Since Labour’s election victory in July, we’ve heard regularly that there will be no more money for the NHS without reform. After an injection of cash in October’s Budget, the NHS knew the first of these reforms would soon follow. Health secretary Wes Streeting duly delivered two weeks later, setting out the first package of what he described as “tough” reforms. While nowhere near on the scale of what’s expected in spring’s ten year plan, these reforms are still wide reaching and will have a significant impact on managers and leaders. That they were announced during a speech to healthcare leaders at the NHS Providers annual conference gives an indication of the intended audience.

In his speech, the health secretary made a point of reassuring NHS managers that he won’t bash them for the sake of it, telling his audience that they can “expect a grown-up break from the past” and that he’s “prepared to make an unpopular argument with the public about the value of good leaders”.

These sentiments might have gone down much better if Streeting hadn’t trailed his speech with talk of “rotten apples” and threats to “sack failing managers” in the media.

As part of his reform package, the health secretary announced key changes to very senior manager (VSM) pay — confirming that the long-awaited new pay framework would be published by April 2025. MiP believes the current VSM pay framework is well out of date. It has significant overlap issues with Agenda for Change, and the only metric used to determine the pay range for senior leaders is the financial turnover of their trusts.

Under the new framework, pay will be linked to performance. Senior managers deemed to be failing will be barred from pay rises, while those performing well will be rewarded. At this stage, it’s not clear how performance will be measured, but the health secretary has said the trust’s levels of both patient care and financial discipline will be taken into consideration.

MiP thinks accountability is the key question here: Put simply, what’s down to the personal performance of the manager and what’s down to the system and policy? The government risks blurring the two, achieving nothing more than giving people another reason to leave or not become a manager in the first place. The framework needs to be able to value a manager in a struggling organisation who may be cutting the deficit while keeping more staff and upholding care standards.

Regional variation in demand, the complexities of care required and available staff could all play a role in performance. If such factors are not taken into consideration, it will become impossible to convince talented managers to take on roles in struggling organisations.

The devil will be in the detail, but the principle of updating VSM pay is welcome. By engaging with MiP and other health unions, there is a lot the health secretary can get right here.

If you thought low rise jeans and Oasis were the only things making a comeback from the year 2000—think again. Former health secretary Alan Milburn is back in Victoria Street and he’s brought his league tables with him.

Providers are once again to be ranked in order from best performing to worst in a very public league table. The NHS Oversight Framework, which sets out how trusts and ICBs are currently monitored, will be updated by April 2025, with the first tables being published around the same time.

Streeting says senior managers in the best performing trusts will be rewarded with more autonomy and freedom over budget surpluses. Managers in the worst performing organisations will face more central oversight, less financial freedom and could be sacked.

The NHS already has vast amounts of performance data available to the public; in reality, since they were introduced by the last Labour government nearly 20 years ago, league tables have never gone away. It’s the throwback to the ‘name and shame’ culture of the time that is causing concern among NHS leaders.

It is right for the NHS to use performance data to improve standards, identify failings and allocate support. But naming and shaming will only serve to demoralise, not only managers, but staff throughout the organisation. And while it’s unlikely the public will bother to check how their hospital is doing in the league before a trip to A&E, there’s a risk that it will gradually erode patient confidence. If a trust’s services are exemplary but it is ranked low purely because it runs a deficit, is that really something patients need to take into account?

It is impossible to create a framework that takes into consideration every nuance of hospital performance. A struggling trust could be facing staffing shortages, financial constraints and overwhelming demand. Yes, this should be identified, but the instinct should be to support the leadership to turn things around, not to publicly humiliate.

It may also prove counterproductive to the health secretary’s admirable aim of getting the best leaders to take on most struggling trusts. With plans to link pay to organisational performance and restrict managerial freedoms in struggling organisations—why would any leader take that personal risk?

If league tables are the stick, then management professionalisation must be the carrot. Amanda Pritchard has set out plans to develop a new NHS management and leadership framework with a single code of practice, set of competences and national curriculum. Implementation is expected to start in summer 2025. She appeared to confirm that it will be mandatory—“it won’t be an option”, she said—and linked the framework to the statutory regulation of managers.

Streeting has also announced a new college of executive and clinical leadership to “train and develop excellent NHS leaders”. Sir Gordon Messenger will be brought back to advise on the leadership and management needed for the ten year plan.

Although it wasn’t mentioned in this speech, Streeting has subsequently announced a consultation on statutory regulation for managers. MiP supports moves to develop and professionalise management and believes that managers themselves should own their professional standards.

Both Streeting and Pritchard agree, for now at least, that no one wants another major reorganisation. But they do want more clarity about which parts of the system do what.

Streeting wants to move to a system where “freedom is the norm” and central grip would be limited to poorly performing providers. NHS England, not ICBs, will be responsible for performance managing trusts to let ICBs focus on strategic commissioning.

On first look, Labour’s NHS reform agenda is certainly a mixed bag. No one knows their local health systems better than the managers working in them and more autonomy and freedom will go a long way in the right hands. Releasing the grip of central oversight could enable more managers to look out rather than up. But the rebrand of league tables could result in organisations focussing on the arbitrary metrics needed for a higher rank, not necessarily better standards of care.

It seems Streeting is starting to understand that he will need the support of managers if his reforms are to have the desired effect. But when he says he won’t bash managers for the sake of it—he must stay true to his word. Darzi was clear in his analysis of the state of the NHS: it was not that there were too many managers, but too few. Let’s not attempt to rewrite this story. //