The UK government’s recent consultation “Leading the NHS: Proposals to regulate NHS managers” has reignited long-standing debates about how we hold healthcare leaders accountable when things go wrong [1]. Regulation alone cannot prevent system failure. The NHS needs to change its culture, which can only be done by focussing on fostering compassionate, competent, and courageous leadership.
The Problem: Accidental Leaders and Late Transitions
In the NHS, many clinicians enter leadership roles by chance rather than by design. Some are appointed late in their careers, often without structured preparation, mentorship, or formal training. Others develop their leadership as a side project, bolted on to clinical excellence, rather than a discipline in its own right. This pattern persists despite strong evidence linking medical leadership to improved organisational performance, patient safety, and staff engagement [2]. As we seek to professionalise healthcare management through new regulatory frameworks, we must ask ourselves: how are we preparing people to meet these standards in the first place?
The RACMA Model: Leadership as a Medical Specialty
Royal Australasian College of Medical Administrators (RACMA) was established in 1968 and is recognised in Australia and New Zealand as a specialist medical college. Its purpose is to train doctors in medical administration; a specialty combining clinical knowledge with expertise in governance, strategy, finance, and systems leadership. The RACMA Fellowship (FRACMA) involves a minimum of three years of formal training, including:
- Completion of a Master’s degree in health service management or public health
- Supervised executive placements within health services
- Workplace-based assessments and reflective practice
- A comprehensive exit examination assessing leadership competence across defined domains
Crucially, RACMA supports doctors to step confidently into full-time leadership roles, including Chief Medical Officer and Chief Executive Officer posts across health systems. This stands in contrast to the UK, where clinical leaders are often expected to juggle strategic responsibilities alongside their clinical duties.
FMLM: A Strong Foundation, But Missing a Formal Pathway
The Faculty of Medical Leadership and Management (FMLM), supported by the Academy of Medical Royal Colleges, has established itself as the professional body for medical leadership in the UK. It provides national standards, professional accreditation through fellowship, and a range of development opportunities across the career continuum [3]. FMLM’s ongoing transition toward becoming a Royal College marks a significant step in formalising leadership as a professional domain.
The Clinical Leadership Competency Framework (CLCF), developed with the NHS Institute, extends this work across 21 regulated clinical professions [4]. However, neither FMLM nor the CLCF currently provides a nationally accredited, structured training pathway comparable to the Fellowship and specialty recognition model offered by RACMA in Australia.
In the absence of a recognised route to specialisation, leadership development will remain fragmented, locally variable, and largely optional. As regulatory proposals evolve, this gap represents a critical weakness in preparing leaders for complex, system-level roles.
Regulation Without Development Risks Blame Culture
The NHS consultation proposes a set of regulatory powers for senior managers, including registration, suspension, and disbarment. It follows a series of high-profile failures such as at the Countess of Chester and University Hospitals Birmingham which have damaged public confidence. However, without investment in structured leadership development, this regulation risks becoming punitive rather than preventative. Regulation must be accompanied by a clear, accredited pathway to support emerging leaders in acquiring the competencies expected of them.
Accountability in leadership is essential, but we must do more than regulate after the fact. We must cultivate the leadership our system deserves; rooted in values, supported by structure, and developed through deliberate investment. Australia’s RACMA model offers one example of how this can be achieved. As we reshape NHS leadership for the next decade, we need to move from a culture of blame to one of capability.
Younger Leaders, Digital Transformation, and the Innovation Gap
One of the most pressing reasons to rethink our leadership pipeline is the urgent need for digital and data-driven transformation across the NHS. Younger clinicians bring fluency in technology, systems thinking, and new models of care but are often excluded from leadership roles until late in their careers.
By contrast, RACMA supports doctors to enter medical leadership roles early, building lifelong careers in health system stewardship. This enables innovation, sustainability, and succession planning. If we are serious about NHS transformation, particularly around AI, genomics, and digital health, then we must nurture a new generation of digitally literate, innovation-focused leaders now.
Recommendations
To ensure leadership regulation leads to learning rather than blame, the NHS must complement accountability with structured development. The following gaps in the current system could be addressed by:
- Establishing a nationally accredited training pathway with specialist accreditation.
Drawing on the structure and curriculum of RACMA, the UK could develop a formal training programme to specialise in health system leadership. The programme should combine academic study, supervised executive placements, portfolio assessment, and national accreditation. For doctors, this could lead to CCT, for non-medical professionals a route to specialist registration via UKPHR or an equivalent professional body.
- Adopt a unified, cross-disciplinary competency framework for leadership.
Existing frameworks are helpful but fragmented. A single, system-wide curriculum, modelled on RACMA’s, could define expectations across domains such as governance, safety, quality, finance, innovation, equity, and digital transformation. This would better align leadership development with emerging regulatory standards.
- Strengthen the leadership and management component of GMC revalidation.
The current revalidation process rightly focuses on patient safety and professionalism but lacks structured assessment of leadership competence. Introducing a dedicated leadership and management domain, linked to national standards, could support reflective development and ensure leaders are supported throughout their clinical careers.
- Expand and formalise early-career leadership pathways.
Schemes like the National Medical Director’s Clinical Fellow Programme are valuable but limited in scope and duration. The programme could be extended to 2 years, by combining academic study, operational placements, mentorship and progression into specialist leadership training. This would allow younger clinicians to develop system leadership capability with the same rigour as clinical specialties.
These recommendations do not replace existing initiatives by FMLM or NHS England, they build upon them, offering a clearer, more credible route to leadership for clinicians at all stages of their career. Regulation may define the boundaries, but capability-building will define the future.
References
- Department of Health and Social Care. Leading the NHS: proposals to regulate NHS managers. July 2025. https://www.gov.uk/government/consultations/leading-the-nhs-proposals-to-regulate-nhs-managers
- West M, Armit K, Loewenthal L, Eckert R, West T, Lee A. Leadership and leadership development in healthcare: the evidence base. London: Faculty of Medical Leadership and Management; 2015.
- Faculty of Medical Leadership and Management. Leadership and management standards for medical professionals. 3rd edition. 2021. https://www.fmlm.ac.uk/resources
- NHS Institute for Innovation and Improvement, Academy of Medical Royal Colleges. Clinical Leadership Competency Framework Project: Report on Findings. National Leadership Council; 2010.
Author
Dr. MaryAnn Ferreux
MaryAnn is the Chief Medical Officer, Health Innovation Network Kent Surrey Sussex. She is a certified healthcare executive and Fellow of the Royal Australasian College of Medical Administrators and Faculty of Medical Leadership and Management.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none