The leadership implosions at Liverpool community health NHS trust and Wirral University teaching hospital NHS trust have been followed by another bout of soul-searching at NHS Improvement about when and how to fire NHS managers.
In an interview with HSJ, recently appointed NHS Improvement chair Dido Harding articulated widely felt disquiet over the health service’s failure to distinguish between people in senior roles whose performance has fallen short and those who have, in her words, “crossed a moral line”.
She described the current approach as “a public beheading and then they pop up somewhere else, and for neither of those groups is that the right treatment”.
Her comments follow HSJ’s revelation that NHS Improvement’s predecessor arranged for Liverpool’s chief executive Bernie Cuthel to move to a senior role in Manchester after the Care Quality Commission found serious failings at the trust. A subsequent inquiry uncovered bullying, patient harm and problems being hidden from regulators.
At Wirral, NHS Improvement had planned to offer a secondment to chief executive David Allison after several directors raised serious concerns about culture and governance.
If these are examples of the system seeking to look after those responsible for egregious failings, NHS Improvement’s national model for improving mental health care, unveiled a few days ago, highlights the dangers of sacking managers who get into difficulty while doing their best. It stresses that a system determined to do better must be able to tolerate failure in leaders so they are willing to take the risks inherent in trying to improve quality.
“Any tendency to blame people and sack individuals when things go wrong without analysing possible systemic failures endangers improvement,” it says.
Too often the NHS reacts wrongly to failure, finding sinecures or soft landings for those who have “crossed a moral line” while battering the reputations, career prospects and, potentially, mental health of senior leaders who have been overwhelmed by the problems facing them despite their best efforts.
Baroness Harding is proposing a two-pronged approach to resolving this: strengthening the fit and proper person test for senior roles to ensure that those who are not up to the job are ejected from the health service, while supporting, retraining and rehabilitating managers who have the talent and commitment to succeed.
Turning these good intentions into policy will be hard. To begin with, drawing the moral line is tougher than it sounds. While blatant conflicts of interest and managing by fear should clearly attract the toughest sanctions, what about hiding the truth from regulators?
Conspiring to cover up patient safety failings looks clear-cut, but how about securing millions of pounds of additional financial support by providing an unrealistically rosy interpretation of a trust’s financial position? It isn’t right but it is certainly understandable, and when the Department of Health has itself indulged in financial contortions to end the year within budget, it is hardly surprising that, faced with a choice of excessive optimism or grief from NHS Improvement, some boards choose the former. Should that end careers?
At the other extreme, rehabilitating talented people who have got into difficulty will work only if NHS Improvement is willing to take a robust approach to managing public perceptions. The expectation among citizens and journalists that failings by public bodies will be answered with instantaneous, grovelling apologies and heads on spikes leaves little space for explaining the complexities of running a big healthcare organisation. Trying to overcome that will require Harding and chief executive Ian Dalton to get in front of the cameras to give difficult cases some context.
But the most important test for Harding’s approach will be whether more managers aspire to become chief executives and directors. There is plenty of anecdotal evidence that talented people – notably doctors – are avoiding high-profile roles because they do not believe the opportunities and rewards outweigh the risk of defenestration and humiliation. If the management environment becomes less punitive and more supportive, that will begin to change.
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