Steve McManus’s work developing the leaders and managers the NHS needs for the 21st century has caught the eye of national leaders. The Royal Berkshire trust chief executive talks to Matt Ross about transforming services, developing leaders and the right way to regulate the management profession. 

“If we continue in this way, we haven’t got a sustainable model of healthcare,” says Steve McManus: we must stem the rise in medical need and cut the cost of providing care, or spending will soon exceed the country’s ability to pay. So big changes are required in organisational structures and working practices — and managers must lead those reforms in an environment that’s highly complex and under great pressure. “We’re both system leaders and statutorily responsible for our own organisations,” he comments. “We’ve got fiscal challenges; performance expectations for the NHS are rightly high; and a different disposition of health needs has emerged over the last five years.”

McManus, the CEO of Royal Berkshire NHS Foundation Trust – one of the country’s largest general hospital trusts – believes these challenges demand a new approach to leadership and management; and his work has caught the attention of national leaders, who’ve been thinking along similar lines.

Announcing a new, multi-disciplinary NHS Management and Leadership framework in June, NHS chief executive Amanda Pritchard said: “Bringing together expertise from inside and outside the NHS, learning from places like Royal Berkshire who already do this well, and working with the Chartered Management Institute and others, we’ll create a new Code of Practice for all managers and leaders.”

Pritchard’s agenda has now met that of the new Labour government. The party’s manifesto pledged to “implement professional standards and regulate NHS managers, ensuring those who commit serious misconduct can never do so again.” Health leaders are clearly facing a more universal and codified approach to performance management and standards of behaviour; this new framework, says McManus, must “create the professional conditions for us to operate in the way we need to, and to be valued in doing that.”

Move upstream

The first task, then, is to understand how managers will need to operate in future. McManus began his career as a nurse in 1987, moving into management via roles in recruitment and specialist surgery – and aiding the late-‘90s push to drive down waiting lists under the last Labour government. So he’s seen the NHS pull itself out of a hole before; though with resources tighter this time, the way forward must lie through targeted capital investments and productivity improvements rather than big increases in resource budgets.

“We’ve got levels of inefficiency inherently locked into aspects of our service pathways,” he comments: his trust still has “services running in a building opened in 1839; it’s an amazing, iconic building, but not fit for 21st century care.”

Improving the NHS’s estate and its digital and data systems would enable staff to make much better use of their time, says McManus. The big savings, though, lie in wider change across the health and care system: this is “still segmented, based on the organisational silos of public health, local government and social care, primary care, community services, and then secondary and tertiary care,” he comments. “And if you plot those as blocks with pound signs, the pound signs get bigger as you move from left to right.”

So the task, he says, is to “move the point of delivery upstream, into a more preventative” approach. “How do we as leaders increasingly support the movement of our people – the expertise and capability within our service teams – so that in five years’ time, more of their working week is spent providing advice, support, guidance, and direct clinical services into community and primary care locations?”

Four dilemmas for ICBs

Integrated care systems (ICSs) will be key to these changes, says McManus, a former interim chief executive of Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board. To realise their full potential, however, ICSs will have to resolve four dilemmas.

The first is that of “scale versus subsidiarity”: finding the right balance between centralising activities at the regional level, and providing services that are responsive and localised enough to meet the needs of individual neighbourhoods.

The second is how to push resources upstream without damaging secondary care providers. “There is over time a strategic commissioning element about the disposition and distribution of funding, that moves that resource but doesn’t destabilise your acute organisations,” he says, adding that this shift will “need provider support”.

The third is the tension between “sovereignty versus solidarity”: NHS organisational leaders are being asked to bend their operations around the wider system’s needs, while being held to account narrowly against their own organisation’s performance goals.

Fourth, ICSs themselves have been given conflicting objectives: their strategic goals involve long-term system change, he notes, but “over the last year or so, a significant proportion of their time and energy has been anchored into a small number of performance areas” such as waiting times and cancer standards.

Reforms demand ‘expert management’

The new Labour administration presents an opportunity to resolve these dilemmas, says McManus: there’s a “better understanding from government about some of the drivers [of changing demand] over the last five years,” and ministers are open about “the conditions we’re working in at the moment, the resource challenges and constraints.”

The young government should do “three big things”, he argues. First, adopt a long-term “approach to public sector capital within the NHS”: that, he adds, means longer than a five-year parliamentary term. Second, ensure stability in political leadership and national policy: “The fact that the secretary of state has said that his expectation and desire is to be secretary of state for the whole life of this Parliament is really welcome.” And third, reform primary care: McManus believes that the current system — under which GPs cluster together in small businesses, often taking personal financial risks and “fighting tooth and nail to get the best out of a contract” — puts them in a “wholly asymmetric relationship” with the much bigger community, mental health and acute trusts. It’s difficult to push care provision upstream, he suggests, when that involves developing dozens of separate relationships with frontline providers of very different sizes, capabilities and attitudes.

All these reforms will demand expert management – and the system has lost a lot of skilled leaders since Covid-19: “People with experience have maybe made the choice to move on and move out,” says McManus. Meanwhile, “because of the pandemic, there was a hiatus in terms of management and leadership development coordinated at the national level, so I think we’ve had several years where there’s been a fallow period,” he adds. “We’ve had a vacuum around that.”

Now – as Amanda Pritchard has made clear – national leaders are focusing on the topic again. “Really positively, we’re seeing a re-emphasis nationally on how we create that talent pipeline,” says McManus, noting that NHS England has “used some of the work that we’ve done here in supporting the development of the relaunched Aspiring Chief Executive programme.” McManus champions both this NHS Leadership Academy scheme — he joined its first cohort in 2016 — and the leadership development work of regional teams, which allows “us at executive and senior leadership level to take a view on how we get talent into the NHS to deal with these complex challenges.”

Steve McManus: managers will engage with professional regulation if “it’s seen as a positive aspect of how we professionalise leadership and management… I think managers and leaders should be have the same standards applied to them as other regulated professions.”

At the trust level, McManus has also caught NHS England’s attention with Royal Berkshire’s “multi-professional management leadership development programme” – which is funded by the apprenticeship levy, provided by Henley Business School, and accredited by the Chartered Management Institute. The three-year scheme has been running for eight years, he explains, providing nearly 300 people with “the knowledge, the skills and the networks to build their career, with the aim of taking on increasingly complex management and leadership portfolios.” Initially aimed at people from minority communities, the programme has since been expanded to pull staff from clinical and medical roles through into leadership jobs.

This has long been a focus for McManus. “When I arrived here in 2017, one of my key aims was to see our senior clinical body and our senior medical body re-engaged with the life of the organisation and our senior decision-making, through their taking formal roles in our management and leadership structure,” he recalls. “We now have a really strong pipeline of colleagues in that space.”

Asked about Labour’s plans to regulate managers’ professional standards, McManus points out that his trust operates a “leadership behaviours framework” that essentially operates as a code of practice. “People really engage with that, because it’s seen as a positive aspect of how we professionalise leadership and management,” he says, noting that regulation could help promote this professionalisation agenda. So he’s a supporter: clinical staff already operate under statutory regulation, he adds, “and I think managers and leaders should have the same standards applied to them as other regulated professions”.

An ‘attractive, permissive environment’

Such regulation must, however, “create a really attractive, permissive environment” for managers – providing would-be NHS managers, chairs and non-executive directors with another reason to join the profession, rather than another risk to avoid. “Regulation can be seen as a way to support the drive for high-quality management and leadership, professionalising it,” says McManus. But it could also be seen as yet another stick with which to beat NHS managers.

If regulation is developed and presented “with a view of, ‘we’re going to regulate out the bad apples; we’re going to regulate out the incapable,’ without balancing that with development and support, then that will create a hugely negative context and risks driving out talent,” McManus argues. The danger here is that regulation could hit the recruitment of both managers – including from among the clinical workforce – and non-executive directors. “We are hugely reliant on our non-executives within statutory organisations, and they play a massively important role,” he says. “There is a risk, if that balance isn’t managed, that we don’t have that pipeline of talent from outside the NHS coming in to support the work that we do.”

Trust leaders have a crucial role to play in attracting high-potential people through into NHS management roles. “Nurturing that talent, creating the right set of cultural conditions within organisations: that’s my responsibility as the chief exec,” he says. “We should not be looking to government or NHS England nationally to help create the right cultural conditions in our organisations — that’s our job. Clearly there are challenges in terms of resource and all the rest of it, but we hold that responsibility.”

To create those positive, attractive environments, however, local managers need the support of national bodies — whose activities can either help that work or undermine it. “What government and NHS England — nationally and regionally — have a unique ability to do is to create language which is positive and supportive,” McManus comments. “Language about ‘too many managers’ and ‘poor management capability’ — language which is about the stick of regulation, not the support of regulation — is a real risk in terms of not creating the right conditions.”

“If we get that balance right, I think there’s a real opportunity over the next five years or so to ensure that we’ve got the right management and leadership capabilities in the NHS,” he concludes. “If we get it wrong, we may well find a challenge in terms of the pipeline of talent that we want to bring in.” //