More managers improve NHS Trust performance

10 July 2017

  • Research finds NHS would work better with a rise in manager numbers
  • Increasing ratio of managers produces improvement in patient care
  • Efficiency and other measures also increase with more managers
  • On average an NHS Trust will have 68 managers running it

New research looking at six years of NHS data has found that more managers lead to NHS Trusts performing better.

Warwick Business School’s Ian Kirkpatrick, alongside Gianluca Veronesi, of the University of Bristol, and Ali Altanlar, of the University of Leeds, used publicly available statistics to measure around 150 acute hospital trusts in England from 2007 to 2012 and found those with a higher level of managers had better outcomes, including improved patient care.

David Cameron’s coalition Government put cutting managerial positions and bureaucracy at the heart of its NHS reforms that led to the Health and Social Care Act 2012.

But, against expectations, researchers found that managers have a significant impact on performance.

Related course: Executive MBA with Healthcare Specialism

Professor Kirkpatrick said: “Contrary to what many policymakers and media commentators would have us believe, our research suggests the NHS is not ‘over-managed' and that managers, as a group, are making significant contributions to efficiency and improved patient care.

“The evidence shows, overall, the positive contributions of general managers appear to be greater than the costs and risks associated with ineffective management.

“This, we believe, is an important finding, and one which should not be ignored as the NHS gears up to deal with the very considerable funding and organisational challenges that lie ahead.”

Today there are close to 40,000 general managers in the NHS, within a total workforce of 1.36 million. Clinical professionals in management roles make up approximately 30 per cent of this number, with the remainder coming from administrative backgrounds, including accounting and business.

Why does the NHS need more managers?

In the paper, Corporatisation and the Emergence of (Under-Managered) Managed Organisations: The Case of English Public Hospitals, published in Organization Studies, the sample managers made up approximately two per cent of the workforce, with an average number of managers for each trust being 68. But in the UK managers make up 9.5 per cent of the workforce, according to the Office for National Statistics. Indeed, from 2007 to 2012 the average ratio of managers to staff in the NHS fell by nine per cent.

The researchers found that a one per cent increase in the management-to-staff ratio of acute trusts - with managers rising from two to three per cent of the workforce - would place those trusts in the top third of trusts in terms of performance for efficiency and patient experience (satisfaction) scores.

This equates to having 39 more managers in the trust and translates into a three per cent improvement in trust efficiency and a two per cent improvement in patient experience (satisfaction) scores.

“We found that higher levels of managers in a trust had a statistically significant relationship with improved outcomes in terms of infection rates and hospital patient experience scores,” added Professor Kirkpatrick.

“Further tests exploring the impact of management pay and stability levels also yielded positive results, showing that when average levels of pay and stability are higher, managers can have an even stronger positive impact on patient experience and efficiency.”

In a final test, the team looked at whether there was a tipping point after which the impact of increasingly high ratios of managers at high pay and stability levels, stopped having a positive impact on outcomes.

The results show that beyond a critical peak, the positive effects of higher proportions of managers progressively diminishes where infection rates and patient experience outcomes are concerned.

This, however, was not the case for efficiency, where rising numbers of managers - with higher pay and stability - lead to successively better performance.

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“The findings call into question many of the assumptions about the failure of general managers in the NHS,” said Professor Kirkpatrick.

“On the contrary, they suggest that despite being relatively few in number - compared to, say, private businesses - managers are making a very significant contribution to the performance of health services, at least in the hospital sector.

“Of course, this is not to suggest that general managers always do a good job. The experience of Mid Staffordshire and other failing hospital Trusts is testimony to that fact. Nor do our findings rule out the possibility that the NHS has become overly bureaucratic with too much time devoted to administration and form filling to comply with targets.

“But the evidence suggests that overall managers make a positive contribution to the running of Trusts.”

Ian Kirkpatrick is Monash Professor of Healthcare Improvement & Implementation Science and teaches Healthcare Improvement on the Executive MBA (London).

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