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The Report
Volume III
Part Two
Chapter 37

Chapter 37. Training and regulation of managers

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Chapter 36
The NHS
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Chapter 38
Duty of candour

Contents

Managers in NHS Trusts

  1. The pressure on the NHS now is probably greater than it was in 2016. Between then and now, the NHS has faced, and only just survived, the pandemic.1 The pressures on many staff – clinical, management and otherwise – remain relentless. The population is ageing, rates of obesity are soaring. There is a shortage of doctors and nurses.
  2. General Sir Gordon Messenger, co-author of the independent report Leadership for a Collaborative and Inclusive Future2 (the Messenger/Pollard report), said in evidence that the NHS workforce faces “eye-watering pressure”.3 He said that people are working very hard, with a reduction in investment in managers and too many people working too hard with little support. It was his opinion that there were some very good leaders in NHS hospitals. He also said that there are too many people who reach the top of the NHS without having the proven credentials or skills. At the same time, there are people within the NHS who do have the necessary skills and abilities to lead but who do not get to the top because they do not get the opportunity. Lord Darzi conducted a rapid review of the NHS in 2024.4 He acknowledged the generally held view that there are too many managers in the NHS, but considered: “The problem is not too many managers but too few with the right skills and capabilities.”5 It may be that both statements are true. No one could argue with the proposition that the NHS needs but does not have sufficient managers with the right skills.
  3. I refer in this chapter to chief executives and board-level directors in NHS Trusts as senior managers. I acknowledge that there is an element of leadership in many management roles at all different levels.

Core purpose of a hospital

  1. In the multiplicity of mission statements, statements of values, visions etc emanating from all corners of the NHS and elsewhere, it is easy to lose sight of what a hospital is for. Stripped to its essentials, the core purpose of a hospital is to diagnose accurately and treat effectively patients with illnesses, conditions and diseases, and to care for those patients with kindness and respect. Discussion between doctors/nurses and patients about appropriate treatment is part of effective treatment and respect. The need to keep patients safe is fundamental.
  2. The purpose of a neonatal unit is to look after and, where necessary, treat babies who need more care than is ordinarily available in a post-labour ward. From the evidence to the Inquiry and from the public discourse, it is plain that parents want to be in partnership with the doctors and nurses, and expect to be – and should always be – consulted about the nature and duration of any treatment of their baby and kept informed of the baby’s condition and progress. They, too, as well as their babies, should be treated with kindness and respect. A range of healthcare professionals provide diagnosis, treatment and care throughout the hospital.

Senior managers’ responsibilities

  1. For many years, much management time in the NHS was taken up with the workings of the NHS internal market. First introduced by the National Health Service and Community Care Act 1990, this separation of health service purchasers (commissioners) from providers (hospitals) was intended to introduce competition, efficiency and patient choice. It continued to be developed as a model for the NHS up until the Health and Social Care Act 2012. These requirements are now significantly reduced.
  2. Fundamentally, the role of the senior managers in a hospital is to make sure that the core purpose of the hospital is achieved. It is the responsibility of senior managers to make sure that those whose direct responsibility it is to treat and care for the patients (doctors, nurses and other healthcare staff) are sufficient in number and suitably qualified, and have the tools to diagnose, treat and care for patients. In brief, senior managers are responsible for the provision of clean and well-maintained buildings, properly equipped wards, operating theatres, medical supplies and administrative support, and must deal with problems that have an adverse impact on those core functions. This requires, particularly for the most senior managers and leaders, close collaborative working with clinicians, involving strategic thinking, planning, obtaining sufficient funds from NHS England or elsewhere, identifying projects which require fundraising, careful stewardship of the hospital’s financial resources, assessing priorities, leading improvement (digital and otherwise), leading teams, innovating, and making sure that the hospital is fit to meet its core purpose, both now and in the future. I acknowledge that this is an oversimplification of a complex role that is more than the sum of the tasks and outcomes. In addition, hospital senior managers must raise their heads above the hospital for which they are responsible, and consider and contribute to the broader NHS, for which senior managers within NHS England are responsible.
  3. Decisions on how to spend (or save) money are difficult. The non-executive directors included accountants, and people with experience in business. The annual reports of the Countess make plain that there was a strong emphasis on finance.6
  4. Sir Rob Behrens, former Parliamentary and Health Service Ombudsman, said in evidence that the Kirkup report on East Kent and the Ockenden report on Shrewsbury and Telford NHS Trust have shown unpleasant working environments where staff do not feel leaders respect what they are doing. He pointed out that “they don’t feel that leaders actually have respect for what they are doing” and “the issues about staff welfare and about the culture of organisations have taken second or third place to issues around productivity, finance and staffing and while that is understandable, it’s not acceptable”.7 He suggested that the way to make people feel more valued comes down to leadership, resources and regulation.
  5. Whilst being good at securing and controlling the money is an essential consideration when running any hospital, it is not the only one. A sound understanding by senior managers of what the people working in the hospital (doctors, nurses and all involved in clinical care) actually do – and why – is also essential. Without it, there can be no real collaborative working, which is essential for making properly informed decisions about spending. This should be part of management training (see below, paragraphs 37.20 to 37.23) and, consistent with this, every NHS Trust board should have amongst its non-executive directors at least one qualified doctor and one qualified nurse in addition to at least one of each profession as Executive Directors. Both Dr Gilby, who took over from Mr Harvey as Medical Director and then from Mr Chambers as Chief Executive in 2018, and Ms Tomkinson, who took over as acting Chief Executive initially in 2022, and substantively from 2024, considered there should be senior clinicians on the Board.8 I would add that there should be respect as between the different professions and between the professions and the managers. There is no place for unquestioning loyalty to your team.

Recruitment

Doctors

  1. The standards for the qualification and recruitment of doctors are very exacting. High academic achievement, often an aptitude test, a proven record of volunteering and a demonstrable interest in health or social care are the minimum standards expected for entry to medical school. The competition is fierce. The same is true for the postgraduate medical degree. The university courses are demanding and lengthy (between four and six years). After that, the newly qualified doctors work for two ‘foundation’ years as resident doctors somewhere in the UK. Next, if they can secure a post, they embark on a training programme that lasts between six and ten years. If successful, they will become first a registrar, then a senior registrar, and ultimately a consultant. Leaving aside the question of shortages of training places and consultant posts, which is outside the scope of this Inquiry, it is sufficient to say that not all resident doctors will obtain consultant posts, notwithstanding about 15 years of training.

Nurses

  1. Nurses are generally expected to hold a degree in Nursing, as was the case at the Countess. Such a degree takes three or four years and its entry requirements include three good grades at A level and five GCSEs. Nurses in the NHS are expected to work shifts (including at night), to attend courses and to acquire specialist skills in order to progress.

Recruitment and training of managers

  1. There is an NHS graduate management training scheme. It is acknowledged to be excellent and attracts good candidates.9 This would be expected to produce very good managers and leaders over time, and I was told it does.10 It is open to graduates with a 2.2 degree in any subject.
  2. Until now, there have been 250 places a year on the NHS graduate training scheme, divided into various specialisms and areas of management.11 There is stiff competition for places. The training takes two years, during which the trainee is paid, and is expected to study outside of working hours. All materials are paid for by the NHS. The 10 Year Health Plan for the NHS launched in July 2025 has promised an increase of 50% in the number of training places on this course.12 That is to be welcomed. A job in the NHS for those completing the training is assured.
  3. Other routes into management are available and well used. Many doctors have management roles at different levels. Some become medical directors and a few chief executives. Many nurses and some midwives also move up to board level, including becoming chief executives, with varying amounts of financial and other support and training from their employers. I note that the Royal Berkshire NHS Foundation Trust now has 150 staff members accredited through the Chartered Management Institute’s Chartered Manager scheme.13 Mr Chambers’ path was not untypical. He trained as a nurse at Bolton College (before nursing was a degree-only profession). He nursed for a short period, then took a degree in Media and Communications and a postgraduate diploma in Health Services Management, before becoming a hospital bed manager. He subsequently took on further and more senior management roles and eventually was appointed Chief Executive at the Countess. Over the years, he attended a number of professional development programmes run by the NHS.
  4. Professor Judith Smith is Professor of Health Policy and Management at the Health Services Management Centre at the University of Birmingham. She has worked in health services, research, evaluation and development since 1995. Prior to that, she had been a senior manager in the NHS, having undertaken the NHS graduate training scheme.14 She expressed the view that those who step onto the management ladder other than from the graduate training scheme do not receive the same quality of training as those on the scheme. In particular, she pointed to the lack of opportunities to work in different areas and the lack of networking available compared with those on the graduate training scheme.15 Leaving aside whether, as Professor Smith explained, that is unfair to the trainees, if the outcome is that the non-graduate-scheme trainees are less well trained, and likely to be less good at what they do, this is detrimental to the NHS. It may also lead, as Sir Gordon identified, to talented people not reaching higher-level management16 – which is not good for the NHS and, ultimately, its patients.

Succession planning

  1. The evidence from Sir Gordon and others was that the NHS is not good at identifying and developing future senior managers.17 There must be a clear-eyed commitment to recruiting the best and then training them appropriately. Academic qualifications do not equate automatically (or sometimes at all) to the ability to manage and lead. As an NHS user and from the evidence heard during this Inquiry, it appears to me that any prospective senior manager must be able to demonstrate the ability to think analytically, to think and work strategically, to understand organisations and finances, to always be looking for ways of improving how things are done, to innovate – and, importantly, to get things done, including complex technology/digital programmes. At all levels, managers will need to be inspirational leaders, of small and then larger teams, progressing as they gain experience. These attributes should be assessed over time. If managers in the most senior roles in a hospital are not up to the job, there will be no respect, no collaborative working and resentment. All of this destroys morale. It is imperative to recruit able people, train them properly and retain them.
  2. There has to be a well-understood route to identifying and bringing on people of ability. This will include significantly increasing the opportunities for potential managers who do not arrive via the graduate training route, while ensuring that there is no decrease in opportunities for those on the graduate training scheme. It is all about providing the best managers in the interests of patients.
  3. Where doctors and nurses take on management roles, they, too, ought to receive good-quality training. Dr Brearey made the point that he received none in his risk management role on the neonatal unit (nor was the 25% protected time for management a reality). This was the common position in many of the professions for decades, but it is not the position now, and it should not be the position in the NHS either. I understand that it is expected that the provision of the NHS Leadership Academy will be expanded. I note that in two NHS regions there are two NHS leadership schemes.18
  4. All doctors and nurses, irrespective of their management ambitions, should have a basic education in the workings of the NHS, how it is funded and, at least in their workplace, who does what. This should be part of the undergraduate training – and subject to examination. Continuing professional development should include this. This, too, will improve cohesion and collaboration.
  5. All non-clinical managers should receive training about what the doctors, nurses and other health professionals in the hospital do, how they do it and what challenges they face. As I have said already, this understanding is fundamental to effective team working.
  6. Effective and practical joint training should be provided to clinically qualified and non-clinically qualified managers and potential managers. With good will, this would bring down barriers between managers from different backgrounds and increase levels of trust.
  7. Since references to ‘them and us’ attitudes continue to persist when people talk about the NHS, effective training must be directed towards changing the behaviours that perpetuate those divisions. It should be unthinkable that, as happened at the Countess, when a department is under strain, the nursing managers should turn on the doctors. The reverse would be equally unacceptable, as would managers turning on nurses or doctors and vice versa. The training will be successful if it is clearly demonstrated to be well thought through, capable of being effective and well delivered. It would have to be compulsory.
  8. Sir Gordon suggested that there should be an induction guide for every new manager joining the hospital.19 He also underlined the importance of putting an “organisational arm around” the shoulder of the new recruit.20 I would suggest that, if such a guide proves to be useful to new recruits, it ought to be offered to all existing members of staff. It does no harm for staff to know what the new recruits are being told and to be reminded of what their hospital is all about. The purpose of the exercise would be to inform individuals and to improve cohesion: everyone receives the same message. As Sir Gordon put it, the message to the new recruits is that you are “embarking on a profession that matters a great deal to the organisation”.21 That message should be given to all those working in the organisation, not just new managers. It should remind everyone of their common purpose, a statement that each individual is doing something important that matters to the NHS and the patients being cared for. It is about being part of something that matters.

Regulation

  1. Doctors are regulated by the GMC and they are subjected to full revalidation, which is an onerous process, every five years. The regulator is funded by the doctors. Where a doctor is found to have committed serious misconduct, they are liable to disciplinary action, including dismissal, and to being referred to the GMC, where they may be found unfit to practise and so erased from the register. This prevents the doctor from pursuing their chosen profession anywhere in the UK.22
  2. Nurses are regulated by the NMC (for which they pay a fee) and are required to renew their registration (currently described as revalidation; see Chapter 18) every three years. In the case of serious misconduct, a nurse is liable to disciplinary action within the Trust, including dismissal, referral to the NMC, and removal from the register. This prevents the nurse from pursuing their chosen profession anywhere in the UK.23

Regulation while in a management role

  1. Both nurses and doctors who move into management remain subject to regulation by their professional bodies when carrying out their management roles, as well as when carrying out their clinical roles. Managers who are not clinically qualified have never been regulated.
  2. There is some law on the question of the extent of the applicability of Good Medical Practice (the code of conduct for doctors) when a doctor is acting in a managerial capacity or in the fulfilment of any managerial function they might have. In Roylance v GMC [2000] 1 AC 311, the Privy Council held that a doctor, who had been the Chief Executive of the Bristol Royal Infirmary, was liable to be erased from the profession for failing to respond appropriately to concerns that had been raised about increased infant mortality in the performance of cardiac surgery, irrespective of the fact that he himself had not performed any of the care under scrutiny.24
  3. Sir Robert Francis referred to this case in his oral evidence. He stated:
    “[T]he sad thing is that if a doctor is brave enough to become a Chief Executive of a Trust and acts in a way which is contrary to the patient’s interests, the GMC can, and occasionally has — it happened to the Chief Executive of Bristol being hauled up before the General Medical Council for their conduct as the Chief Executive because they will be involved inevitably in a breach of the Code of Conduct of a doctor. There is … no such procedure for the non-clinical manager and the result I’m afraid is that people who haven’t done terribly well, one way or the other, may leave one job. You will then find they crop up in another job because there is no overall certification as to whether someone is a fit and proper person at any given time to do these roles.”25
  4. The decision of the High Court in R (on the application of Remedy UK Ltd) v General Medical Council [2010] EWHC 1245 (Admin) was that there are some roles that are so far removed from practising medicine that the GMC’s fitness to practise procedures do not apply to them. However, it points out that medical professionals are still accountable to the GMC when they are performing a wide range of clinical management roles (for example, as a Clinical or Medical Director) or other non-clinical roles (for example, as a medical educator or researcher), even if medical knowledge or expertise is not needed for the roles (for example, as the Chief Executive of a hospital).
  5. Thus, where, for example, the Chief Executive (non-clinically qualified) of a hospital and the Medical Director both fail to act upon concerns about mortality in the hospital, only the Medical Director is subject to regulatory action. It is easy to understand why the current state of affairs is considered by many to be unfair. It is worth pointing out that, whilst the unfairness to the individuals is obvious, it is ultimately unfair to patients.

Unregulated managers

  1. Those managers who are neither nurses nor doctors are not regulated. Part of the reason for this is historical. I heard evidence from Mr Ken Jarrold CBE, a health service manager and the Chair of the working group that produced the Code of Conduct for NHS Managers. Now retired, he had vast experience of management within the NHS over decades. After graduating with first-class honours from the University of Cambridge, he joined the NHS in 1969 as an administrative trainee. He went on to hold increasingly senior posts and lived through the changes in posts from administrators, to general managers (after the Griffiths report – NHS Management Inquiry),26 and then to leaders. He had been part of the system when competition and the internal market were introduced and when there began to be greater recruitment from outside the NHS. He was an impressive witness who had deep experience and understanding of the NHS. He explained that management, unlike nursing and medicine, is not a profession.27 There are no necessary qualifications, no professional body, no code of conduct and, in most places, including the NHS, no regulation. It follows that, until now, there has been no difference between being a manager in the NHS and a senior manager or leader of a company, listed on the FTSE 100 or otherwise. Their work and conduct is governed by their contracts of employment. The same applies to non-clinically qualified managers in the NHS.

Accountability and regulation

  1. The Terms of Reference require me to consider whether, and if so how, the accountability of senior managers should be strengthened. One very effective way of improving accountability is to regulate. The question as to whether to regulate managers has been considered, ignored and reconsidered for decades.28 Scores of recommendations have been made and mostly ignored.
  2. The report of the inquiry into Bristol Royal Infirmary (the Bristol report) made comprehensive recommendations about the regulation and oversight of NHS managers in 2001.
  3. Recommendations 39, 70 and 91 called for the regulation of staff, the formalisation and standardisation of training, and continuing professional development.29
  4. Since 2001, far-reaching action has been taken in respect of clinical staff:
    • The GMC and Postgraduate Medical Education and Training Board merged in April 2010 to create a single regulatory body overseeing all stages of medical education and training.
    • Doctors’ revalidation was introduced in December 2012. This process is considered the gold standard for professional revalidation.
    • The civil standard of proof now applies in fitness to practise cases, and there is increased lay involvement in the regulatory process.
    • Education standards for nurses changed in 2009 and revalidation (in fact, renewal of registration) was introduced in 2016.
    • Professional standards for clinical staff have been updated to reflect learnings from reviews and inquiries.
  5. The Bristol report’s recommendations in respect of managers, although accepted over two decades ago, were not acted upon – in particular, the recommendations that there should be a senior managers’ professional body (70)30 and that managers’ regulation should be aligned with that of healthcare professionals (39, 91).31 Even the current government proposals on regulation, to which I refer below, do not come near to meeting these important recommendations.
  6. Recommendation 91 of the Bristol report stated: “Managers as healthcare professionals should be subject to the same obligations as other healthcare professionals, including being subject to a regulatory body and professional code of practice.”32
  7. DHSC responded at the time (20 years ago): “We agree in part. We do not think it is practical to establish self-regulation for senior managers. We do agree that the standards expected of senior NHS managers should be explicit. We favour a code of conduct, stronger performance management and tighter contracts rather than regulation.”33 All three of those matters – code, stronger performance management and tighter contracts – remain necessary, and the first is in its early stages (see paragraphs 37.92 onwards below).
  8. Following publication of the report (in July 2001) and the government response (in January 2002), Mr Nigel Crisp KCB (later Lord Crisp), then Chief Executive of the NHS and Permanent Secretary to the Department of Health, asked Mr Jarrold to write the code of conduct for senior NHS managers. Mr Jarrold was the right person to be invited to produce this. He did so having brought together a working group that included representatives of the British Association of Medical Managers, an organisation which, Mr Jarrold said, did excellent work in preparing clinicians for management roles.34
  9. The code of conduct was launched in October 2002. The following are the central points:
    “As an NHS manager, I will observe the following principles:
    • make the care and safety of patients my first concern and act to protect them from risk;
    • respect the public, patients, relatives, carers, NHS staff and partners in other agencies;
    • be honest and act with integrity;
    • accept responsibility for my own work and the proper performance of the people I manage;
    • show my commitment to working as a team member by working with all my colleagues in the NHS and the wider community;
    • take responsibility for my own learning and development.”35
  10. Simultaneously, Mr Crisp launched a wider piece of work, Managing for Excellence in the NHS. Mr Jarrold commended the work, which expressed strong support for the code, management development and management standards.36 He considered at the time: “[I]f we are going to help managers to behave differently and better, then we have to address the fundamental issue from the Kennedy [Bristol] Report.”37
  11. Mr Jarrold informed this Inquiry that the text accompanying the code stated it should be incorporated into the employment contracts of all senior managers at the earliest opportunity and that systems should be in place to fairly investigate any breaches of the code. This did not happen – and the NHS, as Mr Jarrold put it, became “consumed with the awfulness of Stafford”.38 As so often, the NHS moved on with business unfinished. Some 25 years have passed since then.
  12. The code of conduct drafted by Mr Jarrold is clear and simple. It does not include reference to diversity, to candour or to the Nolan principles, all concepts that were not specifically recognised 25 years ago and could easily be added to the code as drafted, together with a section on the need for reflection. I am not persuaded that anything more elaborate is needed by way of a code of conduct for managers of all backgrounds, clinical or otherwise.
  13. Mr Jarrold’s aim in writing the code was to make it clear that every senior manager should be able to say: “I will make the care and safety of patients my first concern and act to protect them from risk and to put that ahead of personal interest, the reputation of the organisation, or protecting colleagues.”39 This is an apt, succinct expression of what is required of a senior manager and of managers at all levels in the NHS.
  14. Recommendations 43 to 47 of the Bristol report spoke to the need for staff to be held to codes of conduct.40 As before, although progress has been made with clinical staff regulation, the recommendations call for all staff, including non-clinical staff, to be held accountable through codes of conduct and contracts. After 25 years, there has been very recent movement on that.
  15. Recommendations 57 to 68 call for the recognition of non-clinical skills and for education in these skills.41 This includes investment in developing leadership skills, all clinical staff having education in management, and funded training. The government agreed to these recommendations. Some action was taken – for example, the publication of the NHS Leadership Qualities Framework in 2002. But we know from the Messenger/Pollard report and the work of Lord Darzi that, 20 years later, these skills are still often lacking. A new framework was produced in September 2025 in response to those reports. I deal with that below.
  16. There are also recommendations in the Bristol report for a standard approach to the induction of non-executive directors and training for leaders (52–54). There was agreement that an NHS Leadership Centre would work on this. The focus of the NHS Leadership Academy is said to be on helping “everyone in the NHS discover their full leadership potential”.42 Unsurprisingly, NHS England and DHSC recognise that more is needed here; most recently, the 10 Year Health Plan acknowledged that the NHS has “become less appealing to, and less able to retain, world-class leaders”.43 The government’s latest position, also included in the 10 Year Health Plan, is that it plans to establish a College of Executive and Clinical Leadership.44

Fit and proper person test

  1. Sir Robert Francis sought views on options for regulating NHS managers and introducing a professional duty of candour in 2013. He also recommended a fit and proper person test,45 which was introduced by Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This came into force on 27 November 2014. It was intended to ensure those individuals who have authority in organisations that deliver care are responsible for the overall quality and safety of that care, and can be held accountable if standards of care do not meet legal requirements.
  2. The application of the fit and proper person test was reviewed in 2019 by Mr Tom Kark KC, co-author of A Review of the Fit and Proper Persons Test (the Kark Review), with a particular focus on the skills, competence and qualifications required of directors and the absence of a power to disqualify. In his enlightening and helpful evidence to this Inquiry, Mr Kark referred to some Trusts having a dearth of applications, such that the skills and competence requirement for the post of director “became something of a sliding scale” with “no benchmark”.46 Regarding the lack of a power to disqualify, Mr Kark referred to situations where, as part of a settlement agreement, a Trust would provide an anodyne reference, thus avoiding expensive disciplinary hearings, but creating a problem for a future Trust.47 The Kark Review recommended the extension of the fit and proper person test to board-level leaders.48 Nothing was done about Mr Kark’s recommendations until a Fit and Proper Person Test Framework was introduced by NHS England shortly after this Inquiry was announced. The framework applies to the board members of NHS organisations and was effective from 30 September 2023.49 In February 2024, the NHS Leadership Competency Framework for Board Members was published. This framework is said to form part of the Fit and Proper Person Test Framework for board members.50
  3. Mr Kark was asked for his views on the Leadership Competency Framework for Board Members.51 He had a number of reservations about it, describing the language in the framework as “very aspirational and frankly a bit fuzzy”.52 He had hoped that there would be more specific competencies for each area of expertise on a Trust board. He also observed that, whilst the framework mentions experience and competencies, it does not specify qualifications. Mr Kark said: “I suggested that there should be … specific competencies or qualifications, that’s what I thought we were going to see. And I think some of this language, as I have said, is either too wordy or quite woolly.”53 I agree with him.
  4. Mr Jarrold made four criticisms of the framework:
    1. “[I]t does not specifically refer to the care and safety of patients being the first concern of managers.”
    2. “[I]t appears to depend on self-assessment and that is obviously limited … any proper appraisal system needs to involve 360 degree feedback from colleagues.”
    3. “Appraisal is often not done well … [s]o to rely so heavily on appraisal worries me.”
    4. “[T]he fitness for practice work is also incredibly wordy.”54
  5. The first point is telling, and is a fundamental flaw in the framework. I am confident that every person who has been treated and looked after by the NHS – that is, almost everyone – would agree that the care and safety of patients should be the first concern of managers, as it is for nurses, doctors and other healthcare professionals.
  6. When dealing with the Leadership Competency Framework for Board Members in his written evidence, Sir Stephen Powis wrote: “NHS England expects … greater achievement across the competency domains over time.”55 In other words, it was expected that performance against the framework would improve. Professor Dixon-Woods thought it was too early to assess its impact.56 Whilst I acknowledge that, having spent so long devising a process, it would be reasonable to give it time to bed in, it is not clear to me how the absence of the fundamental duty could be remedied without the process being revised to include it, as was plainly necessary.
  7. Be that as it may, after the Inquiry evidence hearings had been completed, a new framework was developed in September 2025. I shall review that while looking at the current proposals on regulation.

Current government proposals on regulation

  1. On 26 November 2024, the government issued a consultation seeking views, not on whether there should be regulation of NHS managers, but rather on how it should be done. I infer that is the intention. In their manifesto document ‘Build an NHS Fit for the Future’, issued before the 2024 general election, the Labour Party said: “Labour will implement professional standards and regulate NHS managers, ensuring those who commit serious misconduct can never do so again. And we will establish a Royal College of Clinical Leadership to champion the voice of clinicians.”57
  2. The consultation in November 2024 sought “views from all stakeholders, including health and care organisations, regulators, professional bodies, health and care managers and senior leaders, the public, patients and other health and care staff”.58 In addition to views on regulating managers, views were sought on the wholly separate issue of introducing for managers a duty of candour, to which I refer in Chapter 38. The consultation closed on 19 February 2025.
  3. The number of responses seems low: 4,907, of which 748 were from individual members of the public (including patients and carers) and 110 from organisations.* Of the rest, 2,815 (57%) responses came from non-managerial members of the health and care workforce and 1,344 (27%) came from NHS managers. Such a low response rate from the public may have been expected if the topic is of interest only to those working in the NHS. I note that the 2024 NHS staff survey received 732,000 responses online and a further 43,000 on paper. Those responses represent half the workforce (which is over 1.5 million people). I bear in mind that the staff survey is sent directly to all staff and it is their opportunity to have their say. If this consultation was sent to all staff, as it should have been, the response rate is disappointing. However, in a statement to Parliament on 21 July 2025, Ms Karin Smyth MP, Minister of State for Health (Secondary Care), said that the consultation had had a “high level of engagement”. Whilst this seems to me a rather generous assessment of the figures out of a workforce of 1.5 million people (and the general public), the number of responses was considered sufficient. Ms Smyth outlined the next steps to be taken by government as follows:
    “Department officials will prepare draft legislation to provide the HCPC [Health and Care Professions Council] with the powers to implement a statutory disbarring regime for NHS managers. When parliamentary time allows, we intend to bring forward this legislation, which will be subject to a further public consultation. We will continue to engage with stakeholders throughout and we will work closely with NHS England to ensure alignment with the wider work underway to develop and professionalise NHS managers and leaders.”59
  4. According to the consultation document, concerns remain about managers’ accountability when things go wrong.60 This is correct. This reality underlies the Term of Reference requiring me to consider whether accountability should be strengthened. I have no doubt that it should.

Failure to deal with poor performance and the revolving door

  1. There is a widespread view that NHS managers have no real accountability. I have heard and read enough to know that there are some excellent managers in the NHS.61 However, it is inescapable that there is a culture of avoiding dealing with poor performance. I suspect that this avoidance is the result of three factors:
    1. The shortage of staff at all levels (clinical and managerial) means that everything is done to keep people in post.
    2. The time it takes to performance-manage means that it is not done, and poor performers remain poor performers, in post.
    3. The potential expense in time and money if a decision is taken to dismiss a person means that HR advice is very risk averse.

All three lead to poor management and a degradation of morale within an organisation. The Inquiry questionnaire also sought views of senior managers on regulation (see Appendix 2).

  1. I accept that, sometimes, a Chief Executive may be brought in to deal with an intractable problem, not be given the resources to allow them to resolve the problem, and then be blamed and moved out. Sir Robert Francis pointed to the very high risk of failure in the Chief Executive role. He described it as a job with a high turnover and said: “[T]he easy lever to pull is to blame the Chief Executive.”62 In some situations, as was acknowledged by several witnesses, including Mr Chambers, failing managers would be moved, with the active assistance of NHS England, to an alternative post in a process referred to as rehabilitation. Mr Chambers said it is referred to as ‘the donkey sanctuary’.63 Whatever it was called, it allowed the movement of failed managers into new roles, irrespective of the reasons for their failure. This process is well known inside and outside of the NHS. Sir Rob Behrens said: “Chief Executives or board chairs who have presided over unfortunate events in one Trust have moved to another without there being … appropriate training before they take on something else. And in other professions I don’t think that would happen.”64
  2. Mr Kark informed the Inquiry that “a problem in the NHS … for a very long time” has been the “revolving door of the NHS”. He said: “[W]here people have potentially misbehaved or behaved very badly, they come to a settlement agreement with the Trust to save the Trust the bother of having to go through a full disciplinary process, part of that settlement agreement is a vanilla reference. The director moves on to the next Trust down the road.”65 This state of affairs is accepted with almost a collective shrug of senior shoulders. It should not be tolerated.
  3. The government put forward three options in its consultation document:
    1. Statutory barring system: A list of people who are unsuitable to practise, have committed offences or have been found unsuitable to practise, and a body (the Health and Care Professions Council) legally responsible for complaints, using a code of conduct to consider complaints against.
    2. Full statutory regulation: Administrated through a regulator, a full set of professional standards and a professional register. This is the position for doctors and nurses.
    3. Accredited voluntary register: As (b) above, but voluntary. I think it most unlikely that a voluntary register would be considered acceptable to many. It has already been rejected by government and I would not suggest it should be revived.66
  4. The consultation document set out “implementation considerations”. These are, effectively, ‘reasons not to implement’. Tellingly, the first of these described as a potential “barrier to entry” for some individuals is the “formalisation of training requirements and standards for professions”. This could make recruitment from other sectors “much more difficult and deter external talent from joining management and leadership roles in the NHS”. It could also “potentially be a barrier and/or have implications for ongoing employment of existing NHS managers”. I understand this to mean that there are in the NHS managers who do not meet the standards that ought to be expected of them.
  5. On full statutory regulation, the document sets out:
    • Support must be provided to help individuals meet standards.
    • Transition is needed due to managers’ diverse backgrounds and lack of a common entry qualification.

I shall return to this in paragraph 37.85.67

  1. Implementation considerations include that regulation could increase fear of sanctions.68 I do not accept that regulation could create unnecessary barriers to entry. It may well put off those who do not want to be regulated. We would be unperturbed if would-be doctors or nurses did not pursue their ambitions because they did not want to be regulated. The same applies to would-be managers. The fear of sanctions point is no more persuasive than the barrier to entry point. Doctors, nurses, dentists, lawyers, teachers and accountants are all regulated. People still apply for those roles. There is nothing in this objection.
  2. The third implementation consideration was “managers monitor risks and face challenging decisions to balance patient safety, operational performance, and financial sustainability”, and regulation may increase risk aversion.69 The same point can be made about the practice of doctors, where exquisitely difficult clinical judgements have to be made with huge consequences for individuals (the patient and the doctor). It is a reason for the regulation of doctors, not against it. The same applies to managers.
  3. The fourth implementation consideration was that central regulation could reduce the need for local oversight and use of local performance management, encouraging referral rather than local resolution.70 This is about the mechanism of regulation, not whether it is a good idea. It is not clear to me why the fact of regulation would remove oversight or local performance management. They would run in tandem with whatever systems support regulation.
  4. The fifth implementation consideration does not require lengthy thought. The risk of spurious complaints is there, irrespective of whether people are regulated.71 It is not a reason not to regulate. The key is to spot and dismiss the spurious complaint speedily.
  5. The consultation document also said that there would be dual regulation issues for managers with clinical qualifications.72 There are ways of dealing with those issues; the one I would favour, which has been suggested several times before now, is that there should be a common code of conduct for all managers. Whichever way that question is resolved, it is necessary that all managers be regulated, not just those who are clinically qualified and subject to codes of conduct.

Summary of the consultation responses and the government’s response

Consultation responses

  1. 92% of respondents agreed there should be regulation. There was some variation as to the preferred method, but overall the majority of respondents wanted:
    • managers who commit serious misconduct never to hold a management role again, citing examples of unfit managers being moved between NHS roles currently
    • NHS managers to be standardised to improve professionalism and trust and bring non-clinical managers in line with clinical professionals
    • education and training to be available, accessible and an ongoing requirement for managers
    • skills and competencies for NHS managers to include general management, people management, coaching and development of others, operational delivery (managers should understand the systems and structures related to their role, effective governance, meeting targets and quality assurance procedures), financial knowledge and skills (budgeting, balancing costs and saving money are all important for NHS managers), the ability to receive feedback, and the importance of understanding clinical services and patient safety and engagement.73
  2. The 4% who disagreed with regulation commented on the risks of overregulating and the need for proportionality, and the fact that learning and development opportunities are more likely to have an impact on quality of management than regulation is.

Government response

  1. In its response to the consultation, the government expressed its intention to introduce a statutory barring system for board-level directors and their direct reports within NHS bodies. This will be managed by the Health and Care Professions Council, who will have statutory powers to disbar NHS leaders in senior roles who have committed serious misconduct from holding such roles. The response document seemed to accept the proposition from an overall majority of stakeholders, who “showed a slight preference for implementing a barring system”, arguing that “this provides an effective and proportionate means of achieving the primary aim of regulation, enabling the removal of unsuitable managers who have committed offences [emphasis added] or who have been found to be unfit”.74 I infer that the latter part of the sentence refers to a person who has committed serious misconduct but not a criminal offence.
  2. The government explained that a further consultation will be necessary for legislation, with the aim of the bill being laid in the “second half of 2026”, and regulation will commence “within 12 months of legislation being laid”.75 The proposed disbarring system is to apply to NHS bodies (NHS Trusts, Foundation Trusts and ICBs).
  3. In its summary, the consultation response set out that “regulating managers and leaders will help to professionalise NHS leadership and will ensure that NHS managers and leaders are professionally accountable, while improving patient safety and driving up performance”.76
  4. It is not clear how regulating only the most senior managers – that is, board-level directors and their direct reports – within NHS bodies will help professionalise NHS leaders generally, save as a first step to wider regulation.

Profound change is necessary

  1. Leaving aside criminal offences, the first step towards dismissing someone for serious misconduct is to investigate the misconduct and go through the hospital’s disciplinary process. There is a well-known reluctance within the NHS to follow the HR process and a tendency to move people around with few questions asked (see Mr Kark’s evidence above). Even when the person is being moved out, one of the reasons a disciplinary process is avoided and employees paid off is because it is cheaper to do that than to risk the costs of litigation and/or the payment of damages for a successful claim for wrongful or unfair dismissal.
  2. A profound change is necessary in the NHS’s approach to dealing with serious misconduct (and, separately, poor performance). First, the NHS must be prepared to dismiss senior managers for serious misconduct (after due process). Second, it should follow that such managers would not secure employment as a manager in the NHS again. This would happen in any well-run company. NHS employment records must ensure that this is followed. If, worryingly, the reality is that people are currently being dismissed for serious misconduct but are able to return to employment within the NHS (because it is not possible to track people, given the size of the NHS), or worse, being moved around the NHS to different roles to avoid this outcome, then that system failing must be remedied. A barring system is a cumbersome way of achieving what ought to be achieved by effective disciplinary process, record keeping and management.
  3. It ought to be understood that, if a hospital does not invoke the disciplinary process and dismiss for serious misconduct, then, on the current proposals, there would be no basis for barring the manager. Whilst I understand that barring is a cheaper option than full regulation, and certainly necessary, it will not be worth the money spent on it, or the bureaucracy that comes with it, without the prior change of approach set out above.
  4. The government’s rationale for choosing a barring system over other types of regulation is that a barring system achieves the primary purpose – that is, to focus on those who commit serious misconduct no longer being able to work in “senior NHS management positions, preventing unacceptable behaviour and improving patient safety”.77
  5. Failure to regulate at lower levels, combined with an unwillingness to deal with difficult behaviour, means that poor conduct will continue unchecked at all other levels. The government goes on to say that a barring system is intended to fill gaps in the current system without duplicating what is already in place.78 I acknowledge that the mechanisms exist – the fit and proper person test, the Nolan principles, CQC and professional regulations and the Maintaining High Professional Standards framework. The most important gap in the current system is the one I identify above: the failure to use disciplinary process when there is misconduct. The barring system will not fill the gap, it will fall through it.
  6. Doctors and nurses are regulated from the moment of qualification and throughout their careers. Teachers, dentists, the same. When they are removed from the register, they cannot work in their chosen profession at all, either during a period of suspension or after removal from the register. Even were non-clinically qualified managers barred from working in the NHS, it would not follow that they could not be a manager outside the NHS. In other words, the effect of barring would be much less severe for NHS managers than for doctors, nurses and other professionals outside the NHS (teachers, etc).
  7. The government document continues – barring is simpler than a full regulatory system because full professional standards and revalidation are not required, and there is no requirement for a new regulator, no need for a transition period or to deal with existing NHS managers who do not meet any new requirements set, and fewer issues with no dual regulation.79
  8. All of that is true. The fact that full professional standards are not required for NHS managers (and that it is intended that this should continue) should ring alarm bells. The first and essential step is to raise standards. After more than 50 years of management in one form or another, the continued failure to achieve ‘full professional standards’ for all, or at least most, managers is a significant failure by all those responsible for the NHS. I return here to the ‘implementation considerations’ first mentioned in paragraph 37.64. They make plain that which is common knowledge: many managers do not meet the standards that should be expected of them. This must be addressed now.
  9. The same points are relied on again for not introducing full statutory regulation: it would be resource-intensive, the “implementation of education standards and qualifications would be a major challenge for such a diverse profession”, and setting such standards would require “significant additional regulator time”.80 This is not new. If education standards and qualifications are not to be used when recruiting, then other standards have to be set and kept to. Once managers are in the system, there have to be clear standards that they are expected to meet; their potential to meet these should have been tested in the recruitment process. If they do not, after appropriate support and performance management, they should not remain in post. It is just not acceptable to say it is all too difficult, as has clearly been done for decades.
  10. The suggestion that introducing full regulation risks putting individuals off applying for careers in the NHS because they may have to meet more requirements and evidence their continual learning, and because there may be more fear of sanctions with full professional standards, is all more of the same. I have already dealt with the latter point. The other points are not arguable.
  11. Finally, the government position is that a barring system is much cheaper than a statutory regulation system. I do not doubt that. The question is, is a barring system sufficient? The answer is that it may be, but only if it is preceded by a sea change in the approach of the NHS to managing its managers.
  12. Respondents to the consultation want the same standards, qualifications and expectations for all NHS managers. This is obviously right.
  13. The government’s response points to the then new draft Management and Leadership Framework, published in September 2025.81 This draft, and a further draft in 2026, have been superseded by the final published version in July 2026.
  14. The government acknowledges that there are matters still to be decided: how dual regulation will work, and how the barring system will work alongside the fit and proper person test and the Management and Leadership Framework. That this has to be worked out makes plain that the proliferation of tests and frameworks with the fit and proper person test is a recipe for more complication.

Final NHS Leadership and Management Framework

  1. A ‘final’ version of the framework was shared with the Inquiry in February 2026, then published on NHS England’s website in July 2026. It is now known as the Leadership and Management Framework and all references to managers have been changed to ‘leaders and managers’.82

Leadership and Management Framework Code

  1. At the outset, the code sets out the “core principles and behaviours expected of every leader and manager within our health and care system” and sets out “for the first time [emphasis added] the principles and characteristics that all leaders and managers [emphasis added] are expected to meet in the sector”.83 Under the heading ‘Why do we need the code?’ there are links to six documents: the Messenger Review, the NHS Constitution, ‘Our People Promise’, ‘Our Leadership Way’, the 7 Principles of Public Life (the Nolan Principles), and ‘A Healthier Wales: Our plan for health and social care’, with which the code is said to align.
  2. Under the heading ‘Be accountable’, the code reads:
    “As a leader or manager in health and social care, you must:
    • take responsibility for your actions and decisions
    • hold yourself and others to account for doing the job well, working together fairly and effectively and always looking for ways to improve.”

That means “following the relevant professional codes of conduct, including duty of candour where appropriate”.84

  1. There is no professional code of conduct for non-clinicians, other than this one. The structure of the paragraph suggests that this is a duty imposed only on those who are subject to professional codes of conduct. This immediately differentiates between clinical and non-clinical managers. I note the explicit reference to “including duty of candour where appropriate”. I accept that the nurses and doctors (and other healthcare professionals) have a duty of candour under their professional codes. This paragraph suggests that, in the absence of a separate professional code for managers, non-clinically qualified managers are not bound by the duty of candour. If that is the intention, it is unacceptable and wholly unjustified, particularly in light of the provisions of the Public Office (Accountability) Bill requiring the establishment by all public bodies of a duty of candour for staff. I am in no doubt that there should be no exemption for non-clinical managers from this important duty, which should be clear on the face of this code of conduct and should apply to all managers (see also Chapter 38).
  2. The code sets out six principles, which are defined and each followed by examples of effective and ineffective practice:
    • Be accountable.
    • Be collaborative.
    • Be compassionate.
    • Be curious.
    • Be inclusive.
    • Show integrity.

With the exception of inclusivity, these principles broadly follow Mr Jarrold’s much shorter code (see paragraph 37.41).

  1. I readily acknowledge that this code is an improvement on what went before, including the September 2025 document, but nowhere does it put front and centre Mr Jarrold’s first principle, with which surely every manager must agree: “I will make the care and safety of patients my first concern and act to protect them from risk.” It is not enough to say that the reader should read the NHS Constitution or any of the other related documents. This omission rather undermines the document’s credibility. I recommend an urgent review of the code so that this may be remedied.

Leadership and Management Framework Standards

  1. The ‘standards’ are shorter than the draft version (see paragraph 37.89).85 The vision and mission statements have been stripped out, along with other superfluity.
  2. The standards are divided into three ‘focus area’ headings:
    1. Personal impact
    2. Managing people and resources
    3. Delivering across health and care.
  3. Under each focus area heading, there are three subsections – the ‘standards’ – each subdivided into further subsections. There are also standards for the ‘fundamentals’ stage – “for every leader and manager regardless of their level”, and four further stages of management depending on your role.86
  4. The first area of focus is the leader or manager personally, ‘personal impact’. I assume that underpinning this is the belief that, if there is a well-functioning management team, that will be good for patients. The first requirement for the stage 1 ‘new leaders and first-time managers’ is that they should “[p]rioritise for personal productivity”; the second, that they should “[d]evelop personal safety and wellbeing strategies”. Leaving aside which priority matters more (and Professor Dixon-Woods’ priority thicket comes to mind), it is not easy to see how the latter competency, in particular, is properly included as a professional standard. How will a failure to “develop health and wellbeing strategies” be assessed and managed? I note that the stage 2 (‘mid level’) leader or manager is required to “make sure wellbeing is prioritised”. If it is to be a manager’s responsibility to prioritise well-being by promoting conversations about a healthy work culture and encouraging others to prioritise their health and well-being, how is success to be measured? By whether conversations take place? By whether people’s health is protected or well-being improves? I acknowledge that it may be possible for managers (non-clinical or clinical) to protect their own health and wellbeing and those of others in a fully staffed hospital.  However when, as now, there is a shortage of doctors, nurses and managers and the fundamental requirement is to keep patients safe, urging wellbeing strategies may feel somewhat removed from the reality of running a busy ward/department/hospital.  However well meant, it may have the effect of increasing workload with no real benefit. This aspect of the framework should be kept under review.
  5. The approach to patients is buried within the third of the three focus areas – ‘delivering across health and care’ – under the standard ‘improving quality’. It should come first. This is not just about presentation, it is about the fundamentals. The patients/service users are the reason for the NHS. As above, I suggest this is remedied swiftly. That may easily be done by leading with the standards under this heading (delivering across health and care).
  6. The first and fundamental descriptor under this third standard is: “I put patients first and report safety concerns and incidents.” This ought to feature more prominently in the standard and in the code (see above).
  7. It is instructive to compare the standards with the code of practice for doctors and assistants (formerly physician and anaesthetist associates) now called Good Medical Practice. It is clear, practical and specific.87 There is a separate leadership guidance document, 21 pages in length, including endnotes. It is concise and easy to understand. Like the main document, it is not a slide pack. It is written in prose and so is easier to absorb. The opening section makes it plain where the doctors’ duties lie. It explains on the first page what it is, who it is for and how it is structured.88
  8. Importantly, on the GMC website, as part of the ‘Good Medical Practice’ section, there is a webpage titled ‘A patient’s guide to good medical practice’.89 There can be no doubt where the doctor’s priority lies. There is an easy read version too, which includes the most important information in a shorter, even clearer format.
  9. The nurses’ code of conduct can also be found on the website of the NMC.90
  10. I do not doubt that both codes could be improved, but they are both focused on patients and make clear what is expected of nurses and doctors in the course of their work in the NHS.
  11. I acknowledge that time and effort has been directed to producing the responses to the recommendations of the Messenger/Pollard report in 2022 but four years is too long. I hope that, when the required changes are made in response to my observations in this section of the Report, the first effective steps will be taken to raising the standards of conduct and behaviour of managers in the NHS.
  12. To achieve real and enduring change, the issues I raise in respect of recruitment, retention and the enforcement of the terms of contracts must all be addressed. If that is done efficiently, then the proposed barring system has some chance of success.
  13. The introduction of a barring system will not remove the urgent need to manage poor performance effectively. That too requires the attention of Trusts and NHS England.

Footnotes

  1. * There is a difference between the total responses quoted in Hansard (4,924) and the online responses analysed in the consultation response document (4,907).

Endnotes

  1. 1 The Rt Hon. the Baroness Hallett DBE, UK Covid-19 Inquiry Module 3: The impact of the Covid-19 pandemic on the healthcare systems of the United Kingdom, March 2026
    (https://covid19.public-inquiry.uk/wp-content/uploads/2026/03/16164422/M3-report-web-accessible-PDF-NO-COMMENTS.pdf#page=1)

  2. 2 Gen. Sir Gordon Messenger and Dame Linda Pollard, Leadership for a Collaborative and Inclusive Future, 8 June 2022 (https://www.gov.uk/government/publications/health-and-social-care-review-leadership-for-a-collaborative-and-inclusive-future/leadership-for-a-collaborative-and-inclusive-future#executive-summary)

  3. 3 Sir Gordon Messenger 8 January 2025 157/25

  4. 4 The Rt Hon. Prof. the Lord Darzi of Denham OM KBE, Independent Investigation of the National Health Service in England, September 2024 (https://assets.publishing.service.gov.uk/media/66f42ae630536cb92748271f/Lord-Darzi-Independent-Investigation-of-the-National-Health-Service-in-England-Updated-25-September.pdf)

  5. 5 The Rt Hon. Prof. the Lord Darzi of Denham OM KBE, Independent Investigation of the National Health Service in England, September 2024, page 124 (https://assets.publishing.service.gov.uk/media/6a05a27e97000cb6073e4dd8/lord-darzi-independent-investigation-of-the-national-health-service-in-england-updated-14-May-2026.pdf#page=128)

  6. 6 Countess of Chester Hospital NHS Foundation Trust, Annual Report 2015/16, May 2016, page 31 (https://www.coch.nhs.uk/media/133225/abdb_3091_coch-annual-report-2015-16-min-1-.pdf#page=31); Countess of Chester Hospital NHS Foundation Trust, Annual Report & Accounts 2016/17, page 26 (https://www.coch.nhs.uk/media/145316/rjr_chester_annual_report_and_accounts_2016-17_wit.pdf#page=26)

  7. 7 Sir Rob Behrens CBE 10 December 2024 34/11-13 and 35/15-19

  8. 8 Dr Susan Gilby 24 February 2025 124/10-16; Jane Tomkinson 13 January 2025 99/23 to 100/2

  9. 9 Prof. Sir Stephen Powis 17 January 2025 166/23 to 167/14; NHS, ‘Graduate Management Training Scheme’ (https://graduates.nhs.uk/scheme)

  10. 10 Prof. Judith Smith 9 January 2025 143/25 to 144/1

  11. 11 NHS, ‘Graduate Management Training Scheme’ (https://graduates.nhs.uk/scheme)

  12. 12 Baroness Merron, Written answer, NHS: Training – Question for Department of Health and Social Care, UIN HL9242, 14 July 2025 (https://questions-statements.parliament.uk/written-questions/detail/2025-07-08/hl9242#:~:text=Answered%20on&text=The%2010%2DYear%20Health%20Plan,forthcoming%2010%20Year%20Workforce%20Plan)

  13. 13 CMI, ‘Chartered Manager’ (https://www.managers.org.uk/membership/chartered-manager)

  14. 14 Prof. Judith Smith 9 January 2025 59/2-25

  15. 15 Prof. Judith Smith 9 January 2025 144/9-17

  16. 16 Gen. Sir Gordon Messenger 8 January 2025 167/24 to 168/4

  17. 17 Gen. Sir Gordon Messenger 8 January 2025 165/24 to 168/13

  18. 18 Such as the Midlands 100 Leader Pilot Initiative: NHS Midlands NHS Leadership Academy, ‘NHS England – Midlands 100 Leader Pilot Initiative’ (https://midlands.leadershipacademy.nhs.uk/our-offers/nhs-midlands-100-leader-pilot-initiative); and the Future-Fit Leadership Programme 2026 in the North East and Yorkshire: ‘Introducing Our New Future-Fit Leadership Programme 2026’ (https://ney.leadershipacademy.nhs.uk/14291-2)

  19. 19 INQ0108364/2; Gen. Sir Gordon Messenger 8 January 2025 180/25 to 181/4

  20. 20 Gen. Sir Gordon Messenger 8 January 2025 205/24-25

  21. 21 Gen. Sir Gordon Messenger 8 January 2025 206/2-3

  22. 22 GMC, ‘What is revalidation?’ (https://www.gmc-uk.org/registration-and-licensing/ managing-your-registration/revalidation/what-is-revalidation)

  23. 23 NMC, ‘What is revalidation?’ (https://www.nmc.org.uk/revalidation/overview/what-is-revalidation)

  24. 24 GMC, Good Medical Practice, 22 August 2023, updated 13 December 2024 (https://www.gmc-uk.org/cdn/documents/good-medical-practice-2024—english_pdf-102607294.pdf); Written Closing Submissions on Behalf of Family Group 2 and 3 7 March 2025 137/para 599

  25. 25 Sir Robert Francis KC 30 September 2024 86/6-21

  26. 26 Ken Jarrold CBE 7 January 2025 68/18 to 70/18

  27. 27 Ken Jarrold CBE 7 January 2025 95/7-13

  28. 28 Ian Kennedy, The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001 (https://www.bristol-inquiry.org.uk/final_report/the_report.pdf); Dr Bill Kirkup CBE, Reading the Signals: Maternity and neonatal services in East Kent – the Report of the Independent Investigation, October 2022 (https://assets.publishing.service.gov.uk/media/634fb0afe90e0731ae2a147a/reading-the-signals-maternity-and-neonatal-services-in-east-kent_the-report-of-the-independent-investigation_web-accessible.pdf); Tom Kark KC and Jane Russell, A Review of the Fit and Proper Persons Test, March 2019 (https://assets.publishing.service.gov.uk/media/5c937b7e40f0b633f5bfd89c/kark-review-on-the-fit-and-proper-persons-test.pdf)

  29. 29 Ian Kennedy, The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, pages 442, 446 and 448 (https://www.bristol-inquiry.org.uk/final_report/recommendations.pdf)

  30. 30 Ian Kennedy, The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 446 (https://www.bristol-inquiry.org.uk/final_report/recommendations.pdf#page=14)

  31. 31 Ian Kennedy, The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, pages 442 and 448 (https://www.bristol-inquiry.org.uk/final_report/recommendations.pdf)

  32. 32 Ian Kennedy, The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 448 (https://www.bristol-inquiry.org.uk/final_report/recommendations.pdf#page=16)

  33. 33 Ian Kennedy, The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 448 (https://www.bristol-inquiry.org.uk/final_report/recommendations.pdf#page=16); INQ0108022/45

  34. 34 Ken Jarrold CBE 7 January 2025 76/5-10

  35. 35 INQ0107810/7

  36. 36 Ken Jarrold CBE 7 January 2025 77/24 to 78/16

  37. 37 Ken Jarrold CBE 7 January 2025 81/1-4

  38. 38 Ken Jarrold CBE 7 January 2025 83/10; Sir Robert Francis KC, Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009, Volume I, February 2010 (https://assets.publishing.service.gov.uk/media/5a7c1b11e5274a1f5cc75d16/0375_i.pdf)

  39. 39 Ken Jarrold CBE 7 January 2025 81/6-9

  40. 40 Ian Kennedy, The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 443 (https://www.bristol-inquiry.org.uk/final_report/recommendations.pdf#page=11)

  41. 41 Ian Kennedy, The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995, July 2001, page 444 (https://www.bristol-inquiry.org.uk/final_report/recommendations.pdf#page=12)

  42. 42 NHS England Leadership Academy, ‘About us’ (https://www.leadershipacademy.nhs.uk/meet-the-team)

  43. 43 UK Government and NHS, Fit for the Future: 10 Year Health Plan for England, July 2025, page 106 (https://assets.publishing.service.gov.uk/media/6888a0b1a11f859994409147/fit-for-the-future-10-year-health-plan-for-england.pdf#page=108)

  44. 44 UK Government and NHS, Fit for the Future: 10 Year Health Plan for England, July 2025, page 107 (https://assets.publishing.service.gov.uk/media/6888a0b1a11f859994409147/fit-for-the-future-10-year-health-plan-for-england.pdf#page=109)

  45. 45 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers#introduction)

  46. 46 Tom Kark KC 17 January 2025 3/22 to 4/2

  47. 47 Tom Kark KC 17 January 2025 4/11 to 5/17

  48. 48 Tom Kark KC and Jane Russell, A Review of the Fit and Proper Persons Test, March 2019, Recommendation 1 (https://assets.publishing.service.gov.uk/media/5c937b7e40f0b633f5bfd89c/kark-review-on-the-fit-and-proper-persons-test.pdf)

  49. 49 NHS England, ‘NHS England Fit and Proper Person Test Framework for Board Members’, September 2023, Recommendation 4 (https://www.england.nhs.uk/long-read/nhs-england-fit-and-proper-person-test-framework-for-board-members)

  50. 50 NHS England, ‘NHS Leadership Competency Framework for Board Members’, 28 February 2024 (https://www.england.nhs.uk/long-read/nhs-leadership-competency-framework-for-board-members)

  51. 51 NHS England, ‘NHS Leadership Competency Framework for Board Members’, 28 February 2024 (https://www.england.nhs.uk/long-read/nhs-leadership-competency-framework-for-board-members)

  52. 52 Tom Kark KC 17 January 2025 32/13

  53. 53 Tom Kark KC 17 January 2025 37/25 to 38/4

  54. 54 Ken Jarrold CBE 7 January 2025 87/2-19

  55. 55 INQ0017495/259/para 974

  56. 56 Report to the Thirlwall Inquiry: Addressing Part C of the Terms of Reference by Prof. Mary Dixon-Woods INQ0102624/97

  57. 57 Labour Party, Change Labour Party Manifesto, 13 July 2024, page 98 (https://labour.org.uk/wp-content/uploads/2024/06/Labour-Party-manifesto-2024.pdf#page=98)

  58. 58 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers)

  59. 59 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers); Hansard, HC, Deb 21 July 2025, vol. 771, cols 75WS, 76WS (https://hansard.parliament.uk/Commons/2025-07-21/debates/2507216000013/RegulationOfNHSManagersConsultationResponsehighlight=care)

  60. 60 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers)

  61. 61 Gen. Sir Gordon Messenger 8 January 2025 190/8 to 191/4; Sir Robert Francis KC 30 September 2024 14/9-13; The Rt Hon. Prof. the Lord Darzi of Denham OM KBE, Independent Investigation of the National Health Service in England, September 2024, page 131 (https://assets.publishing.service.gov.uk/media/66f42ae630536cb92748271f/Lord-Darzi-Independent-Investigation-of-the-National-Health-Service-in-England-Updated-25-September.pdf#page=135)

  62. 62 Sir Robert Francis KC 30 September 2024 141/6-7

  63. 63 Tony Chambers 27 November 2024 190/12-13

  64. 64 Sir Rob Behrens CBE 10 December 2024 36/6-12

  65. 65 Tom Kark KC 17 January 2025 4/13-22

  66. 66 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers)

  67. 67 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers)

  68. 68 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers)

  69. 69 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers)

  70. 70 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers)

  71. 71 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers)

  72. 72 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation document’, 26 November 2024, updated 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/leading-the-nhs-proposals-to-regulate-nhs-managers)

  73. 73 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation response’, 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs-managers-consultation-response)

  74. 74 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation response’, 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs-managers-consultation-response)

  75. 75 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation response’, 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs-managers-consultation-response)

  76. 76 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation response’, 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs-managers-consultation-response)

  77. 77 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation response’, 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs-managers-consultation-response)

  78. 78 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation response’, 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs-managers-consultation-response)

  79. 79 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation response’, 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs-managers-consultation-response)

  80. 80 UK Government, ‘Leading the NHS: Proposals to regulate NHS managers: Consultation response’, 21 July 2025 (https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers/outcome/leading-the-nhs-proposals-to-regulate-nhs-managers-consultation-response)

  81. 81 NHS England, ‘Draft Management and Leadership Framework’, 4 September 2025
    (https://www.england.nhs.uk/wp-content/uploads/2025/09/item-8i-appendix-a-mgmt-and-leadership-full-draft-standards.pdf)

  82. 82 NHS England, ‘Leadership and Management Framework’, July 2026 (https://lmframework.leadershipacademy.nhs.uk)

  83. 83 NHS England, ‘Leadership and Management Framework: Code’, July 2026 (https://lmframework.leadershipacademy.nhs.uk/code)

  84. 84 NHS England, ‘Leadership and Management Framework: Code’, July 2026 (https://lmframework.leadershipacademy.nhs.uk/code)

  85. 85 NHS England, ‘Leadership and Management Framework: Standards’, July 2026 (https://lmframework.leadershipacademy.nhs.uk/standards)

  86. 86 NHS England, ‘Leadership and Management Framework: Standards’, July 2026 (https://lmframework.leadershipacademy.nhs.uk/standards)

  87. 87 GMC, Good Medical Practice, 22 August 2023, updated 13 December 2024 (https://www.gmc-uk.org/cdn/documents/good-medical-practice-2024—english_pdf-102607294.pdf)

  88. 88 GMC, ‘Professional Standards: Leadership and management’, 12 March 2012, updated 13 December 2024 (https://www.gmc-uk.org/cdn/documents/leadership-and-management-for-all-doctors—english_pdf-48903400.pdf)

  89. 89 GMC, ‘A Patient’s Guide to Good Medical Practice’ (https://www.gmc-uk.org/professional-standards/patient-guides-and-materials/a-patients-guide-to-good-medical-practice)

  90. 90 NMC, The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates, 29 January 2015, updated 10 October 2018 (https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf)

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Chapter 36
The NHS
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Chapter 38
Duty of candour