Placing the cart before the horse: proposals to regulate NHS managers.

BackgroundPolicy and reviews of health-care safety and quality emphasise the role of NHS managers in ensuring safe, good-quality patient care through effective staffing. Guidance requires that NHS managers combine professional judgement with evidence-based workforce planning and deployment tools and technologies (WPTs). Evidence has focused on the effectiveness of WPTs, but little is known about supporting their implementation, or the impact of using WPTs across settings.ObjectivesThe review answered the following question: ‘NHS managers’ use of workforce planning and deployment technologies and their impacts on nursing staffing and patient care: what works, for whom, how and in what circumstances?’.DesignA realist synthesis was conducted. A programme theory was formulated and expressed as hypotheses in the form of context, mechanisms and outcomes; this considered how, through using WPTs, particular conditions produced responses to generate outcomes. There were four phases: (1) development of a theoretical territory to understand nurse workforce planning and deployment complexity, resulting in an initial programme theory; (2) retrieval, review and synthesis of evidence, guided by the programme theory; (3) testing and refinement of the programme theory for practical application; and (4) actionable recommendations to support NHS managers in the implementation of WPTs for safe staffing.ParticipantsNHS managers, patient and public representatives and policy experts informed the programme theory in phase 1, which was validated in interviews with 10 NHS managers. In phase 3, 11 NHS managers were interviewed to refine the programme theory.ResultsWorkforce planning and deployment tools and technologies can be characterised functionally by their ability to summarise and aggregate staffing information, communicate about staffing, allocate staff and facilitate compliance with standards and quality assurance. NHS managers need to combine local knowledge and professional judgement with data from WPTs for effective staffing decisions. WPTs are used in a complex workforce system in which proximal factors (e.g. the workforce satisfaction with staffing) can influence distal factors (e.g. organisational reputation and potential staff recruitment). The system comprises multiple organisational strategies (e.g. professional and financial), which may (or may not) align around effective staffing. The positive impact of WPTs can include ensuring that staff are allocated effectively, promoting the patient safety agenda within an organisation, learning through comparison about ‘what works’ in effective staffing and having greater influence in staffing work. WPTs appear to have a positive impact when they visibly integrate data on needs and resources and when there is technical and leadership support. A collaborative process appears to be best for developing and implementing WPTs, so that they are fit for purpose.LimitationsThe evidence, predominantly from acute care, often lacked detail on how managers applied professional judgement to WPTs for staffing decisions. The evidence lacked specificity about how managers develop skills on communicating staffing decisions to patients and the public.Conclusions and recommendationsThe synthesis produced initial explanations of the use and impact of WPTs for decision-making and what works to support NHS managers to use these effectively. It is suggested that future research should further evaluate the programme theory.Study registrationThis study is registered as PROSPERO CRD42016038132.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

The NHS began life in 1948 with the noble intention of providing free health care for all from cradle to grave. Today the NHS is the largest employer in Europe employing in excess of one million people and it has commonly been held that, since the NHS is an organisation committed to treating and providing care to patients, those working for the NHS are generally perceived to hold, in the main, altruistic values. Over the last two decades NHS managers have been given the responsibility for the implementation of the various NHS reforms which have been aimed at making the NHS more efficient, effective, accountable and business like. This paper explores the extent to which the managers in this role as change agents believe that they hold core values that are in line with the altruistic service ethos of the NHS and as a result the extent to which they believe they are seen to be performing and behaving in a socially responsible manner. Furthermore this study also provides an insight into understanding the managers' perceptions of their public image and assesses the extent to which this has an impact on the managers’ psyche, performance and commitment to the NHS ethos. Twenty eight managers from two Acute Care and one Community Care NHS Trusts in London were interviewed, after completing questionnaires, with a view to understanding their perceptions of their managerial culture and their public image. It appeared that managers generally believed that all NHS workers, themselves included, share altruistic values and demonstrated a collective commitment to the altruistic service ethos of the NHS. This therefore demonstrates the managers' commitment to behaving and performing in a socially responsible manner. As far as the managers’ perceived public image is concerned the research revealed that the majority of the managers, despite holding values that were altruistic in nature and similar to those held by clinicians, appeared to be convinced that the general public believed that doctors and nurses are the only professionals in the NHS who are motivated by a desire to serve/provide care to society and that these groups alone have an altruistic ethos. The managers indicated that they felt the public viewed them in a generally poor light and did not confer upon them the service driven values that were ascribed to clinicians. It is in the context of being the main change agents within the NHS that NHS managers appear to have become unpopular with the general public who tend to hold the view that “a service which managers are trying to make ever more efficient, rational and controlled cannot at the same time be caring and people centred” [Learmonth, 1997, pg. 219]. Whilst the NHS managers were aware of this negative view held by the public, they felt certain that this public perception was misguided and driven by several unfair and politically motivated agendas. They do not appear to have allowed this perceived negative public opinion to affect how they view their own role and in fact offered various reasons to explain why this public opinion was misguided and misinformed. This paper considers the implications of these views as regards the managers' role and commitment to the NHS.

As England approaches the elections this spring, politicians should pledge to increase the numbers of medical doctors and other clinically experienced staff within NHS management. The NHS is a popular point-scorer in electoral debates because of the ongoing crisis it faces in funding, strikes, under-staffing and disruption in hospitals. One problem that is not being sufficiently addressed is that NHS governance is out of touch with medical doctors and other frontline staff. A survey in 2008 showed that 87% of senior doctors and NHS managers want doctors involved in business planning, and 78% want doctors involved in budgeting, finance and resource allocation. Clinical staff are still excluded from core NHS decision-making, such as spending large sums of public money on management consultancies, restructuring and other non-essential expenses. In 2013, the NHS spent £210,000,000 on getting advice/help from private management consultancy companies such as Ernst & Young, McKinsey and Pricewaterhouse. The reality that many NHS managers have no first-hand experience of working with patients or clinical teams could be blamed for this sort of poor decision-making and the inappropriate application of models from the business world. The British Medical Association has questioned the use of efficiency targets that are not clinically evidenced, the erosion of clinical staff as a way of making efficiency savings and the exclusion of clinical staff from NHS decision-making. Billions of pounds in NHS ‘efficiency savings’ have come from cuts to the numbers of clinical staff with dire consequences for patient care. Some hospitals are resorting to desperate measures such as postponing all nonemergency operations and asking non-clinical staff (e.g. HR/IT staff) to work on wards. The lack of clinical prioritisation in NHS spending is compounded by government funding cuts, and the result has been the current funding crisis. Twothirds of hospitals in England are now in deficit, with an estimated £500 million shortfall accumulated by NHS England within just the first three months of this financial year. Pay freezes and worsening working conditions due to under-staffing prompted NHS health personnel to embark on nationwide strikes in 2014. The latest planned strike (due to take place on 29 January) was called off when the government improved its pay offer. Increasing staff pay, public spending on the NHS and ward staffing levels will, however, not solve the problems if there remains under-representation of clinical staff in NHS management. In one hospital, an entire team of accident/emergency consultants resigned at the same time because of chronic staff shortages and the hospital’s management reported reluctance to listen to suggestions about how to improve the department. Clinicians cannot play a central role in NHS decision-making because the current structure gives them a peripheral role – they are consulted if need be; for example, clinical senates were introduced after the NHS acknowledged the need to gain their advice before making decisions. There are 12 clinical senates across the country and they comprise doctors, nurses, allied health professionals, patients and others. The problem is that the structure of the NHS isolates clinical senates. It was intended that they will advise clinical commissioners, Health and Wellbeing boards, the NHS Commissioning Board and others, but it is not clear how they can systematically influence decisionmaking while being geographically restricted and while potentially competing with clinical networks to fulfil the same advisory function. In the case of clinical commissioning groups, the requirement is that there should be at least one doctor per group but this is not enough and it is not surprising that only 38% of general practitioners in non-leadership roles within clinical commissioning groups feel that they and their colleagues’ views are properly represented. The idea of clinicians as people who should be consulted occasionally on an ‘if need be’ basis is not an approach that has worked. The alternative option, whereby clinicians become integral to the running of

Introduction: Calls in the UK have been made to prescribe inhaler devices with lower global warming impact to patients with asthma and COPD (chronic obstructive pulmonary disease). Aims: We evaluated the most important factors in treatment decisions relating to the inhaler device and ranked the relative importance of treatment efficacy, environmental impact and other factors (Fig. 1). Methods: A ten-minute online survey was undertaken by 150 patients (asthma and / or COPD), 90 HCPs (healthcare professionals; 30 GPs, 30 pulmonologists, 30 respiratory nurses) and 10 NHS managers. Further in-depth qualitative interviews were held with 12 respondents. Results: Inhaler efficacy was the most important factor in treatment choice for nearly all respondents; 95% patients, 99% HCPs, 100% NHS managers. In contrast, the environmental impact of inhalers was the least important factor for all groups; patients (65%), HCPs (39%), and NHS managers (35%) (Fig. 1) Figures: Conclusion: HCPs, NHS Managers and patients view inhaler efficacy as the highest priority factor in treatment decisions. While many are open to considering ways to reduce the environmental impact of inhalers, any suggested changes to prescribing protocols to minimise environmental impact must demonstrate a consideration for inhaler efficacy and patient outcomes.

The image of the UK National Health Service manager has not always been positive. Like others in the public sector, NHS managers are sometimes associated in the media with waste and inefficiency, in contrast to those in 'front line roles'. Thus healthcare professionals and members of the public might ask, in the tradition of Monty Python's Life of Brian, what NHS managers have ever done for us. In this short article, we outline some of the evidence from the literature on attitudes to, and role of, healthcare managers, before drawing on our own interview and observation based fieldwork with managers themselves. We argue that the role of the healthcare manager is not always well understood, and that in a sector facing ever more intense and large scale organisational challenges, managers should be seen as important partners in a health service focused on clinical outcomes.

Ethical philosophers’ deliberations may seem far removed from NHS managers’ everyday concerns it's certainly easy for them to become buried under a mound of paperwork, hidden behind NHS targets and blurred by the current focus on structural reform. But health care managers, perhaps more than their colleagues in any other sector, need to consider the ethical consequences of their daily working lives.

The changing role of the manager has been a growing area of both academic and popular literature over recent years. In addition, the interest of the popular press has made terms like "grey suit" and "fat cat" common terminology. Management roles and managerial authority within today's organisations have seen many changes. This has led to frustration and anxiety for managers as they have watched their role change. In the NHS, like other sectors, managers have become a target for organisational redundancies and have experienced increased responsibility, closer monitoring of performance and heightened job insecurity. This paper aims to offer a contribution to the empirical data on managers by investigating one group of NHS managers' own perceptions of how others see their role. The findings suggest that NHS managers are very aware of the largely negative perceptions that surround them but accept this as an integral part of their role.

Being an NHS manager is a fool’s errand

A very British coup

I'm not much given to quoting from longdeparted leaders of the Conservative party who aren't called Churchill, but Stanley Baldwin's fine line from 1931 denouncing the press barons Lords Beaverbrook and Northcliffe for exercising “power without responsibility, the prerogative of the harlot throughout the ages” has been much on my mind of late.

Presents the results of empirical work examining public attitudes towards UK NHS managers. The findings indicate a strong lack of sympathy for managers. Discusses possible explanations for these results. The preferred explanation is that NHS managers as a group tend to share an ideology about the nature of the NHS and the role of management within the NHS which is at odds with the beliefs held by most members of the public on these matters. Explores the origins and nature of managerial ideology (managerialism) in the NHS and discusses possible reasons why the ideology might tend to be unpopular with the public. Concludes by suggesting that the traditional core values of the NHS as perceived by the public could be being violated by managerialism. This violation may be the principal cause for the low public esteem in which NHS managers are currently held.

Editor—Klein acknowledges that rationing is “inescapably a political process,”1 yet he accepts “muddling through,”2 albeit elegantly, as a way out of the dilemma. The practice of muddling through—for which read...

The Department of Health's new Code of Conduct for NHS Managers is reviewed and its crucial differences from the Institute of Healthcare Management code are considered. A symbolic gesture, or something more?

In the 1950s, the Ministry of Health, supported by interested groups outside government, recognised the political importance of productive efficiency. For leadership, organisational models and techniques the Ministry looked to the movement for industrial productivity. The NHS was receptive, but private-sector approaches were modified and dampened as they were imported. NHS management was to be the provider of technical expertise, but the deployment of this expertise was limited by clinical autonomy and de-coupling from financial incentives. This article casts new light on the history of productivity policy, NHS management and the moving frontier between state and civil society.

NHS managers’ code released