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1 Building management capabilities within NHS providers The NHS will need highly capable managers to deliver the vision set out in the white paper Equity and Excellence: Liberating the NHS. This article investigates how well NHS Trusts are developing management skills at the moment, through analysis of current spend by NHS Trusts and interviews with eleven senior leaders from eight different Trusts. It asks three questions: Are NHS providers investing sufficiently in the development of management capabilities? Are Trusts investing in the right capabilities to deliver the White Paper agenda? Are NHS skills building investments working? The answers to these questions indicate thatt there is enormous variation in spend on local leadership and management training by Trust, with some organisations spending more than ten times others. Furthermore the focus of spend is on developing leadership skills rather than management skills, even though there are worrying gaps in management skills (particularly below Director level). With this context, it is difficult to have confidence thatt current training and education plans are likely to provide a good return on investment or build the skillss needed to manage the changes facing the NHS. There are relatively straightforward practices to improve this: focus training and development on delivering organisational outcomes; pull rather than push training; get the learning environment right; and set high expectations for the return on investment from training programmes. However, this article also proposes a fifth, more novel idea of using competition and collaboration with other organisations to achieve greater returns. How well are NHS Trusts developing management skillss at the moment? 1. Are NHS providers investing sufficiently in the development of management capabilities? Currently 5billion is spent annually by the NHS on education and training through the multi spend by providers on professional education and training fund (MPET) 1. However, there is additional training and education which accounts for a further 184 million 2, approximately 0.3% of trust operating costs and equivalent to 200 per employee per year [figure 1]. This typically covers local development requirements, including management and leadership development. Is this sufficient? According to the CIPD s annual survey on learning and development, the median spend spend per employeee for those UK organisations who provided data is 250. The CIPD data also shows that public sector organisations typically spend 116 per employee and private sector 320 per employee [figure 1]. This would suggest thatt NHS organisations are investing more in learning and development than other public sector organisations, but are under investing compared to private sector organisations. Further examinationn of the NHS spend shows that there is huge variation by provider, even taking into account outliers, with some providers spending towards 1000/employee and others spending under 1 Liberating the NHS: Developing the Healthcare workforce 2 Local Spending Reports NHS Trusts ( 95m 2009/10) and Foundation Trust ( 89m 2009/ /10)

2 100/employee [figure 2]. While there are likely to be data accuracy issues associated with how Trusts allocated this spend, this is unlikely to account for the full extent of variation. This degree of variation is concerning, particularly when the forthcoming system changes require strong management and leadership skills. As the King s Fund highlighted in their 2009 report on Workforce planning 3 : The planning and funding of broader workforce development, including leadership skills, should be given a higher priority. Most of the planning and funding activity evident in the NHS is focused on doctors and other health professionals. Much of the responsibility for management and leadership development rests with local employers; this creates significant disadvantages for the nonclinical workforce. Given the impact of poor management and leadership on the rest of the service, this disadvantages the system as whole. 2. Are Trusts investing in the right capabilities to deliver the White Paper agenda? Significant research and investment has been made into developing leadership capabilities within the NHS, for example the development of the NHS Leadership Qualities Framework 4, SHA Emerging Leaders Programmes. Trustss have translated these into local programmes to build skills and accelerate staff with high potential, however, the interviews indicate that these programmes are often for relatively small numbers of staff (often fewer than 20 staff members) which would be too slow to match the pace of change set by the Government s agenda. While much of the focus has been on leadership capabilities, the interviews highlighted a potentially larger concern around building management capabilities, particularly below the Director level. While there were concerns about capability gaps in the following areas, there are few examples of planning or guidance for training in these areas: Developing strategic plans for business units, underpinned by robust analysis of the available financial and activity data; Analysing and presenting the financial position of business units, enabling them to improve services and deliver efficiency savings; Managing and delivering improvement and change projects and programmes to meet Trust objectives; Influencing and negotiating with external stakeholders e.g., other providers, GP commissioners; Building effective multi disciplinary enabling senior managers to steps back from the operational teams; Self direction, details. 3. Are NHS skills building investments working? The NHS does not evaluate training and education investments with the same rigour as it does other activities. None of the interviewees were able point to effective evaluation methods within their own Trust, nor were they able to identify effective evaluation approaches used by other Trusts. As a result, 3 NHS WORKFORCE PLANNING: Limitations and possibilities, The King s Fund,

3 more subjective rationale is being used to justify training investments, for example, views that training is a good thing, it boosts staff morale and it helps with staff retention. The Developing the Healthcare workforce consultation paper 5 highlights this as a priority area: For education and training, we also want to see much better information on the quality of education and training and the outcomes being achieved. The lack of measurement means that it is very hard to tell whether training and education has been effectivee and provided a good return on investment (for example, improving patient experience, outcomes or productivity). How can management development be improved within NHS providers? These findings suggest that there are plenty of opportunities for Trusts to become more effective at building the capabilities needed. However, achieving them will require organisations thinking about their development strategy in quite a different way. We have drawn on international best practices on development, suggestions from our interviewees and approaches that we have found to work in our experience building development programmes within the NHS, to identify the following practices to improve the effectiveness of development programmes Outcome focused training: Focus the development strategy on solving clearly definedd and urgent business problems and on delivering improved organisational outcomes. For example, building leadership skills in our managers becomes more tangible when refocused on outcomes: improving Trust productivity by 10% through a programme of improvement projects supported by mentoring and training for service delivery teams. Pull rather than push training: While there may need to an initial push from the centre (e.g., HR), a training programme will be most effectivee if it is responding to pull from the business units and if the businesss units are closely involved in commissioning and steering the training programmes to meet their requirements. Get the learning environment right: training typically doesn t have much impact... The most significant improvements lie in rethinking the mind sets thatt employees and their leaders bring to training, as well as the environment they come back to afterward 6. As this quote suggests capabilities will only grow if the right conditions are in place, namely: those being trained understand why the skills are valuable and how they can apply them in their day to day work; they can learn from others who are successfully applying them in similar contexts; they receive effective training on the skills in a way which is consistent with their working environment; and their working environment is supportive to growing and developing the new skills. We have found that programmes combining case based training with structured mentoring are an effective way of creating such an environment. Set high expectations and evaluate against these: Set high expectations for the changes in skills and behaviours required following training programmes and performance manage training 5 Liberat ing the NHS: developing the Healthcare Workforce, Department of Health, December Getting more from your training programs, McKinsey and Company

4 providers against these. Use meaningful measures that sum benefits from the training and divide thesee by the costss (delivery plus attendance opportunity costs). Establish the measures at the start, during the training development phase. As well as knowing whether the training has been effective, setting clear expectations for training providers will also help to improve the quality of training. Opportunities for collaboration and competition Beyond these good practices there are also opportunities that can be realised from the competitive and collaborative dynamics that are being encouraged between Trusts. Collaboration opportunities: The core management capabilities that trusts need to develop are largely the same between trusts: basic IT and financial skills, effective project management and delivery, robust analytical skills, targeted leadership skills. By pooling training budgets, trusts could develop higher quality and better utilised training programmes to develop staff across organisations. Furthermore, there are benefits from cross pollination of staff, particularly when training collaboration takes place with organisations where there are additional reasons to partner (e.g., other organisations along the patient pathway). Such collaboration is already being encouraged by the NHS to replace training and education currently provided by SHAs. Competition opportunities: Trusts could choose to differentiate themselves through the calibre of their people. In other sectors, this is a well recognised strategic approach, for example, through developing the right people with the right skills Corrections Corporation of America (CCA), a private enterprise prison, has been able to save costs and run a better prison than other providers, and Southwest Airlines was able to successfully pioneer the low cost airline model. Putting management development at the heart of strategy would be a bold and distinctive move which could reward Trusts with a cost effective approach to deliver high quality patient care. Conclusion The huge variation in spend on training and development across Trusts and gaps in management skills appear to be linked to a lack of robust evidence on what works in developing these skills. This can lead to development programmes which are not integrated with Trust strategies, with no outcome measures, and ultimately wasted money. However, positive returns on investment from training can be achieved by integrating training with the businesss needs of the organisation and performance managing the training programme against these businesss needs. Further improvements can also be realised from more strategic collaboration and competition between Trusts around people development. Caroline Cake, Director, 2020 Delivery, February 2011 From a series of articles by 2020 Delivery on effective capability building for public services (www. 2020delivery.com)

5 Figure 1 Median training spend per employee ( ) Private sector Voluntary and community Public sector NHS Source: CIPD Learning and talent Development Annual survey report 2010, 2020 analysis. Note: NHS data excludes MPET training and is based on provider training and education spend by the total number of employees (clinical and non clinical) Figure 2 Source: NHS Provider spend data 2009/10, 2020 analysis Note: includes all non Foundation Trust NHS providers