Leadership for a collaborative and inclusive future

On 8 June, General Sir Gordon Messenger and Dame Linda Pollard published their final report on the review of leadership and management in the health and social care sector, as commissioned by the Secretary of State for Health and Social Care in October 2021. The review was extensive in its scope, covering all parts of the system and utilising a 'listen and learn' approach to engage with a diverse range of stakeholders. The report acknowledges the complexity of the system and its structure, as well as the pressures the NHS currently faces in tackling a backlog in care against the backdrop of significant staff shortages. It also recognises the important relationship between driving improvement in leadership and the positive effects on productivity and efficiency. Our Reality Check report, also published on 8 June, further explores the tough financial ask of trusts in this financial year.  

Despite these challenges, the review team see a window of opportunity afforded by the statutory footing for ICSs in the Health and Care Act 2022, as well as the merging of Health Education England and other bodies into NHS England and the changes to the world of work being navigated across the country as we emerge from the pandemic.  

When the review was first launched, NHS Providers was supportive but raised concern at the potential for it to descend into a 'blame game'. We are, therefore, reassured by the engagement undertaken by the review team and the supportive messages contained within the findings that acknowledge the importance of inclusive leadership and culture on recruitment, morale and retention.  

In March, as part of the review team's stakeholder engagement, we facilitated a roundtable with a number of members at challenged trusts. We are, therefore, pleased to see a specific recommendation (7) within the final report outlining details of a support offer for leaders who take on these difficult roles. We are also pleased to see that the review addresses the four leadership challenges we highlighted in a Health Service Journal blog in February this year.  

In this briefing, we have summarised the key areas covered by the report, grouping recommendations under the below headings. It is worth noting that the recommendations included in this report largely address NHS England and the government yet stress the critical importance of co-production at a local and system level.  

The report contains two recommendations specifically focused on training, including recommendations 1 and 3. Recommendation 1 outlines a need for targeted intervention at entry-level and mid-career level (for managers) to promote collaborative leadership and common organisational values, which should include specific modules on equality, diversity and inclusion (EDI). For middle managers, the report recommends a three to five day in person training offer across health and social care, local government and relevant voluntary and private sector organisations. The report notes this could align with the national leadership programme detailed in the integration white paper.  

Recommendation 3 calls for a unified set of leadership and management standards, alongside training bundles to help achieve these standards. The review team specifically point towards good practice in the social care sector, for example the registered manager standard, as a cross-sector learning opportunity.  

As part of its findings, the report notes a legacy of competition within the service and suggests the collaborative nature of system working will change this dynamic, leading to better outcomes for staff, and patients – it calls this a ‘culture of collaboration’. It also suggests that leadership is, at present, seen as the responsibility of those with ‘manager’ in their job title – yet recommendation 1 seeks to address this by engendering a sense of belonging across the wider workforce.  

With regard to standards and structures, the report refers to stakeholder feedback on a lack of career structure for managers, as well as a lack of universal standards, resulting in the perception that management is not viewed as a 'professional activity'. The review team hope to address this through recommendation 3, as well as through those set out below under 'Development'.  

The review also looks specifically at clinical leadership, noting the central role clinicians can play in culture and behaviour setting, alongside their knowledge of patient and population health. Despite this, stakeholder engagement highlighted that many clinicians with management responsibilities felt unprepared for their leadership roles and noted an assumption that seniority equates to leadership knowledge. Training and development opportunities outlined in the recommendations within this report therefore need to be applied to clinical leadership roles as well as to non-clinical managers. 

Further to recommendations on training, the report considers the system for appraisals, talent management and non-executive director (NED) development. Recommendation 4 outlines the need for a consistent system for appraisals on an annual basis for all NHS staff, as a unified process should remove silos and unwarranted variation. Appraisals should focus on role performance, both technical and behavioural, as well as staff future career aspirations. In the short-term, this recommendation calls for a focus on fulfilling this recommendation for non-clinical managers within the NHS in 2022/23. Manager training for these appraisals should be included as part of the training bundle in recommendation 3.  

Regionally, the report calls for a career and talent management function in Recommendation 5. Evidence from stakeholders suggests that there is currently a lack of clarity in management career progression, a sense of a failure to utilise diverse and available talent, and a shortage of candidates for management roles at challenged trusts. The report suggests this regionally based talent management function would have authority for succession planning, career support, data analysis, talent management and the oversight of compliance to standards, as well as training and appraisal processes.  

In Recommendation 6, the report calls for the expansion of NHS England’s non-executive director talent and appointments team to allow this support group to further expand its reach and to diversify the talent pool for NED appointments, both in terms of equality, diversity and inclusion and expertise from other sectors. The report specifically notes the need for renewed efforts to appoint more women, Black and disabled non-executive directors. We support the recognition of the important role NEDs play in NHS trusts and foundation trusts, and agree that there is a need to ensure a wider cross section of society see themself fulfilling this vital role and to provide support for effective induction, training and talent development of NEDs. 

However, it is important to understand that NHS foundation trusts are constituted so that their councils of governors appoint NEDs and many welcome the flexibility that comes with designing their own role specification and recruitment and assessment processes. While foundation trusts may welcome assistance from NHS England, this should not be imposed upon them. It will also be important that the recommendations of this report do not become out of step with the newly produced code of governance.   

We also support the acknowledgment that training and development in the board role are as crucial for non-executive directors are they are for their executive colleagues. While NHS England may serve an important role, we do not support the full centralisation of training and development provision and we firmly believe that it should be the NHS provider sector that influences the shape of training and development provision. 

Finally, regarding oversight, the report acknowledges the often unhelpful pressurised environment managers and leaders, as well as frontline staff, are working in, citing internal and external political pressures as part of this.