What next for NHS management? Messages for Messenger

Key points

1. The habit of denigrating managers in the NHS is misplaced and counter-productive. At worst, it channels investment away from management and administration, forcing busy clinical professionals to pick up the slack, exaggerating the workforce crisis and preventing reform. The cumulative effects of this could exacerbate the workforce crisis and hold up much needed reforms in the NHS.
2. Policymakers should change the narrative about NHS managers, to view them as part of the solution. This could imply a commitment to increasing investment in managers to a level which is closer to the average in other sectors across the UK.
3. Linked to the wider People Plan, the NHS should develop a workforce strategy for the future employment and development of managers as an occupational group, including clinical leaders.
4. The NHS should invest in new data science management capabilities to support ongoing service improvement work. By strengthening in house capabilities, the NHS could reduce its (expensive) reliance on external management consultants.
5. Wider governance and regulatory demands in the NHS should be adjusted to empower managers and create more space for local innovation and service improvement.

Introduction

Writing over a decade ago, Professor Sir Chris Ham, now co-chair of the NHS Assembly, warned against the ‘denigration of managers and the role they play in delivering high-quality health care’. He went on to say ‘without managers nothing happens…from deciding on and buying the weekly grocery shop to designing, building and running the giant atom-smasher at Cern.’ [ ¹ ]

Managers make a distinct contribution as the people who organise care, fix problems and ultimately take responsibility for the delivery of services

This conclusion remains valid today. While some politicians and media commentators associate managers with waste and red tape, across our series we have shown that these views do not hold up to scrutiny. The NHS is not overmanaged and nor has it ever been so. Managers also make a distinct contribution as the people who organise care, fix problems and ultimately take responsibility for the delivery of services. 

In this long read we now turn to the question of what should happen next. General Sir Gordon Messenger and his team will form their own conclusions, but for us, any future shopping list for policy would, ideally, include four main commitments.

Changing the narrative

First, we desperately need to change the narrative about NHS managers, re-framing the narrative so that managers are viewed not as the problem, but part of the solution. For politicians and the media this requires an end to the popular but ultimately destructive pastime of manager-bashing. Myths about excessive NHS management must not be unchecked as they shape public opinion and become the dominant logic through which policy is filtered. Rather than sitting back and observing these stories, the NHS needs to mobilise the evidence and the real lived experience of those who work in it, briefing MPs, town councils and national and local media to ensure they have the facts to hand.

Clinical professionals also need to be part of this exercise. While interest in leadership has grown in recent years – moving from the ‘dark side’ to centre stage [ ² ] – doubts about the value or even necessity for management are still deeply rooted in the occupational culture of medicine. Powell and Davies, for example, concluded that even after three decades of reform there is a pressing need for ‘dialogue and conflict resolution’ to improve ‘doctor–manager relationships.’ [ ³ ]

This of course is not to suggest that clinical professionals should hold back from challenging managers, especially when mistakes are made. Rather it is to encourage a new ‘compact’ between clinicians and society – one that encourages dialogue and recognises the legitimacy of management as a process for delivering and improving healthcare in the wider public interest. [ ⁴ ]

Ultimately, for an alternative narrative to be persuasive, it must be grounded in practice. This could mean that the NHS re-states its commitment to invest in management and leadership. However, in our view it should also imply new ways of signalling that commitment. For example, as part of any national workforce plan, the NHS could increase investment in managers to a level that is closer to the national average for other UK organisations. As we have seen in previous long reads, the NHS is currently ‘undermanaged’, so these investments are likely to pay dividends. This is especially in primary care where expenditure on management is currently running at below 1 per cent of total costs.

A management workforce strategy

Second, the NHS needs to be more strategic in its approach to developing management capabilities and careers.

Elements of this are of course already in place. The NHS Graduate Management Training Scheme was established in 1956 and now recruits 300 new trainees annually. The NHS Leadership Academy, part of the NHS People Directorate within NHS England and NHS Improvement, also runs a variety of courses aimed at strengthening management and leadership development at all levels. [ ⁵ ] While there is clearly scope to enhance the quality of these programmes, the evidence suggests that they can be beneficial, enhancing individual-level outcomes (such as knowledge, motivation, skills and behaviour change) and services. [ ⁶ ]

Nevertheless, the development of managers in the NHS has, for the most part, been unplanned and ad hoc. Take for instance the implementation of the Productive General Practice Programme. [ ⁷ ] This emphasised the need to reduce pressures on GP time by improving administration and professional services functions. However, no clear workforce plan was agreed.

It is essential for the NHS to think about the workforce planning of managers as a discrete occupational group

This absence of planning had dangerous consequences. While primary care network (PCN) leaders were able to recruit into diverse clinical roles (under the Additional Roles Reimbursement Scheme – ARRS), they had no means to re-allocate managerial and administrative work. This subsequently led to a very costly problem of rising workloads during the pandemic. According to the BMA: ‘Way more funding is needed for management. Coordinating clinical work is time consuming and complex, let alone the work involved setting up relationships with other parties who have no contractual requirement to do so. To think that this management support is possible on 50p per patient is totally unrealistic.’ [ ⁸ ]

It is therefore essential for the NHS to think about the workforce planning of managers as a discrete occupational group. This is different from the investment in leadership. The NHS focus on leadership and particularly systems leadership is critical for the complex challenges facing the NHS. But it has meant the NHS has taken its eye off the ball in terms of planning the management workforce needed to support the ambition for systems leadership.

A model for this could be the NHS People Plan, focusing not just on talent management (to recruit, retain and develop managers), but also staff wellbeing, working patterns and diversity. [ ⁹ ] In our view, such planning should extend beyond clinical professionals [ ¹⁰ ] to other groups, including managers.

Taking this step also means focusing on the development of all managers, not just senior leaders. This would include clinical leaders such as senior nurses or doctors who take on hybrid ‘professional-manager’ roles.

As we saw in the previous long read for this series, there is now growing evidence to suggest that clinical leaders at the board level of NHS organisations can have a significant impact on performance. But while there have been moves to invest in these roles, including the formation of the Faculty of Medical Leadership and Management, more needs to be done. Many hospitals have little or no management or leadership development for their consultants, or directorate leads, and that is mirrored in primary care where opportunities for GPs to develop these skills are sparse. [ ¹¹ ]

It is also notable that few NHS organisations engage in succession planning to support doctors moving into executive roles (such as board membership). Unlike some high-performing health systems in the US (for example, Kaiser Permanente), in the NHS there are no structured career routes for medical leaders and the rewards associated with it are negligible. [ ¹² ]

Invest in new capability

Third, as part of a workforce strategy the NHS also needs to invest in new management capabilities. Data scientists and analysts are a prime example. Despite being a world leader in the collation of big data – including state-of-the-art tools, such as the Model Health System [ ¹³ ] – the NHS has historically not invested in managers with data science expertise.

By all accounts this has been a mistake. One key lesson from the pandemic was the power of real-time, data-informed decision-making [ ¹⁴ ]. This commitment to data to enable professional practice decision-making, by embedding real-time data into healthcare teams, is at the heart of high-performing health systems such as Buurtzorg [ ¹⁵ ] and Intermountain Healthcare. [ ¹⁶ ] In all these high-performing systems: ‘Information plays a critical role in analysing and improving care.’ [ ¹⁷ ] 

In the NHS the relative scarcity of in-house data science expertise to support this work has contributed to the growth of outsourcing to management consultants. Most recently, plans have been announced to spend up to £42 million on seven external management consultancies (including McKinsey, Deloitte and KPMG), some of it to provide analytical support for the management of waiting lists. [ ¹⁸ ]

These contracts have become day-to-day practice in the NHS, acting as an ‘assurance’ for NHS England and NHS Improvement and the Treasury. However, while this may sound reasonable it is also problematic. Our research has shown that far from securing efficiency gains, the big spend on consultancies (NHS trusts spend on average £1.2 million annually) actually leads to rising inefficiency, with no impact on quality-related outcomes. [ ¹⁹ ] Furthermore, our latest analysis (unpublished) reveals that NHS trusts that have invested more in managers that are able to support ‘internal consulting work’ tend to perform better (in terms of efficiency) than those trusts which rely mainly on external consultants.

An enabling environment for managers to perform

Lastly and more controversially are concerns about whether NHS managers have sufficient autonomy to deliver meaningful improvements. In an earlier long read we noted that managers do often face significant constraints linked to regulatory standards and requirements. In our view this does not remove all opportunities for managers and clinicians to innovate. Nevertheless, it does beg the question: what might be achieved if NHS leaders were allowed to exercise even greater discretion?

When considering this matter it is again useful to look at the recent experience of the COVID-19 pandemic. On the one hand the management of the pandemic response highlighted some of the familiar hidden costs of top-down control in the NHS. Over the past two years, central directives have been frequent, absorbing significant management time and effort.

An example is the vaccination as a condition of deployment (VCOD) policy. This required hundreds of hours of management time consulting staff and preparing dismissals – of people they valued – only to find the decision reversed at the last minute. [ ²⁰ ] 

The public announcement of booster vaccine availability on a Sunday evening, without prior notice to the NHS managers and GPs, meant across the country those primary care leaders were forced to work through the night to ensure that the capacity was in place. There can be no other management workforce that receives its delegated work in this way. Indeed, the fact that NHS leaders were prepared to then spring into action on a Sunday evening is a testament to their commitment and professionalism.

In some areas, the NHS has been able to reduce bureaucracy and empower managers to get things done

However, during the pandemic there is also evidence to suggest that many clinical professionals and managers were able to innovate and exercise greater autonomy. [ ²¹ ] We found that, in responding to the pandemic, the NHS was able to adopt many of the characteristics of high-performing health systems, moving away from the overreliance on central control. For example, noting how ‘CQC disappeared the minute the pandemic started…’ one manager explained: “I see things happening very quickly now, making decisions and getting on with implementing them immediately rather than having to go through all the usual red tape’. Therefore, it seems that in some areas, the NHS has been able to reduce bureaucracy and empower managers to get things done.

Thinking ahead, we believe it is essential for the NHS to build on and extend these new ways of working. In a recent report commissioned by the NHS Confederation, Professor Sir Chris Ham argues that the time is now ripe for the NHS to reassess its operating model, shifting the balance from top-down control to local autonomy. [ ²² ] In our view, this would also complement other policies aimed at enhancing the status of NHS managers and workforce planning. Indeed, we envisage a virtuous circle whereby moves to strengthen management capabilities and invest in workforce planning increase both the ability and willingness of policymakers to relax control.

Conclusion

In this series we have tried to focus on the evidence base to dispel a number of myths and misconceptions about NHS managers. We have demonstrated that the NHS is undermanaged and that investment in management and professional support functions is essential.

Progress can only be made if NHS managers are viewed not as part of the problem, but unambiguously as key to the solution

Needless to say, we hope that General Messenger and his team will take these concerns seriously. Indeed, we think it is essential for them to do so because prejudices and assumptions about NHS managers are getting in the way of helping the NHS face the biggest challenge in its history.

On a more positive note, we also feel that this challenge is not unsurmountable. More investment in the management workforce is needed to increase its diversity and effectiveness. So too is a workforce plan focusing on staffing levels, careers and wellbeing.  But underpinning all of this needs to be a mindset change. Progress can only be made, we believe, if NHS managers are viewed not as part of the problem, but unambiguously as key to the solution.

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.