Is the NHS overmanaged?

Key points

• NHS managers make up circa 2 per cent of the workforce compared to 9.5 cent of the UK workforce.
• In recent years the number of managers has been cut, at a time when the NHS is facing its biggest challenge.
• The NHS as a whole is under, not over, managed. However, persistent and misleading media headlines continue to claim that the NHS is overmanaged.

Introduction

As the COVID-19 pandemic continues to rage, NHS managers are, once again, in the media and political spotlight. And, as usual, not in a good way.

In October, the Secretary of State for Health and Social Care commissioned General Sir Gordon Messenger to lead a review of leadership in health and social care. This review, labelled “the most far-reaching” in 40 years, is premised on the assumption that the NHS is poorly managed and possibly also overmanaged. Opposition politicians agree. Shadow health secretary Wes Streeting, for example, recently complained about the huge sums of taxpayers’ money being paid to managers and “NHS bosses leeching cash away from frontline medical staff”. [ ¹ ]

As our own research and that of others has consistently shown, the NHS is not ‘overmanaged’ and nor has it ever been so

These claims of spiralling NHS management costs and bureaucratic bloat are a recurring and depressing theme in British politics. Successive governments have made open pledges to reduce the number of ‘men in grey suits’ (as notoriously described by Alan Milburn, a former health secretary). [ ² ]

Spectacular media headlines such as ‘death by bureaucracy’ and ‘cure the NHS with fewer managers’ have fuelled the fire and undermined public trust. And the stakes are now high with rumours of a white paper on leadership and management set to follow the Messenger Review. But while these views are popular among some commentators and widely shared, they are also mistaken. As our own research and that of others has consistently shown, the NHS is not ‘overmanaged’ and nor has it ever been so.

What do we mean by NHS management?

To understand why this is the case, it is useful to start with some definitions. In much of the discussion there is confusion about what we mean by labels such as management, managers and administration.

A common mistake, for example, is not to distinguish between what Chris Grey terms ‘management as an activity’ and ‘management as a social or occupational group’. [ ³ ]

The former relates to the work involved in the process of managing people and/or resources. This activity might of course be performed by anyone, even if they don’t hold a formal job title of ‘manager’. In the NHS, hospital consultants and senior nurses often engage in ‘managerial’ work, such as the supervision or mentoring of junior colleagues or leading clinical improvement projects. One study, funded by the National Institute for Health Research, found that more than one in three clinical professionals spent time on these hidden management activities. [ ⁴ ]

By contrast, ‘managers’ and ‘administrators’, sometimes referred to as ‘bureaucrats’, are a far narrower category. This group consists of people employed in these roles with formal job titles, who devote all (or the bulk) of their time to the activity of coordinating the work of others. Included here are senior and middle managers, specialist managers in areas like finance, procurement and human resources, and clinicians who take on part time or ‘hybrid’ management roles (such as clinical directors).

If Florence Nightingale were carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge

Most organisations also employ large numbers of administrators, mainly on clerical grades, who do not exercise management authority or control significant resources. This broad category would also include professionals in support roles, such as data analysis and scientists.

Given the size and complexity of the NHS, currently the world’s fifth largest employer, there has always been significant demand for administrators, although not as many as might be assumed. Most recently, the Daily Mail noted that: “The number of backroom staff and managers in the health service has been creeping up over the past decade…” This implied that because “only 52.5 per cent are clinically trained staff”, the remainder were bureaucrats. [ ⁵ ]

This is highly misleading. Of the remaining 48 per cent, almost half are support staff such as cleaners, porters and canteen staff who keep the service running, not to mention the hundreds of thousands of healthcare assistants who provide direct care to patients.

Only the other half are what we might term administrators, defined by the NHS Workforce Data Set as ‘central functions, senior managers and managers, administrative staff clerical and administrative and estates’. Using this data in our own research, we calculated that in NHS acute trusts the ratio of all administrative staff to all staff employed stood at 24.2 per cent, or 26.6 per cent if managers are included. [ ⁶ ]

By definition, managers are far fewer in number. In the NHS, the push to employ managers began in 1983 following a review of the service by Sir Roy Griffiths. After only a few months, Griffiths, the chief executive of a large supermarket chain, jokingly observed ‘…if Florence Nightingale were carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge’. [ ⁷ ]

Based on his report, the NHS began to recruit general managers to run hospitals. [ ⁸ ]

Since that time the number of managers has risen steadily [ ⁹ ] with their own distinct body of expertise, enhanced graduate training programmes and occupational identity. [ ¹⁰ ]

How many managers are working in the NHS?

Using the Binleys Database*, we counted 25,119 managers in the NHS as a whole in 2018/19. This increases to 31,361 if central functions (for example, staff working in NHS England and NHS Improvement) and other roles, such as clinical leads are included, with over 80 per cent in England. Women made up a majority (around 57 per cent) of managers and just under 50 per cent of strategic roles (including board membership). Interestingly, 3,829 management roles were held by doctors, or just over 15 per cent.  This means that a large proportion of managers employed are effectively part time, in most cases, combining this activity with clinical practice. [ ¹¹ ]

Importantly, while the Binleys data counts lead nurses and directorate nurse managers, it does not include other, more operational nurse line managers.

Clearly, given these numbers, it is hard to argue that the NHS is ‘overmanaged’. At approximately 2 per cent, managers are a very small proportion of the NHS workforce. By comparison, ‘managers, directors and senior officials’ in the UK as a whole make up 9.5 percent of the workforce. [ ¹² ] As Stephen Black has argued, even medical charities employ more managers than the NHS. In reality, he suggests, the NHS is possibly “one of the most undermanaged organisations on the planet.” [ ¹³ ]

In recent years the number of managers in the NHS has actually fallen

Similar concerns apply when comparisons are made between the salaries of top managers in the NHS and their counterparts in the private sector. While the majority of NHS trust chief executives are paid under £200,000, some chief executives of large foundation trusts can be paid around £250,000 per annum.  The chief executive of NHS England and NHS Improvement, who is responsible for the NHS's annual budget of almost £150 billion and the service's 1.2 million staff, is paid around £200,000.

However, these salaries are well below those of chief executives running FT 100 companies of a similar scale. [ ¹⁴ ] For instance the chief executive of Severn Trent was paid £2.8 million last year [ ¹⁵ ] And if anything, the challenges, stresses and risks associated with managing NHS organisations are even greater. As one of the world’s leading management gurus, Henry Mintzberg famously observed: “Running even the most complicated corporation must sometimes seem like child's play compared to trying to manage almost any hospital”. [ ¹⁶ ]

Further exacerbating this problem is the fact that in recent years the number of managers in the NHS has actually fallen. This process began with the Lansley reforms after 2010 and the (largely hollow) promise to direct "more money on to the front line”. Since then the downward trend has continued. While the data are imperfect, for the NHS overall, Binleys notes a decline of roughly 16 per cent from 29,940 managers in 2007 (not including central functions) to the figure of 25,119 reported above (for 2018). [ ¹⁷ ]

*Accurately counting the exact number of managers in the NHS isn’t always easy. Nevertheless, a reliable source of information is the Binleys Database of NHS Management supplied by Wilmington Healthcare Ltd. Collected and published since 1991, a new updated version is published every four months. In the database, a ‘managerial’ role is assigned to any individual with decision making power, specifically in relation to budgeting, financial management and allocation of resources, with over 100 roles listed.

Fewer managers, rising workloads

Within NHS organisations, these trends mean that managers and clinicians have faced mounting pressures. This is notably true in primary care, where less than 1 per cent of costs relate to management. In the face of increasing demand (appointments are up 10 per cent from pre-COVID-19) doctors and nurses are desperate to get support from data scientists, project managers and administrators so that they can focus their time and effort on clinical work. However, they are finding the additional roles reimbursement scheme (ARRS) money for primary care can only be used for clinical or clinically associated roles.

Similar pressures are felt in secondary care. Over the past decade many acute trusts have grown in size, from approximately 3,760 full-time equivalent staff in 2009 to around 4,930 in 2017. Over this same period, the average number of managers also increased from around 65 in 2009 to 79 in 2017, but this has not kept pace with the larger size and complexity of acute trusts. While staff numbers rose by 31 per cent, the number of managers grew by only 21.5 per cent. Similarly, the ratio of staff supported by each manager increased from 58 in 2009 to 62 in 2017. [ ¹⁸ ]

Why do misconceptions about NHS managers persist?

So, to conclude, there is a marked gap between the media and political rhetoric about spiralling management numbers and the reality. The idea that the NHS, as one of the largest organisations in the world, employs an unjustifiably huge number of managers is plainly wrong.

There is a perception among the general public that managers are largely irrelevant for the delivery of healthcare

But why do these views persist? And, more specifically, why do misconceptions about NHS managers persist and continue to shape the policy debate? One answer, hinted at already, is that NHS managers represent an easy target for journalists and politicians who are either unaware or maybe uninterested in the consequences of these attacks.

There is a perception among the general public that managers are largely irrelevant for the delivery of healthcare. Spending money on managers is viewed as wasteful, with little attention given to the ways that managers routinely support and enable the work of clinical professionals to deliver services.

It is also worth noting that contemporary policy discourses about managers have deeper ideological origins. Public choice theory, for example, is a strand of economic thinking which emerged in the US and is critical of government and its bureaucracy. It argues that bureaucrats have no real public service ethos and their primary motivation is ‘rent seeking’, that is they want to use the organisation’s resources to obtain economic gain without giving anything back to society. According to this theory, bureaucrats are only interested in expanding their ‘empires’ by hiring more bureaucrats and in turn growing their salaries. [ ¹⁹ ]

In the UK, NHS managers have also been branded with this anti-bureaucrat rhetoric. The neo-liberal remedy is to reign back the state and the power of bureaucrats (including managers) to allocate resources by using private organisations that are incentivised to make profits instead. Following this logic, in the long-term competition and privatisation are the answer, not more managers.

As we shall see in the next instalment in this series, these arguments are far off the mark. This, of course, is not to turn a blind eye to management failures or to the need to invest in more training and regulation. However, while there is scope to improve management in the NHS, that is not the same as arguing – wrongly and in the face of overwhelming evidence – that the NHS is overmanaged.

About the authors

Prof. Ian Kirkpatrick is professor of public management at the University of York.

Prof. Becky Malby is professor of health systems innovation at London South Bank University.