One of the hot topics for the election is yet again the call to reduce public sector bureaucracy. When it comes to NHS bureaucracy the link is immediately made to the NHS having "too many managers" and promises to "reduce the number of NHS managers". But in reality there is limited evidence that the NHS has too many managers and a growing body of research which suggests that rather than having too many managers, there may be too few, and that under-management could actually add to increases in the costs of running the NHS.
The King's Fund, the Health Service Journal and other expert commentators have attempted to debunk the myths around NHS managers.1 This blog attempts to summarise some of these arguments and present the Centre's overview of the issues.
In most industries managers are vital to performance and the NHS is no exception. Yet NHS managers do a vital job as part of the wider healthcare team, releasing clinical staff to spend more of their own time and scarce resources in caring for patients within a transparent and accountable system. In addition to day-to-day responsibilities for managing pay and performance, other resources and assets, NHS managers are responsible for managing an increasing number of challenging policy initiatives, such as waiting times targets; responding to the requirements of new regulators by implementing and monitoring new regulations (healthcare arguably the most heavily regulated of all industries). Managers are also responsible for collating and publishing measures of hospital and commissioner activity and performance; running staff and patient surveys and managing extensive contracting out of a wider range of support services.
Senior managers, are critical to planning how to improve access and move to a 24/7 service. They also keep patients safe by monitoring and holding clinicians to account for complaints, incidents, activity and outcomes data, obtaining answers for unwarranted variations in performance. But they also ensure clinicians have a fully functioning, equipped and well maintained workplace, while at the same time attempting to balance the books. Negative rhetoric not only damages morale and retention, it can also result in having to implement policies that undermine good management: such as restructuring and blanket pay freezes. Reducing the capacity and capability of managers means clinicians either sacrifice care to manage the necessary processes or focus on care and services fail.
An increasing volume of evidence shows good healthcare management is directly linked to the quality of patient care. This evidence demonstrates that good staff management offers significant financial savings for the NHS, "allowing leaders to respond to the challenge of sustainability in the face of increasing costs and demands". Patient mortality, infection rates, patient satisfaction, staff absenteeism and turnover are all influenced by the way that staff are managed. Staff surveys show that supportiveness of immediate managers and positive feelings about communication, staff involvement, innovation and patient care, directly predicts patient satisfaction.2
Twenty-first century technologically driven healthcare also requires more sophisticated management. These include appointment bookings, record keeping and safety monitoring. Managers support patients by planning and organising these appointments, signposting patients to the right services and helping to shape services around patient needs.
Mangers work with clinicians to identify equipment needs but mange the process of tendering/contracting and procuring the equipment. While clinical directors and directors of nursing lead the clinical and health professional workforce, the NHS also needs non-clinical mangers to ensure that the NHS has enough equipment; laundry, catering and cleaning; and properly maintained buildings.
The NHS spends over £100 billion of taxpayers' money a year, or nearly £2 billion every week, providing a universal, comprehensive health service, based on need and not ability to pay. Without managers to co-ordinate the complex interactions involved, the likelihood of an affordable, accountable, equitable, fair and safe system is unlikely.
New evidence on leadership and management, found that some three per cent of staff are "officially designated as managers", but around a third of hospital staff have substantial management responsibilities, many working in dual roles as clinicians and managers. Many middle managers in healthcare are also working in `extreme jobs', characterised by long hours, fast pace and high intensity (over half of those surveyed in a new study believed their jobs to be increasingly unmanageable).3
NHS Confederation analysis of NHS health and social care workforce data suggests that 2.6 percent are managers and senior managers, a percentage that has declined in each of the past four years.4 By comparison, Office for National Statistics data suggests that the proportion of managers in the UK's workforce as a whole was 15.4 per cent in June 2010. Meanwhile the King's Fund identified difficulties finding an accurate figure for the number of managers, given different definitions used. Its best estimates suggest that the NHS spends roughly £8 billion of its £100 billion budget on management and administration with roughly 77,000 hospital and health service managers or 4.8 per cent of the NHS workforce. At most the NHS managerial workforce is one-third the size of the management resources deployed by the wider economy. Moreover at a time when activity and numbers of other staff across the NHS are increasing, managers are decreasing.5
The adverse effect of the negative perception of NHS management is that more than a third of NHS trusts have vacancies on their boards, with increasing reliance on interims and 'churn' of senior leaders. This is especially the case in trusts in special measures where a loss of leadership risks creating strategic instability, wasting financial resources, reducing staff morale and affecting quality of care. Indeed the average time in post of an NHS chief executive is 2.5 years.6
Nor is pay that attractive. Given the limited supply of capable, experienced and willing applicants for senior positions you might expect that pay could and should be an inducement. Yet the reality is that the NHS Pay Review Body report for 2014 showed the mean annual total earnings for senior managers was £78,600 and for managers, £49,300 reflecting pay restraints over the past four years, with increments frozen and limited cost of living increases.
Attempts at denigrating NHS managers is bad for patients and reduces supply of talented staff needed to run an effective NHS while undermining patient and public confidence in healthcare. The political and media clamour for greater transparency, better comparable performance data to inform choice, drive accountability and improve quality - all come at a cost - and the cost is investment in good quality, effective management. A conundrum that needs to be resolved as soon as possible.
Footnotes
2 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215454/dh_129658.pdf
5 http://www.kingsfund.org.uk/topics/nhs-reform/mythbusters/nhs-managers
6 http://www.kingsfund.org.uk/publications/leadership-vacancies-nhs
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