NHS Managers: The Other Frontline?

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NHS Managers: The Other Frontline?
By David Buchanan

Almost everyone seems to agree that there are too many managers in the health service. But is this borne out in practice? Together with colleagues, I am currently working on an extensive study of NHS managers.

First, is it true the number of NHS managers has risen? The answer is yes. In 1999, the service employed around 20,000 managers and senior managers, and by the end of 2009 that number had ‘ballooned’ to almost 45,000, according to official statistics. However, total employment in the NHS has also grown over this period, and the proportion of managers has risen from just over 2 per cent in 1999 to 3 per cent in 2009. This is hardly a dramatic increase. And if one considers the pressures and demands that the service has been under over that decade - more stringent regulation, foundation trusts that are expected to operate as businesses, an increasingly complex funding regime, the ‘quality, innovation, productivity and prevention (QIPP) agenda - one might be astonished that the number of managers hasn’t increased by considerably more than it has.

But are all these managers supporting a bureaucracy that in fact isn’t necessary, and that if you chop back to the essentials, then many of them wouldn’t be needed? Certainly, the first part of this statement is absolutely correct: a lot of managers, especially middle managers, are supporting a vast regulatory regime. So when they are accused of being bureaucrats and paper shufflers, to some extent that is true. But they also play a major role in change, development and service improvement.

The regulatory regime – the bureaucracy – that they are accused of generating has in fact been generated by government policy. A review last year by the NHS Confederation identified 35 different regulatory, auditing and inspecting agencies to which healthcare providers are subject, and many of these agencies ask for similar information, but in different formats. That burden of regulation is externally imposed; this isn’t a bureaucracy that managers themselves have created. It has been created for them, and prevents them from performing their core management roles.

The popular political message at the moment is to ‘preserve front line jobs’ by cutting back on the non-essentials. If the ranks of managers were sharply diminished, would we miss out on much? The problem is, there is more than one front line. In healthcare, one of those frontlines, of course, delivers patient care. But there is another front line which delivers service improvement and change. And government policy is currently emphasizing the need for rapid, radical, transformational change in the NHS. Over the next three years the current coalition government is expecting the NHS to deliver twenty billion pounds (around a fifth of the current annual budget) in efficiency savings. Now that creates a challenging change agenda. Who is going to deliver that change agenda if management posts are culled?

If we want that other front line of change and improvement to be delivered, then the imperative is not to cut managers, but to free them up to do the job. The recipe to achieve this has two main dimensions. One is to simplify the regulatory regime; the duplication and micromanagement are stifling, and consume a vast amount of management time without adding significant value. In fact, we have come across a number of examples where experienced clinical staff, doctors and nurses, have been taken away from patient care in order to complete some of the audit and compliance paperwork which requires specialist knowledge.

The second component of change at the front line centres around the quality of clinical/medical - managerial relationships. Managers in the health service get a consistently bad press, and that interferes with their ability to work with clinical and medical colleagues. To deliver the changes and the gains in quality and efficiency that government and the public are expecting, and that most if not all NHS staff would support, better collaborative working relationships between clinical and managerial staff will be required. We need to find ways to strengthen those relationships. Instead of the fashion for teaching clinicians to be managers, a more effective strategy could be to develop in clinical and managerial staff the teamwork skills required to collaborate more effectively.

By all means, let’s protect front line jobs in the NHS. But let’s also recognize the other frontline, led by managers, delivering change and service improvement. NHS managers are currently juggling too many other issues, reducing the time and the energy that they can devote to organization development. Cutting management costs is superficially attractive and politically fashionable, but this is a deeply flawed policy. Financially, targeting a budget line item that accounts for only 3 per cent of annual spend is not going to generate significant savings. Strategically, this policy will diminish the capacity of the NHS to implement and absorb the changes that the government, the public, and NHS staff would like to see.

Acknowledgements: The research on which this presentation is based was funded by the National Institute for Health Research Service Delivery and Organization programme (award number SDO/08/1808/238, ‘How do they manage?: a study of the realities of middle and front line management work in healthcare’).

Disclaimer: This presentation is based on independent research commissioned by the National Institute for Health Research. The views expressed in this presentation are those of the author, and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

David Buchanan is Professor of Organizational Behaviour.

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