers have a fundamental responsibility to be open and honest with those who are under their management and care. The statutory (organisational) duty of candour was introduced in 2014 for NHS trusts and NHS foundation trusts, and in 2015 for other health and social care providers registered with the Care Quality Commission (CQC). The duty places a direct obligation upon providers to be open and honest with patients and service users, and their families, when something goes wrong that appears to have caused or could lead to moderate harm or worse in the future (known as a ‘notifiable safety incident’) and to apologise.

The statutory duty is a crucial, underpinning aspect of an open and transparent culture and permits a level of objective scrutiny to be applied for each situation, looking at what could have been done better and to make changes to advance patient safety. The government is clear that the statutory duty of candour should act as a catalyst for providers to improve openness and commit to a safety, learning culture. In response to concerns that the statutory duty is not always met as intended, the department is progressing a review into its effectiveness. The findings of the call for evidence on the statutory duty of candour indicate that the duty is functioning well in some places but is underwhelming in totality. This cannot be justified, and the aim of the review is to ensure that all providers and their leaders ensure that the duty is correctly followed.

Many individuals working for the NHS are registered healthcare professions, whose professional conduct is overseen by independent regulators (such as the General Medical Council (GMC) for doctors and the Nursing and Midwifery Council (NMC) for nurses and midwives). An individual professional duty of candour is included within existing regulatory standards for these professions. For example, GMC includes a duty of candour as part of the standards that doctors are required to demonstrate in order to become a registered professional and to practise. Similar duties of candour constitute part of regulatory standards of other healthcare professional regulators, for example NMC and HCPC. The professional duty of candour is distinct from, but aligned with, the statutory duty of candour on providers.

The consultation demonstrated strong support for NHS leaders to have a professional duty of candour as part of the standards they are required to meet, and for NHS leaders to ensure that the statutory duty of candour is correctly followed in their organisation.

Government position

The government will support a regulatory system for NHS leaders that gives consideration to the relevant legislation underpinning the statutory duty of candour. We are clear that there should be consistent and correct application of the existing statutory duty of candour across the NHS to increase accountability, openness and honesty. This should support the NHS to develop a just and learning culture where providers do not seek to blame individuals for what went wrong but acknowledge what happened and try to understand why it happened, how future risks can be reduced and how the needs of the patient and staff can be met in order to help them recover.

We also support the importance of candour as a leadership behaviour as part of the management and leadership framework being developed by NHS England, including professional standards and a single national code of practice.

Duty to respond to patient safety concerns

The consultation asked if 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.

Advancing patient safety and reducing harm in the NHS is a priority for this government. We acknowledge the importance of recording and responding to patient safety incidents as also highlighted in the final report of the Infected Blood Inquiry.

While there was overwhelming support for NHS leaders to have such a duty, we recognise that this would be complex to implement and enforce, have significant resourcing implications, and actually be counter-productive in terms of advancing candour and safety culture across the NHS. We have emphasised this point in the government’s full response to the Infected Blood Inquiry’s report.

Government position

We will support a regulatory system that holds NHS leaders accountable for the mechanisms in their organisations associated with recording and responding to patient safety concerns to support organisational learning. This would be integral to the management and leadership framework being developed by NHS England, including professional standards and a single national code of practice. Mechanisms to advance patient safety should recognise the importance of staff and patients being able to freely raise concerns with management (without any negative consequences) and support the NHS to develop a just culture.

Analysis

The following sections provide detailed analysis of how people responded to the questions in the consultation on proposals to regulate NHS managers. The full data used in this section can be found below.

In total we received 4,907 responses to the consultation, which can be seen in the table below.

Table 1: respondent type - summary of responses

Responses	Total and percentage
A non-managerial member of health or care workforce sharing my professional views	2,815 (57%)
An NHS manager or leader sharing my professional views	1,344 (27%)
An individual sharing my personal views and experiences (such as a patient, carer or member of the public)	638 (13%)
On behalf of an organisation	110 (2%)

To preserve anonymity, low values (where frequency is lower than 5) have been suppressed throughout. These values are all noted in the tables below.

System of regulation

Question

Do you agree or disagree that NHS managers should be regulated?

Of the 4,902 responses:

• 3,752 (77%) strongly agreed
• 767 (16%) agreed
• 155 (3%) neither agreed nor disagreed
• 122 (2%) disagreed
• 93 (2%) strongly disagreed

The majority of respondents to this question (92%) agreed with the proposal to regulate NHS managers and 4% disagreed.

Support for NHS manager regulation differed by respondent type, but the majority of respondents agreed in each group. The vast majority of non-managerial health or care workforce agreed with NHS manager regulation (98%), closely followed by 95% of the public. Support was slightly lower among NHS managers (79%).

We received 2,706 responses to the open text portion of this question.

A common reason respondents supported NHS manager regulation was to increase trust and accountability of managers’ decision making. Respondents argued that this was important because NHS managers hold great responsibility over staff, patients and finances and their decisions need monitoring. Some respondents emphasised the necessity for accountability by explaining their experiences witnessing unfairness in management recruitment processes. For example, common instances of nepotism and promotions based on ‘knowing the right people’ have allowed underperforming managers to move around the NHS and up the career ladder.

Some respondents also shared their personal experiences of poor management, including bullying, discrimination and turning a blind eye to serious concerns. Therefore, respondents often argued that a wider cultural change was needed within the NHS management system. Through regulation, some respondents discussed improving attitudes and behaviours of NHS managers to be better aligned to core values of integrity and patient safety, and impose consequences for their actions.

Another justification for regulating managers was for an improvement in patient safety, through ensuring managers follow the correct processes and that safeguarding remains a priority. Respondents highlighted the direct impact of managers’ decisions on patient care, with some sharing how they have experienced managers not understanding patient safety or taking it seriously. Often, respondents drew a comparison between non-clinical and clinical managers, proposing regulation for non-clinical managers to bring them in line with clinical regulation. In some instances, the respondents’ comparisons pointed to some non-clinical managers lacking front line knowledge and a patient focus. By regulating non-clinical managers, they argued that a consistent approach could be had across professions, standardising knowledge and values.

Among those who disagreed with regulating NHS managers, many accepted that there is a problem with the culture of NHS leadership, but they were concerned regulation was not the right solution. Some respondents suggested alternative options to regulation, including a clearer, actionable focus on performance management and HR frameworks to improve management. Another regulation alternative proposed was to focus on learning and development initiatives to improve NHS management. Other frequent concerns with manager regulation were related to the time and cost of setting up a system of regulation being too large and not being cost effective. On a systemic level, respondents showed concern that regulation would not be a good use of taxpayers’ money. However, on a personal level, healthcare workforce in particular expressed concern that regulation would bring unnecessary bureaucratic processes, paperwork and time away from their core work.

Organisation responses

Alongside individuals, we also received responses from a number of organisations. We summarise their views below.

Responses from organisations were mixed but cautious on regulating NHS managers. Many organisations emphasised the importance of clearly defining the scope and objectives of regulating NHS managers. Without this clarity, the purpose and effectiveness of regulation remains uncertain. Some questioned whether the goal is public trust, patient safety, accountability, or capability and/or competency.

Organisations recognised potential benefits of regulation such as improved standards, accountability and public confidence, but cautioned against risks like overregulation, costs and unintended consequences. Many contextualised this as a balance between raising standards and confidence, versus excessive administrative burden and creating a chilling effect that would deter aspiring leaders.

A recurring theme across organisations was that regulation alone cannot address underlying issues and must be paired with efforts to encourage a positive, open and compassionate culture. Most argued that safety issues are reduced in more open and compassionate cultures, and worried that new regulations could introduce fear or blame if not carefully designed.

Several organisations suggested that rather than introducing a new regulatory system, existing frameworks should be improved or better used. Some advocated better use and improvement of mechanisms like the fit and proper person test and the Nolan principles. Others questioned why current systems are not producing desired outcomes given that management can already be highly regulated through CQC and professional regulations.

There was widespread support for regulation to focus on capability and excellence, supported by professional development, rather than being purely punitive. In their view, the narrative could and should be framed around improving capability and championing excellence rather than entirely deficit based. Most thought that development and accountability should come together.

A consistent view from organisations was that there should be consistency across the NHS and independent sectors, and across the UK nations, in order to ensure fairness and effectiveness. Finally, some organisations stressed the importance of a proportionate and targeted approach to regulation, that should be risk-based.

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?

Of the 4,897 responses:

• 3,834 (78%) strongly agreed
• 727 (15%) agreed
• 198 (4%) neither agreed nor disagreed
• 88 (2%) disagreed
• 29 (1%) strongly disagreed

The majority of respondents agreed with introducing a disbarring process to regulate NHS managers (93%) and 2% disagreed. Support was slightly higher for a disbarring mode of regulation than for a professional register (90%) and/or professional standards (88%).

Agreement is highest among non-managers (97%), closely followed by members of the public (95%) and lowest for NHS managers (85%).

We received 2,096 responses to the open text portion of this question.

A frequent reason respondents supported a disbarring process was that it could ensure underperforming, unfit managers are not able to move roles within the NHS. Respondents reasoned that unfit managers can easily move between NHS roles when they fail at their job, rather than being held accountable for their actions. Therefore, a key justification respondents gave for a disbarring service was that, by banning NHS managers who commit serious misconduct, it avoids them being able to escape the consequences of their actions and protects future patients and staff working with them.

Respondents also referred to public distrust of NHS management, in support of a disbarring service, and suggested that this could improve confidence in the NHS management profession itself. Respondents argued that a disbarring list would build trust that NHS managers are doing their job effectively, delivering patient care to a high standard and keeping patients safe.

Another frequent reason given in support of a disbarring process was to standardise the management profession in line with clinical professions. Respondents recognised the effectiveness of a disbarring process within clinical professions and suggested aligning the approach would create consistency.

Some respondents used the open text question to raise concerns over the logistics of a disbarring system, indicating that the consequences should be dependent on the type and severity of misconduct. Respondents highlighted the distinction between an ‘intended’ misconduct and an ‘accidental’ misconduct, and whether the consequences should be decided on a case-by-case basis. For example, respondents questioned whether managers who make errors due to lack of training, supervision or resource to practise safely would have the chance to learn and undertake management positions in the future. This ties into another concern raised by respondents, related to whether there would be an opportunity for managers to learn from mistakes and/or failings, essentially undergoing a period of rehabilitation, for unintended forms of misconduct.

Organisation responses

For ease of reading, we group organisational responses for both this and the following question about disbarring.

Most organisations who responded supported the establishment of a mechanism to prevent managers who have committed serious misconduct from holding management roles in the NHS. There was a strong consensus that NHS managers must be held accountable for serious misconduct, with a clear process to prevent those found guilty from holding similar roles in the future.

While there is agreement on the need for a process, several organisations expressed caution about imposing absolute or permanent bans. Other professional regulation typically does not impose absolute bans, allowing for reinstatement (for instance, after 5 years has passed). Generally, the permanence of sanction should be proportionate to the misconduct.

Organisations frequently drew parallels with established regulatory systems for other professions - such as clinicians, teachers or financial sector managers. The Teaching Regulation Agency for teaching, or the UK Senior Managers and Certification Regime both act as models of barring and holding senior managers accountable.

Organisations emphasised the importance of clearly defining ‘serious misconduct’ and ensuring that any barring process relies on thorough, case-by-base assessments. There is also a call for the responsible organisation to have a variety of sanctions available beyond just barring, to ensure that responses are proportionate to the misconduct. Regulators, such as the Teaching Regulation Agency, for instance already have powers like suspension and conditions which are less severe alternatives. Suspension or training and/or rehabilitation should be determined on a case-by-case basis. Many supported alignment with right-touch regulation principles.

As mentioned earlier, many respondents advocated for a range of sanctions, such as suspension, training or rehabilitation.

There was some concern about managers moving to other sectors (for example, social care) if disbarred from the NHS, which fed into later responses about who should be covered by the proposed regulation.

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?

Of the 4,876 responses:

• 3,453 (71%) strongly agreed
• 921 (19%) agreed
• 211 (4%) neither agreed nor disagreed
• 153 (3%) disagreed
• 89 (2%) strongly disagreed

The majority of respondents agreed with the use of sanctions on NHS managers who do not meet the standards (90%) and 5% disagreed.

Agreement is highest among non-managerial workforce (96%) and lowest for NHS managers (76%). Over one in ten (12%) NHS managers disagreed with the use of sanctions within a disbarring process.

We received 1,414 responses to the open text portion of this question.

A frequent reason respondents gave in agreement with using sanctions was to consistently bring manager regulation in line with other clinical professions. Respondents indicated that standardising sanctions across professions could lead to a cohesive approach to regulation.

Respondents also showed concern for the proportionality of the sanction process, highlighting the importance of the disbarring process and any sanctions being robust, fair and flexible.

A professional register

Question

Do you agree or disagree that there should be a professional register of NHS managers (either statutory or voluntary)?

Of the 4,898 responses:

• 3,566 (73%) strongly agreed
• 828 (17%) agreed
• 240 (5%) neither agreed nor disagreed
• 150 (3%) disagreed
• 90 (2%) strongly disagreed

The majority of respondents agreed with the use of a professional register for NHS managers (90%) and 5% disagreed.

Agreement is highest among non-managerial workforce (95%) and lowest for NHS managers (79%). Around one in ten (11%) NHS managers disagreed with the use of a professional register for NHS managers.

We received 1,645 responses to the open text portion of this question.

A frequent reason respondents supported a professional register was to improve accountability and provide assurance that standards are being met. Some respondents referred to a current lack of accountability and inconsistency in the qualification standards and expectations of managers, so they argued a professional register could mitigate knowledge gaps.

Many respondents shared their view that the management profession should be aligned to other clinical professions, to standardise regulatory techniques. Respondents indicated that using a professional register for NHS managers could join up regulation approaches across professions. However, when respondents drew comparisons between clinical and non-clinical managers, they brought to light concerns around time, cost and efficiency of dual registration. Thus, some respondents suggested only non-clinical managers would benefit from a proposed professional register, with clinical registration being sufficient for healthcare professionals.

Organisation responses

Organisations typically responded to this and the following question together. These have been summarised together after the next question.

Question

Do you agree or disagree that joining a register of NHS managers should be a mandatory requirement?

Of the 4,391 responses:

• 3,448 (79%) strongly agreed
• 693 (16%) agreed
• 138 (3%) neither agreed nor disagreed
• 66 (2%) disagreed
• 30 (1%) strongly disagreed

The majority of respondents agreed with introducing a mandatory professional register for NHS managers (94%) and 2% disagreed. Interestingly, this is supported more than a professional register that could be mandatory or voluntary (90%), indicating respondents’ preference towards a mandatory professional register model.

Agreement with a mandatory professional register is highest among non-managers (98%) and lowest for NHS managers (85%). However, NHS managers supported a mandatory register more than a register that could be voluntary or mandatory (79%).

We received 1,106 responses to the open text portion of this question.

Many respondents supported a mandatory professional register because it could improve accountability and provide assurance that standards are being met. Respondents suggested that an honest and transparent culture would be improved through a standardised professional register and it would professionalise NHS managers.

Alongside making managers more accountable, many respondents wanted to bring managers in line with other clinical professions to standardise the approach to regulation. Respondents believed that using a mandatory professional register for NHS managers could lead to cohesion across professions.

One reason to support a mandatory register, which differed from a general (voluntary or mandatory) register, related to the limitations of a voluntary register. Respondents suggested that a voluntary register would result in inconsistent standards, for example, the worst managers able to avoid registration. Therefore, the mandatory register would ensure underperforming managers are not able to escape regulatory standards.

Organisation responses

Most organisations expressed support for establishing a professional register for NHS managers, although there are mixed views on whether it should be mandatory.

For those supporting making it a mandatory requirement, they argued that a voluntary register would not be able to function effectively because those most in need of regulation would be unlikely to be attracted to it. A mandatory register would prevent gaps in information, depending on if this also includes organisations commissioned to provide NHS services.

Those who did not support immediately making it a mandatory requirement suggested that a voluntary register might be a useful stepping stone to full regulation. They typically argued that a voluntary register could act as a quicker, light touch option that could be used to assess the impact before committing to stricter regulation. These were fuelled by worries that introducing a full regulatory option would take a long time to introduce.

Some organisations suggested that any register should provide transparent, clear information, aligning with recommendations from the Messenger Review for consistent management standards and collaborative leadership.

Supporters of the voluntary system still thought that with NHS backing it could effectively act in practice to appoint only voluntarily registered individuals, even if not a legislative requirement, and that it might be more able to balance professional development and accountability.

Scope of managers to be included

Question

Which, if any, of the following categories of managers within NHS organisations do you think a system of regulation should apply to?

There were 4,889 responses to this question, which are shown in the table below. Response totals may sum to higher than the total base for questions where respondents could select multiple options. Percentages may also sum to more than 100 for these questions.

Table 2: categories of managers within NHS organisations respondents thought a system of regulation should apply to

Categories	Total and percentage
Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)	4,549 (93%)
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)	4,320 (88%)
Chairpersons	4,127 (84%)
Non-executive directors	3,903 (80%)
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)	3,709 (76%)
All NHS staff aspiring to be board-level directors	3,560 (73%)
First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)	2,171 (44%)
Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)	1,449 (30%)

Senior and mid-level managers and leaders were selected by respondents as needing regulating significantly more than foundation and first-time line managers. The category of manager identified most frequently for regulation was ‘senior strategic level managers and leaders’ (93%).

We received 1,310 responses to the open text portion of this question.

Generally, respondents tended to use the open text question to clarify the categories of managers they felt needed regulation. Respondents frequently highlighted the importance of all levels of management being regulated. For example, respondents mentioned that regulation at lower grades was just as important as for senior managers because it could break the cycle of poor organisational culture by developing successful leaders early on in their careers. In support of this, the professionalisation of NHS management could support career progression and offer training opportunities.

However, some respondents clarified that only senior managers and leaders should be regulated, and this was often linked to the strategic influence and decision making of these roles. A reason respondents gave in favour of only regulating senior leaders was considering effectively balancing the impact and cost of regulation. Since senior managers and board members hold the most influence in decision making and resource allocation, respondents suggested it would be most cost effective for these roles to be regulated.

Organisation responses

Organisations widely agree that regulation should target senior managers with significant decision-making authority and accountability. Within this group, they usually cited board-level directors, chairpersons and non-executive directors, and senior strategic managers.

However, there was caution against including mid-level (for example, bands 8a to 8c) or junior managers, due to the risk that extending regulation to these levels could overburden the workforce, discourage career progression, and be disproportionate, as these managers have less strategic control.

Question

Which, if any, of the following categories of managers in equivalent organisations do you think a system of regulation should apply to?

There were 4,839 responses to this question, which are shown in the table below. Response totals may sum to higher than the total base for questions where respondents could select multiple options. Percentages may also sum to more than 100 for these questions.

Of the 4,839 responses:

• 4,324 (89%) selected ‘board-level members in all CQC-registered settings’
• 4,293 (89%) selected ‘appropriate arm’s length body board members (for example, NHS England)’
• 4,022 (83%) selected ‘managers in the independent sector delivering NHS contracts’
• 3,692 (76%) selected ‘managers in social care settings’;

The vast majority of respondents felt that managers in equivalent organisations should be subject to regulation. The board member categories, in CQC settings (88%) and arm’s length bodies (88%), were selected more than others.

We received 769 responses to the open text portion of this question.

Respondents supported the regulation of managers in equivalent organisations because it could ensure a standardised approach across the NHS system. Similar to NHS managers, it was important to many respondents that unfit managers are not able to move around the healthcare system and continue to lead. Therefore, the accountability of managers and board members in equivalent organisation was highly supported by respondents.

Improving patient safety, through widening regulation to managers in equivalent organisations, was also emphasised by respondents. This theme was identified irrespective of the categories of managers respondents selected as generally any extension of regulation to the healthcare sector would be beneficial to patient safety. Respondents indicated that managers in equivalent organisations also had responsibility over patient care and that regulation would improve and uphold the standards of care.

Organisation responses

Many organisations support extending regulation to managers in equivalent organisations beyond the NHS to ensure consistency across the integrated health and social care system. This extension was believed to prevent perverse consequences and align standards across sectors.

Some noted that management structures vary across healthcare settings (for example, hospitals versus dental practices), with differing levels of oversight and influence of senior leadership. Instead, some respondents argue that the focus of regulation should be on the nature of responsibility and impact rather than job titles or pay bands. It was also argued that an evidence-based approach was needed to evaluate this. Other respondents perceived the focus of the approach to lean heavily on secondary care and clinical managers, underrepresenting primary care roles.

As before, organisations cautioned against over-regulation, which respondents argued could impose excessive administrative burdens, negatively affect workforce morale, and deter professionals from pursuing management roles.

The responsible body

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?

Of the 4,804 responses:

• 2,763 (58%) selected ‘professional membership body’
• 966 (20%) selected ‘executive agency of DHSC’
• 731 (15%) didn’t know
• 178 (4%) selected ‘other’

The majority of respondents (60%) felt that a professional membership body is the best option to exercise a statutory barring system.

We received 911 responses to the open text portion of this question.

Respondents wanted the operating organisation to be independent, to ensure robustness and mitigate biases between professions. Respondents suggested that establishing a new independent organisation encouraged a clear purpose and code of conduct to be set out from the beginning. The importance of establishing clear values for an organisation from the outset tied into comments respondents made about ensuring recruitment processes are honest and fair. Similarly to the agreement with a disbarring list question, some respondents highlighted nepotism as a cultural issue, adding that it could be improved through an independent organisation running the system.  

Linking to independence, some respondents specified the importance of the organisation being independent from DHSC and government influence. The reasons behind this included mitigating conflicts of interest and ensuring impartiality.

Other responses compared managers to other professions and highlighted standardising NHS professional regulation through a statutory barring system. Some respondents mentioned their concern with dual regulation, suggesting clinical managers should only be required to register once to avoid duplication.

Organisation responses

A strong emphasis was placed on ensuring that the regulatory body remains independent from government and existing system regulators to maintain impartiality and avoid conflicts of interest. For statutory barring, suggestions ranged from an executive agency to using the Disclosure and Barring Service as a suitable existing body to avoid overburdening regulators.

Concerns were raised about preventing overlap in regulatory efforts and addressing challenges for individuals who might face dual regulation.

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?

Of the 4,766 responses:

• 2,301 (47%) selected ‘an independent regulatory body’
• 1,428 (30%) selected ‘a professional membership body’
• 419 (9%) selected ‘an executive agency of DHSC’
• 29 (1%) selected ‘other’

An independent regulatory body was selected most frequently (49%) as the best organisation type to exercise a professional register, followed by a professional membership body (30%).

We received 590 responses to the open text portion of this question.

A recurring theme was that respondents wanted the operating organisation to be independent, to ensure robustness and mitigate biases between professions. Respondents suggested that a new independent organisation encouraged a clear purpose and code of conduct to be set out from the beginning. Also, respondents expressed concern over current recruitment processes for NHS managers being unfair and mentioned that establishing an independent organisation could help prevent nepotism from occurring.

Respondents also tended to draw comparisons between managers and other healthcare professionals, suggesting that we learn from the successful professional registers. For example, setting up an independent organisation for managers distinguishes it as its own profession and maintains objectivity.

Question

If managers are brought into some form of regulation, do you have an organisation in mind that should operate the regulatory system?

This question was answered by 4,690 respondents, which are shown below. Response totals may sum to higher than the total base for questions where respondents could select multiple options. Percentages may also sum to more than 100 for these questions.

Of the 4,690 responses:

• 759 (16%) selected ‘an existing regulator’
• 617 (13%) selected ‘an existing membership body’
• 335 (7%) selected ‘an existing arm’s length body (for example, an executive agency)’
• 2,568 (55%) selected ‘establish a new independent regulatory body’
• 1,114 (24%) selected ‘establish a new membership body’
• 351 (7%) selected ‘establish a new arm’s length body (for example, an executive agency)’
• 13 (0%) selected ‘other’

The majority indicated that a new body should be established to operate the regulatory system. Over half (55%) of respondents specifically selected to establish a new independent regulatory body to operate the regulatory system. Almost one in four (24%) selected a new membership body to regulate NHS managers.

We received 723 responses to the open text portion of this question.

Thematic analysis for this question primarily gave insight into which existing membership and/or regulatory bodies respondents had in mind to operate the regulatory system. Of those suggesting an existing body be used, the most frequent suggestion given was for the Chartered Management Institute (CMI) to run the system. Other suggestions included HCPC and GMC to undertake NHS manager regulation.

A prevalent reason respondents supported a new independent regulator was the importance of it being independent and impartial. For example, they suggested that a separate regulator for the management profession would mitigate bias between professions and promote fairness. Some respondents emphasised that existing organisations have already formulated cultures, opinions and biases, so it would be essential for new regulation to begin on a fresh slate. Additionally, some respondents suggested that a new independent organisation encouraged a clear purpose and code of conduct to be set out from the beginning. It was indicated through some respondents’ personal experiences that existing regulatory bodies would be unfit for purpose, due to their experiences of regulators failing to fulfil statutory duties, such as poor levels of response to serious issues and discriminatory practices. Existing regulators were also suggested to be unfit for purpose because they have been established for specific professions rather than management.

Organisation responses

The Professional Standards Authority (PSA) was frequently cited as a potential overseer or operator of the regulatory system. Some noted it had expressed an interest in this role and would have capacity to regulate individuals while providing support and learning. There was a call to keep professional membership functions distinct from regulatory functions. Some declined to give a view. Nonetheless, there was alignment between organisations on the principles of independence, efficiency and the appropriateness to the regulatory model.

Professional standards

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?

Of the 4,882 responses:

• 3,477 (71%) strongly agreed
• 832 (17%) agreed
• 264 (5%) neither agreed nor disagreed
• 180 (4%) disagreed
• 106 (2%) strongly disagreed

The majority of respondents agreed with introducing professional standards for NHS managers to be assessed against (88%) and 6% disagreed. Although professional standards are supported highly, it is supported less than other forms of regulation, such as a disbarring service (93%).

Agreement is highest among non-managers (94%) and lowest for NHS managers (77%). Around one in seven (14%) NHS managers disagreed with introducing professional standards for managers.

We received 1,311 responses to the open text portion of this question.

A common reason respondents gave in support of professional standards was the standardisation of leadership and management qualifications for NHS managers. Standardisation, for example through setting specific recognised qualifications as a benchmark for managing, was indicated to ensure consistency of knowledge and understanding. Additionally, these standards could provide uniformity between professions to reduce knowledge gaps and clarify conflicting learnings. Agreement with professional standards due to the standardisation of knowledge was particularly highlighted by non-managers in the health and care workforce.

Regardless of their view on professional standards, respondents frequently commented on the need for education and training to be available and accessible for NHS managers and leaders. Respondents indicated that educational opportunities should be offered to help managers obtain professional standards, particularly in the initial phases of regulation, to mitigate gaps in knowledge and skillsets. Ongoing learning opportunities through continuous professional development (CPD) were also identified by respondents to aid managers’ growth and ensure knowledge is kept up to date.

A frequent concern respondents had with professional standards was that it does not value experience as a form of knowledge. Some respondents argued that experience should be valued equally, or even seen as more valuable than qualifications. For example, some respondents expressed that experience is ‘practical’ whereas formal education is ‘theoretical’ and therefore professional standards could disparage NHS managers trained on the job. They also showed concern that professional standards would act as a barrier to career progression for ‘skilled’ staff who were trained on the job, because they do not hold the recognised qualifications. One repeated suggestion was for ‘equivalent experience’ to remain alongside qualifications for new leadership roles.

Organisation responses

Several organisations explicitly support the introduction of education or qualification standards for NHS managers. They view standards as an opportunity to raise professionalism, endorse competencies and ensure accountability. They also advocated for a code of practice and CPD to be part of this, but want standards to be consultatively developed.

Some organisations expressed reservations about professional standards. Concerns most often revolved around the diversity of management roles and pathways making it challenging to design a single formal qualification and feared it might create unnecessary barriers. Some feared strict qualifications could restrict access to managerial or leadership positions.

Question

Which categories of NHS managers should this apply to?

This question was answered by 4,286 respondents, which are shown in the table below. Response totals may sum to higher than the total base for questions where respondents could select multiple options. Percentages may also sum to more than 100 for these questions.

Table 3: categories of managers respondents thought professional standards should be applied to

Categories	Total and percentage
Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)	4,076 (83%)
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)	3,938 (80%)
Chairpersons	3,668 (75%)
Non-executive directors	3,523 (72%)
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)	3,475 (71%)
All NHS staff aspiring to be board-level directors	3,571 (73%)
First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)	2,204 (45%)
Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)	1,476 (30%)

‘Senior and mid-level managers and leaders’ were selected for regulation by professional standards more than ‘foundation’ and ‘first-time line managers’. The category of manager identified most frequently was ‘Senior strategic level managers and leaders’ (83%).

We received 420 responses to the open text portion of this question.

Ensuring consistency of knowledge through all managers meeting professional standards was a frequent reason given by respondents. Respondents identified the importance of consistency flowing through the management bands by professional standards being met by junior managers as well as senior managers. It was felt by all respondent types that a standardised approach would help to create a culture of professional and competent management from the bottom upwards. Although a standardised approach was emphasised, some respondents reflected that the frameworks and/or requirements should differ between management levels, to ensure that the standards are proportionate to the role and skillset.

Some respondents used the open text question simply to clarify which categories of managers professional standards should apply to and indicated that only mid to senior level managers should be subject to this. Respondents explained that these senior categories of managers held greater responsibility, and their decisions had wider impact. Therefore, they inferred that professional standards were only appropriate and valuable for senior management.

Organisation responses

Most organisations either did not directly respond to this question or repeated earlier views on the scope.

Revalidation

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?

Of the 4,879 responses:

• 3,471 (71%) strongly agreed
• 884 (18%) agreed
• 238 (5%) neither agreed nor disagreed
• 131 (3%) disagreed
• 123 (3%) strongly disagreed

The majority of respondents agreed with NHS managers having to revalidate their professional registration (89%) if a professional register is implemented and 5% disagreed.

Agreement is highest among non-managers (94%) and lowest for NHS managers (79%). Around one in eight (12%) NHS managers disagreed with revalidating a professional registration.

We received 1,013 responses to the open text portion of this question.

Respondents supported professional register revalidation because it could ensure that high standards are maintained over time. For example, knowledge and skills of managers can be refreshed so that standards do not slip. It was also highlighted by respondents that the value and utility of the professional registration lies in it being up to date.

Some respondents questioned whether a revalidation system would incorporate learning and development opportunities, urging training and paid time to be factored in for managers maintaining skills. If managers were to be periodically revalidated, they argued that CPD would be important for managers to maintain knowledge and upskill. Additionally, an appraisal system to give managers regular feedback and monitor progress was suggested by respondents and could be integrated within a revalidation system.

Respondents argued that NHS managers should be held to the same standards as other clinical professionals. Therefore, periodic revalidation frequency should be consistent with other professions, which could standardise the professional regulatory system.

Question

How frequently should managers be required to revalidate their professional registration?

Of the 4,347 responses:

• 990 (23%) selected ‘annually’
• 648 (15%) selected ‘every 2 years’
• 1,378 (32%) selected ‘every 3 years’
• 1,229 (28%) selected ‘every 5 years’
• 37 (1%) selected ‘less frequently than every 5 years’

Respondents indicated mixed opinions on how frequently NHS managers should have to revalidate their professional registration. Every 3 years was indicated most often, by one in three respondents (32%) and the vast majority wanted revalidation to be every 5 years or more frequently (98%).

We received 789 responses to the open text portion of this question.

Respondents often discussed bringing managers’ revalidation schedule in line with other clinical professions. Interestingly, respondents proposed a variety of frequencies when comparing to other professions, such as being in line with doctors, nurses and consultants, reflecting the mixed opinions on this question. Those suggesting managers should be revalidated in line with doctors have reflected that an annual revalidation should be linked to an appraisal, which allows managers to identify and address errors and areas of improvement early on.

Respondents who selected 2 or 3 years for revalidation often gave the reason of striking a balance between revalidating often enough for it to be valid and useful, and not so often for it to not cause unnecessary work burden.

Question

What skills and competencies do you think managers would need to keep up to date in order to revalidate?

There were 1,332 responses to this open text question.

A variety of skills and competencies were cited by respondents as being important for managers to keep up to date. General management and people management skills were often suggested, such as leadership skills and skills associated with coaching and developing others.

Another frequent skill identified related to operational delivery. For example, this included the necessity for managers to understand the systems and structures related to their role, effective governance, meeting targets and quality assurance procedures. Financial knowledge and skills were also identified by respondents, who stated that skills such as budgeting, balancing costs and saving money are important for NHS managers.

Respondents often expressed the value of managers regularly being given feedback, from staff, patients and 360 feedback. Although this is not explicitly a skill or competency, it is a useful tool that was identified to aid NHS managers’ professional development. Feedback was recognised as going hand in hand with CPD, such as maintaining and developing subject-specific skills needed to perform their roles effectively.

Another competency highlighted as useful by respondents was clinical knowledge. Some respondents highlighted the importance of NHS managers understanding the clinical services they manage, such as subject-specific processes. Alongside having a deeper appreciation of their subject area, they suggested an understanding of patient safety and engagement with patient experience was also useful.

Respondents often suggested that a sufficient understanding of equality, diversity and inclusion was important to keep up to date.

Organisation responses

There was widespread agreement from responding organisations that NHS managers should be required to periodically revalidate their professional registration. This was viewed as a mechanism to ensure ongoing competence and professionalism. They also saw this as consistent with other regulated professions.

Views on how often revalidation should occur varied across providers: some suggested a fixed time frame (for example, every 3 to 5 years), and others advocated for a flexible, adaptable model to ensure relevance and reduce unnecessary burden, which would take into account the role or context of a particular manager.

There was limited detail from organisations about specific skills and competencies, but where mentioned, the focus was on leadership, management and professional development tailored to individual roles, with the expectation that different managers have different needs. Some thought this depended on the model of registration. There was also some concern about how revalidation would apply to managers with clinical roles, particularly whether existing professional registrations could suffice.

Dual registration

Question

Do you agree or disagree that clinical managers should be required to meet the same management and leadership standards as non-clinical managers?

Of the 4,886 responses:

• 2,810 (58%) strongly agreed
• 1,107 (23%) agreed
• 403 (8%) neither agreed nor disagreed
• 321 (7%) disagreed
• 175 (4%) strongly disagreed

The majority of respondents agreed with dual registration for NHS managers (80%) and 10% disagreed.

Agreement with dual registration was higher among members of the public (86%) than both NHS managers and non-managerial workforce (79%).

We received 1,153 responses to the open text portion of this question.

One reason respondents supported dual registration was by recognising clinical management and operational management as requiring 2 different skillsets. For example, managing people requires an interpersonal, leadership and problem-solving skillset that differs from clinical leadership and therefore requires its own registration.

It was also highlighted that non-clinical managers should be held to account consistently with other professions. Respondents justified their support for dual registration through indicating that management standards should apply to all managers, and these should be standardised to ensure consistency.

Some respondents used the open text question to explain why they disagreed with dual registration for clinical managers. A concern raised by respondents was that dual registration would cause duplication, resulting in unnecessary work burden and costs for individuals.  

Question

How should clinical managers be assessed against leadership or management standards?

There were 3,872 responses to this question, shown in the table below.

Table 4: how managers should be registered

Responses	Total and percentage
They should hold dual registration with both their existing healthcare professional regulator and the regulator of managers	2,322 (60%)
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	1,123 (29%)
They should only hold registration with an existing healthcare professional regulator that will determine any leadership and managerial competencies	201 (5%)
Other	30 (1%)

The majority of respondents (60%) selected dual registration for NHS clinical managers as a preferred assessment option.

We received 393 responses to the open text portion of this question.

Respondents often supported dual registration for clinical managers by recognising clinical management and operational management as requiring 2 different skillsets. For example, managing people requires a skillset that is distinct from clinical knowledge and therefore registration with a clinical profession would not be sufficient. Existing clinical regulatory bodies were also suggested to not be sufficient for regulating managers as a separate profession. Respondents highlighted that the focus of clinical regulators is not on management, and some indicated that existing regulators lacked management knowledge and expertise necessary to regulate managers effectively.

Some respondents also supported dual registration because it could ensure manager standards are consistently applied across NHS professions. They indicated that to improve management standards and expectations across the board, it would be necessary for clinical managers to dual register in order to consistently hold all managers accountable and to the same standards.

Concerns were raised over the burden to individuals having to dual register. For example, respondents questioned whether this process would be overly bureaucratic and cause additional work for clinical managers. Additionally, respondents were concerned over the potential cost impacts on individuals, with 2 registration costs being seen as unfair if they were to occur regularly.

Organisation responses

Most organisations who responded agreed that clinical managers should meet the same management and leadership standards as non-clinical managers. They emphasised the importance of consistent leadership and management across all managers.

However, while there is broad support for common standards, there is apprehension about requiring dual registration for clinical managers. Many organisations expressed concern that dual registration - where clinical managers are regulated by both their clinical body and a separate management body - could lead to overlapping oversight, increased workload and unnecessary complexity. There was also concern that requirements to register, renew or revalidate twice with 2 sets of fees could potentially deter career progression.

Organisations emphasised the need for clear definitions, processes and co-ordination between regulators to avoid confusion. Some stressed the importance of having a clear process for the public and staff to raise concerns, avoiding risks of complaints being duplicated or ‘falling between the cracks’. It was also noted that dual or multiple registrations are already common, and in this situation, one regulator typically taking the lead in investigations, suggesting this could be a model to explore for clarity and efficiency.

Many said that standards should be tailored to the role and level of responsibility, ensuring they are proportionate and relevant rather than a one-size-fits-all approach.

There is some concern that additional regulatory requirements could discourage clinicians from pursuing management roles; some cited existing concerns about workload, stress and cost of living from the workforce. It was also raised that dual registration could impact public confidence if a manager barred from a clinical register could still practice as a manager.

Some organisations believed that current regulatory frameworks already address leadership and management, preferring to strengthen these rather than a new system. Some professional bodies noted they already have guidance on leadership and management. Some warned of potential conflicts between clinical and managerial conduct and said fitness-to-practise processes must differentiate these roles clearly.

Phasing of a regulatory scheme

Question

Do you agree or disagree that a phased approach should be taken to regulate NHS managers?

Of the 4,858 responses:

• 1,109 (23%) strongly agreed
• 1,369 (28%) agreed
• 622 (13%) neither agreed nor disagreed
• 758 (16%) disagreed
• 892 (18%) strongly disagreed

Around half of respondents agreed with the use of a phased approach (51%) and 34% disagreed.

There were mixed responses on using a phased approach across all respondent types. NHS managers were the most supportive of a phased approach to regulation (61%) and both non-manager workforce (38%) and members of the public (38%) disagreed the most with a phased approach.

We received 1,326 responses to the open text portion of this question.

The open text question revealed a variety of reasons for the respondents’ mixed opinions on a phased approach. A key reason respondents were opposed to a phased approach was that they wanted the regulation to start immediately. Some respondents explained their concerns over a delayed implementation as lacking clarity and firm deadlines. Respondent concerns also linked back to apprehension that managers would not be held accountable, as a tiered, phased approach could allow some managers time to move roles and escape culpability. Scepticism over a voluntary regulatory system was another reason respondents opposed a phased approach. Some respondents questioned the effectiveness of a voluntary system, which could be a phased approach strategy, suggesting that it would fail to hold the worst performing managers accountable.

Respondents in favour of a phased approach argued that practically, this would be the most sensible way to implement regulation and mitigate any issues. Managers tended to cite this reason in support of a phased approach more than others. For example, allowing time for managers to adjust and meet the requirements of the regulation, as well as the practical benefits of spreading costs and resources.

Organisation responses

A phased approach refers to implementing the manager regulation in stage - potentially targeting specific groups of managers or aspects of regulation initially - before expanding to full implementation.

There was a general consensus in favour of phasing the regulatory scheme and some expressed very strong support. The main reason was around the practical benefits around cost, time and logistics. Organisations felt that it would minimise the risk of any delays and reduce the burden of immediate widespread implementation.

Another angle raised by organisations was that a phased approach is a way to test and refine the regulatory scheme before full adoption. Some say it could also help gather more evidence to establish whether progressing to statutory regulation is necessary, framing the phasing as an evidence-gathering pilot phase. Broadly, these organisations suggested a cautious, iterative approach to regulation. Some suggest that specific groups - namely senior leaders - should be prioritised for any phasing of the regulation.

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?

Of the 4,858 responses:

• 3,852 (79%) strongly agreed
• 803 (17%) agreed
• 94 (2%) neither agreed nor disagreed
• 28 (1%) disagreed
• 37 (1%) strongly disagreed

The majority of respondents supported a professional duty of candour being extended to NHS managers (96%) and 1% disagreed.

Agreement with a professional duty of candour for NHS managers was highest among non-managers (99%) and members of the public (95%).

We received 711 responses to the open text portion of this question.

Respondents often supported a professional duty of candour for managers to encourage a culture of honesty, openness and transparency within NHS management. They explained that honesty would be promoted through a professional duty of candour, and this would be essential to establish a workplace of integrity and to hold managers accountable for their actions. A professional duty of candour was also supported because it was considered an essential ethical standard within the NHS and healthcare system. Many respondents felt that ethically, a duty of candour is a necessity and NHS managers and leaders holding responsibility over patients and services should follow these guidelines if they do not already.

Some respondents also suggested that a professional duty of candour should be extended to NHS managers to standardise professions and ensure consistency in the guidelines being followed. The responses tended to reference NHS managers as needing to abide by the same standards as clinical professions, or suggesting all should be subject to the same rules.

Question

Which categories of NHS managers should a professional duty of candour apply to?

This question was answered by 4,618 respondents, shown in the table below.

Table 5: categories of managers respondents thought a professional duty of candour should apply to

Categories	Total and percentage
Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)	4,437 (96%)
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)	4,288 (93%)
Chairpersons	4,214 (91%)
Non-executive directors	4,142 (90%)
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)	3,887 (84%)
All NHS staff aspiring to be board-level directors	3998 (87%)
First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)	3,068 (66%)
Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)	2,484 (54%)

The category of manager selected most for a professional duty of candour was ‘senior strategic level managers and leaders’ (96%), closely followed by ‘senior managers and leaders’ (93%) and ‘chairpersons’ (91%).

We received 447 responses to the open text portion of this question.

The open text question was often used by respondents to clarify the categories of managers they had selected. One justification respondents gave for selecting all manager categories was to ensure a standardised approach is taken. The consensus of responses was that a professional duty of candour should apply to all managers across all grades, to ensure a common set of standards are adhered to.

Additionally, all manager categories were selected due to the importance of honesty and transparency at all levels of management. Respondents indicated that the duty of candour is a necessary process to hold managers accountable for their mistakes.

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?

Of the 4,849 responses:

• 3,740 (77%) strongly agreed
• 856 (18%) agreed
• 127 (3%) neither agreed nor disagreed
• 31 (1%) disagreed
• 35 (1%) strongly disagreed

The majority of respondents supported NHS managers having a duty to ensure a statutory duty of candour is being followed (95%) and 1% disagreed.

Agreement with a statutory duty of candour for NHS managers was highest among non-managers (97%).

We received 392 responses to the open text portion of this question.

Respondents expressed that NHS managers should uphold a statutory duty of candour because it is important for all managers to be held accountable. Responses indicated that for an organisational duty of candour to be effective, every manager needs to take responsibility in proactively practising integrity and accountability.

However, some respondents indicated that only senior level management should be responsible for the statutory duty of candour, and lower-level management should not. Their comments explained that senior managers and leaders hold more responsibility and therefore it should be part of their job to ensure the organisational duty of candour is being followed. Additionally, some respondents felt that the scope of an organisational duty of candour is too wide for first-time line managers, foundation managers and lower grade managers, who would not have oversight of the wider organisation.

Question

Which categories of NHS managers should the statutory duty of candour apply to?

This question was answered by 4,160 respondents, shown in the table below.

Table 6: categories of managers respondents thought a statutory duty of candour should apply to

Categories	Total and percentage
Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)	4,005 (96%)
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)	3,825 (92%)
Chairpersons	3,814 (92%)
Non-executive directors	3,748 (90%)
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)	3,406 (82%)
All NHS staff aspiring to be board-level directors	3,591 (86%)
First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)	2,651 (64%)
Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)	2,141 (51%)

The category of manager identified most frequently for a statutory duty of candour was ‘senior strategic level managers and leaders’ (96%). Senior and mid-level managers and leaders were selected by respondents as needing to uphold a statutory duty of candour significantly more than foundation and first-time line managers.

We received 243 responses to the open text portion of this question.

Thematic analysis for this question revealed that some respondents used the open text portion of the question to clarify the categories of managers they had selected. Respondents often suggested that all managers at all levels need to be accountable for ensuring that the statutory duty of candour is upheld in their organisation. Similarly to the previous question, an opposing theme to emerge was that senior level management should be responsible for the statutory duty of candour. Reasons for this theme included senior managers having greater responsibility, impact of decision making and oversight of their organisation.

Duty to respond to safety incidents

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?

Of the 4,832 responses:

• 3,721 (77%) strongly agreed
• 814 (17%) agreed
• 149 (3%) neither agreed nor disagreed
• 53 (1%) disagreed
• 47 (1%) strongly disagreed

The majority of respondents supported NHS managers having a duty to respond to safety incidents (94%) and 2% disagreed.

Agreement with NHS managers having a duty to respond to safety incidents was highest among non-managers (97%).

We received 628 responses to the open text portion of this question.

Respondents justified their support for a duty to respond to safety incidents by suggesting it could ensure managers are held accountable for poor decision making and would be transparent with issues that arise. They also expressed the importance of staff and patients being able to raise concerns without fear of poor managers dismissing them without consideration. Negative experiences of whistleblowers and those speaking up were highlighted by some respondents, suggesting a duty to respond would protect staff and patients and hold managers accountable.

A duty to respond was explained by respondents as a basic ethical approach within healthcare, with some respondents expressing that it is already being followed (or should be). However, some respondents recommended that processes should be in place to deal with concerns on a systemic level rather than having managers directly respond. For example, they proposed a triage system to proportionately address concerns, with serious forms of misconduct subject to this duty and less serious concerns dealt with differently.

Question

Which categories of NHS managers should this apply to?

This question was answered by 4,421 respondents, shown in the table below.

Table 7: categories of managers respondents thought a statutory duty to record, consider and respond to concerns should apply to

Categories	Total and percentage
Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)	4,210 (95%)
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)	4,036 (91%)
Chairpersons	3,967 (90%)
Non-executive directors	3,891 (88%)
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)	3,643 (82%)
All NHS staff aspiring to be board-level directors	3,753 (85%)
First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)	2,764 (63%)
Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)	2,148 (49%)

The category of manager identified most frequently was ‘Senior strategic level managers and leaders’ (95%). Senior and mid-level managers and leaders were selected by respondents as having a duty to respond to concerns significantly more than foundation and first-time line managers.

We received 228 responses to the open text portion of this question.

Many respondents used the open text portion of the question to clarify the categories of managers they had selected. Respondents often suggested that all managers should be subject to a duty to respond to safety incidents to ensure they are held accountable for their actions and decision making. Some respondents agreed that it should be everyone’s responsibility to respond to concerns and there should not be exceptions.

However, some respondents expressed the view that the duty to respond to concerns should only be the responsibility of senior managers and leaders. These respondents indicated that the greater influence and impact of decision making associated with senior managers equated to this duty, and that it would not be appropriate for lower grade managers to take this on.

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?

Of the 4,808 responses:

• 3,737 (78%) strongly agreed
• 824 (17%) agreed
• 107 (2%) neither agreed nor disagreed
• 40 (1%) disagreed
• 50 (1%) strongly disagreed

The majority of respondents supported NHS managers having a duty to ensure processes are in place for responding to concerns (95%) and 2% disagreed.

Agreement with NHS managers having a duty to ensure processes are in place, for responding to concerns, was highest among non-managers (97%).

We received 380 responses to the open text portion of this question.

Often, respondents commented that the statutory duty to ensure processes are in place was already being carried out by NHS managers and it should continue to do so. Respondents suggested this was happening already, and if it was not, then it should be as a basic ethical standard. Another reason for support was that NHS decision makers should be held to account and have a consistent approach. A statutory duty to ensure processes are in place and followed was indicated to strengthen and make processes robust. This was closely linked to respondents’ concerns that a cultural change is needed to improve how trusts and organisations operate.

Question

Which categories of NHS managers should this apply to?

This question was answered by 4,378 respondents, shown in the table below.

Table 8: categories of managers respondents thought a statutory duty to ensure processes are in place to record, consider and respond to concerns, should be applied to

Categories	Total and percentage
Senior strategic level managers and leaders or very senior managers (includes CEOs and executive directors, some medical and dental directors, for example clinical directors)	4,158 (95%)
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)	3,942 (90%)
Chairpersons	3,913 (89%)
Non-executive directors	3,839 (88%)
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)	3,536 (81%)
All NHS staff aspiring to be board-level directors	3,644 (83%)
First-time line managers (approximately bands 6 to 7, for example project manager, staff nurse, occupational therapist, team supervisor, team manager)	2,614 (60%)
Foundation managers (approximately bands 4 to 5, for example administrator, receptionist, medical secretary, clinical support worker, clinical assistant, healthcare assistant)	1,991 (45%)

The category of manager identified most frequently was ‘Senior strategic level managers and leaders’ (95%). Senior and mid-level managers and leaders were selected by respondents as having a duty to respond to concerns significantly more than foundation and first-time line managers.

We received 175 responses to the open text portion of this question.

Similar to previous questions, respondents tended to clarify the categories of managers they felt should be subject to monitoring a statutory duty of candour. Respondents indicated that all staff have the responsibility to uphold the statutory duty to ensure processes are in place to respond to concerns. Responses conveyed the importance of all managers being responsible and accountable for their decisions and the necessity to ensure concerns are taken seriously.

However, some respondents expressed the view that the duty to ensure processes are in place should only be the responsibility of the most senior managers and leaders. Responses reflected that the duty should be part of their roles, due to the influence and oversight of senior managers.

Organisation responses

Organisations typically responded to the duty of candour questions and duty to respond to safety incidents as one response, and consequently, we have aggregated their views.

There is broad support among responding organisations for introducing a professional duty of candour for NHS leaders. Many see it as consistent with duties already imposed on healthcare professionals and essential for patient care. Typically, organisations saw this applying to grades above 8d, although some also wanted to see 8a and above.

Some organisations also supported it becoming a statutory duty. As before, organisations saw this as a way to formalise accountability and consistency. There were varying degrees of enthusiasm and significant caveats, however. The main concern raised was whether a legal duty alone would improve safety outcomes or encourage an open culture, with some suggesting they worry it would undermine openness. Some organisations suggested that a statutory duty needs to see effective processes and whistleblower protections, rather than just a focus on compliance. Other concerns were raised too, about enforcement mechanisms and potential overlap with existing duties.

There is general agreement that NHS leaders should have a statutory duty to respond to safety concerns and ensure processes are followed, though responses were less detailed and many simply reiterated points made previously.

Effectively throughout, however, are 2 considerations - that cultural changes (enabling staff to raise concerns without fear) are as important as regulation, and worries of a potential chilling effect on leadership roles if duties are overly punitive.

Next steps

We will take forward legislative change to ensure that HCPC can regulate NHS managers. We intend to lay the regulations within this Parliament, and in alignment with planned legislation to modernise HCPC’s regulatory framework. Legislation brought forward to implement a statutory disbarring regime for NHS managers will be subject to further consultation and include further details on the role of HCPC as the regulator. We will continue to engage system stakeholders throughout the process of developing the regulatory system, and we will continue to work closely with NHS England to ensure alignment with the wider work underway to develop managers and leaders.

Impact assessment

Prior to the statutory consultation being published, we will publish an impact assessment on GOV.UK.