In defence of NHS managers: a response to the Conservative plan to cut 5,500 posts

NHS managers are once again under attack. To generate funding for much needed new GP surgeries and treatment centres, the Conservatives have suggested slashing NHS manager numbers to pre-COVID levels. It’s not the first time we’ve heard such a call. Over the last parliament, a string of politicians have demanded cuts in the number of ‘NHS bureaucrats’ and railed against ‘useless’ or ‘incapable’ managers. 

This week’s announcement does recognise the ‘important role that managers play in supporting operational processes’ and pledges to focus the cuts in non-front-line organisations. But these nuances have, unsurprisingly, been lost in much of the coverage. What’s left is the impression that NHS management is a burden rather than a benefit to the service, and something that can be scaled back without any negative repercussions. 

The value of managers

Such a narrative flies in the face of evidence that management is key to the NHS’s ability to deliver on its current priorities and drive its future transformation. It’s also contrary to arguments within government circles about the value of management. For example, the recent Messenger review of NHS leadership and management – commissioned by a former Conservative health secretary – couldn’t have been any clearer about why management matters. Ironically, it’s sometimes the same people who argue the NHS has too many managers, or that they’re overpaid, who also argue that the NHS should ‘be more like the private sector’ – but the NHS has proportionately fewer managers than the wider UK economy, and its managers are often paid less than equivalent roles in the private sector.

Why are NHS managers seen as disposable?

Lack of visibility may be one reason. Few of us ever see a manager in our encounters with the NHS, or hear about the work they do to keep the service running. But they are often responsible for large, complex services with multimillion-pound budgets that employ thousands of people. And with the honourable exceptions of bodies like Proud2bOps and Managers In Partnership, managers don’t have the same range of influential advocates in their corner as the NHS’s clinical professions have with their royal colleges and other professional bodies. It’s easy to see why negative perceptions of managers take root and are so hard to shift. 

What can be done to improve the perception and experience of NHS managers? 

The first priority is to bust the myth that an NHS stripped of its managers would lead to better, more responsive patient care by releasing resources to the front line. Look at the experience of Google, which once did away with its project managers in the belief that its engineers would flourish in their absence. The experiment didn’t last long. Without anyone to keep delivery on track, provide feedback, disseminate key information, troubleshoot problems and resolve tensions within the team, staff morale and performance soon suffered. Managers were brought back. 

This offers a cautionary tale for those who want to ‘liberate’ NHS clinicians by cutting management numbers. Interestingly, the Health Foundation's recent deliberative research found that while the public want to see the NHS reduce waste, they often point to waste arising from the absence of good management – administrative and communication failures, poor staff retention, poorly maintained equipment, and so on – rather than from having too many managers.

Second, NHS leaders and policymakers need to be far more bullish and upfront about the positive impact good management has on the service. There is no shortage of evidence to this effect. One seminal study led by Nick Bloom revealed a strong association between the use of good management practices in health care and a range of improved quality and financial outcomes. Elsewhere, research by Ian Kirkpatrick found that an increase in managers, from 2% to 3% of the workforce, was associated with a 15% reduction in infection rates and a 5% improvement in hospital efficiency. 

Third, a better understanding is needed of the NHS management population and their training and support needs. At present, we don’t even know for certain how many NHS staff have management responsibilities, let alone whether they have the training and support necessary to do their jobs effectively. The national statistics we have miss large numbers of clinicians who have management responsibilities, and there is a dearth of up-to-date evidence about the day-to-day experiences of NHS managers. 

Research from the late 2000s characterised the role of the NHS middle manager as an ‘extreme job’ given the stress, pace and intensity of the work and the constant ‘firefighting’ it entailed. This intensity is, if anything, likely to be greater today given the resource and workforce pressures facing the NHS and the ever-widening remit of managers – due to, among other things, increased partnership working at the system level and the need to embrace new technology, AI and data systems. These challenges need to be better understood before the NHS can decide how many managers it needs, where they should be deployed and what skills they should have – which is why the Health Foundation is commissioning new research on this topic.

Ultimately, divisive narratives that pit clinicians against full-time professional managers are neither helpful nor accurate, not least given the fact that many clinicians today are themselves managers and leaders. Instead, what’s needed is efforts by government and employers to challenge negative perceptions of NHS managers and better acknowledge their contribution to the NHS – something that will be particularly important if the health service is to recruit and retain the talent it needs to tackle its current and future challenges.