Six reasons why the NHS needs more managers
10 June 2019
By Ian Kirkpatrick
The NHS is, it seems, in perpetual crisis, as it struggles to cope with a litany of familiar and mounting problems: an aging population, the increasing complexity of elderly patients with multiple illnesses, public health issues and huge financial pressures.
In the past managers have been brought into the NHS to help address its problems, but they have built up a negative public image.
The media is very cynical of managers, often referring to them as ‘pen-pushers’ or ‘time servers’ who absorb resources and contribute nothing. Frequently managers are portrayed as obsessed with targets and not interested with patient care in a rumbling tension with clinicians and frontline staff.
Yet research uncovers a different story, that managers are in fact just as vital for the survival of our NHS. This was the conclusion of the 1983 Griffiths report, which first recommended the need for managers.
Sensibly it called for doctors and nurses themselves to be the managers, but this idea was initially resisted by the professional establishment. In response, managers were brought in from the private sector.
Today the NHS has its own internal manager training scheme, with the number of managers now at 35,000. These managers are clinical and non-clinical. In fact, around 30 per cent are doctors or nurses who are part-time, hybrid managers, such as clinical directors.
But, while management in the NHS has expanded, it is not bloated. In reality there are surprisingly few managers. In a workforce of around 1.5 million less than three per cent are managers compared to six or seven per cent in the UK economy as a whole.
Managing in the NHS is also a high stress job and turnover is high. The average CEO lasted just two and half years during the ‘targets and terror’ regime of Tony Blair’s New Labour Government.
Despite this, the NHS needs these managers and here are six reasons why:
1 More managers will be better for patient care
Evidence from acute hospital trusts in England suggests managers add value in terms of patient experience and even clinical outcomes are improved.
There is plenty of evidence also showing managers are committed to public service and the NHS, after all they could be earning a lot more in private companies.
Research shows the performance of managers increases when they are paid more and when they have longer contracts. It also reveals that more clinicians in management improves hospital performance, especially if they sit on the boards of hospitals.
2 Complex organisations like the NHS need management
Managers provide necessary expertise in the co-ordination of services, without which the NHS would not be able to function.
Indeed, the more complex an organisation the harder it is to organise, and they don’t come more complex than the NHS, which is the fifth biggest organisation in the world.
Clinicians are too busy to perform all of this co-ordination work, so we need dedicated and well trained managers to keep the show on the road.
3 Managers take responsibility for efficiency as well as quality
The word efficiency may ring alarm bells for some people, but it is not about cost-cutting. It means delivering good results at lower costs and getting better value for money for the taxpayer (which means all of us). It doesn’t mean undermining quality or equity (equal access for everybody).
Efficiency is important in a tax-funded system where there is more demand for less money. Clinicians look to provide the best quality service possible - that is how they are trained - but left to their own devices costs would spiral.
Lord Carter’s 2016 review of acute hospitals in England found “unwarranted variations” in service, ie inefficiencies, which, if addressed would save the NHS £5 billion.
Only managers, in partnership with clinicians, have the time or expertise to address this challenge. There is a lot of evidence-based knowledge that takes forever to be put into practice on the frontline - and some of it never gets there - or it is patchy, with one trust using the new treatment and another next door not. This could be dealt with if the NHS had more effective management.
4 Any NHS revamp needs managing
It is becoming obvious that the current UK healthcare system is not fit for purpose because of an aging population, plus increasing demand for mental health services and public health issues like obesity that could be solved with better preventative measures before people need hospitalising. That requires reorganising and integrating services. But who is going to oversee that?
You can have clinicians leading it, but you also need managers to assist that process. Clinicians do specialised work in silos so they often don’t have the big picture.
Managers can help to visualise that bigger picture, to think about how the system needs to be organised or configured to suit the changing needs of populations.
5 Managers can shield clinicians from political fall-out
NHS organisations face public scrutiny, because they use a lot of taxpayers’ money, so their reputation is important. Managers provide a boundary management role, absorbing that public scrutiny and maintaining the hospital or trust’s reputation.
When this works well it creates air cover for clinicians to get on with what they need to do. The NHS has endless performance targets and this is not likely to change as the public (rightly) demands accountability.
But somebody has to collect that data and front the organisation in dealings with the public and politicians - that is what managers do, so clinicians can focus on what they do best, curing patients.
6 Cheaper and better than management consultants
The cost of bringing in external expertise - ie management consultants - is far too high for the NHS. But if you don’t have enough managers, you have to bring in consultants.
On average trusts spend £1.2 million a year on consultants, with the total bill being £640 million in 2014 and yet data shows that they make hospitals less efficient.
Let’s have more in-house mangers who are committed to the NHS and know it better to do this work. Public managers - with a capital ‘P’ - that manage in the public interest, and work in partnership with clinical professionals rather than control them, would deliver better results.
Ian Kirkpatrick is Monash Warwick Professor of Healthcare Improvement & Implementation Science and teaches on the Executive MBA (London).
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