Chief nurses are not opposed to accountability for managers and leaders – but they think the government has designed the wrong system.
This article was first published in the Health Services Journal.
Comment piece by FNF’s CEO Professor Greta Westwood and FNF’s Head of Policy and Influence Dr Lisa Plotkin
For the first time, it is proposed that the NHS in England will regulate NHS managers – both clinical and non-clinical – starting with the most senior roles. After Mid Staffordshire, East Kent, and the Countess of Chester scandals, no one wants to see senior leaders walk away from failure and quietly re-emerge somewhere else. The proposed statutory barring system is meant to stop that from happening.
However, when chief nurses and executive nurse directors from across the system came together recently at a Florence Nightingale Foundation (FNF) roundtable to discuss these plans, many left uneasy – not because they want less accountability, but because they believe the proposed model risks creating more confusion, more blame, and ultimately less safety.
Nobody in the room argued that senior leaders should be able to commit serious misconduct and then move on untouched. As one chief nurse put it: “We have all seen people come back through the door and thought, how on earth are they back here?”
But support for the goal does not mean support for any system that claims to deliver it.
The current proposals will initially apply to only NHS England integrated care board and trust board members and their direct reports. On paper, this sounds sensible. In practice, this misses where a lot of the risk sits.
In most NHS organisations, the decisions that shape safety day to day are made in divisional and directorate teams who decide staffing levels, balance budgets, and choose whether to act on frontline warnings. Many of these people will sit outside the scope of the new scheme.
At the same time, the design of the regulation ignores power further up the chain. National bodies and the Department of Health and Social Care set the targets that drive behaviour locally. As one chief nurse pointed out, Mid Staffordshire was not just a local leadership failure; it was also about a national push for Foundation Trust status and meeting financial targets at almost any cost.
Leaving the most senior, national leaders outside the scope of regulation does not just weaken reform — it signals that those at the top are exempt from it.
Dual regulation is risky
What worried chief nurses most was the idea of being regulated twice.
Clinical leaders are already professionally regulated. Adding a second regulatory regime on top opens the door to double jeopardy, where the same set of events can trigger two investigations and two sets of sanctions. That means duplicated evidence, repeated interviews and longer, more stressful processes.
It also creates incoherent outcomes. Someone could be barred as a manager but still allowed to practise clinically, or struck off professionally, but not barred from a senior management role. From a public safety point of view, that makes little sense.
Using regulation as a stick while starving the system of support would be a familiar NHS mistake — punishing failure without tackling what causes it.
Several leaders also raised a deeper concern about who would be regulating this. Under the current proposal, the Health and Care Professions Council (HCPC) would be asked to judge the conduct of nurses and midwives as leaders, despite having no remit to regulate nursing and midwifery practice. They worried that HCPC would be forced to interpret complex clinical and professional decisions through generic managerial frameworks – and that, when harm occurs, it would fall back on familiar and often simplistic narratives about nursing failure.
This matters because nursing and midwifery already bear a disproportionate share of accountability in the NHS. Nurses are the most visible at the point of care, even though the risks they manage are often created by upstream decisions. A second, non-specialist regulator would likely reinforce that distortion.
A better way
The government will soon publish the new NHS Management and Leadership Framework, developed by NHSE with partners including the FNF. This framework sets out, for the first time, a unified Code of Practice and standards for leadership and management across clinical and non-clinical roles.
Clinical regulators such as the Nursing and Midwifery Council (NMC) should be required to adopt these standards into their codes of practice. Leadership failures would then be assessed as part of fitness to practise, with consequences that prevent individuals from holding senior NHS roles.
The new statutory barring scheme should then apply only to non-clinical managers.
This creates one set of standards, embedded in existing structures, rather than layered on top. It addresses the real gap – that leadership and management are not currently regulated in their own right – without creating duplicate regulation for those who already answer to a professional body.
If ministers really want safer leadership, they will need to fund the things that make it real: development pathways, meaningful appraisal and professional review, and time for leaders to build the skills the framework demands. Using regulation as a stick while starving the system of support would be a familiar NHS mistake — punishing failure without tackling what causes it.
