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NHS is undermanaged not overmanaged, finds major report

A major study has called for the government to “rethink” cuts to administration and management after finding no substantive evidence that the NHS is over-managed.

The report by the King’s Fund Commission on Leadership and Management in the NHS found the health service in England was “over administered” but not over managed, despite claims to the contrary.

It concluded: “There is no substantive evidence that the NHS is over-managed. There is appreciable evidence…that it is under-managed – even if some of that management may not always be highly effective and is centred on the wrong things.”

The 2010 NHS white paper announced 45 per cent cuts to management to tackle “excessive bureaucracy, inefficiency and duplication” and a document accompanying the Health and Social Care Bill set out a “one third real reduction in administrative spending by 2014-15”.

The commission called the targets “simply arbitrary” and said ministers and the DH should “re-think” the cuts.

It said the result of creating new bodies, such as consortia and health and wellbeing boards, “is likely to be an increase in management and administrative posts, not a reduction, and not necessarily an improvement in either management or leadership.”

Commission chair and King’s Fund chief executive Chris Ham told HSJ the NHS may not be able to “keep control” of its finances if it loses too many managers.

He said: “There has already been a loss of experienced leaders… that is to be regretted if we don’t now have in place people who have been in the NHS before when finance was tight.”

He added: “If the government wants to cut back on management costs it has to look at how those costs arise in the first place.”

The commission found the rise in the number of managers in the health service in England since 1997 was not matched in the rest of the UK. It said much of the administrative burden was due to “targets and terror” and demands from government.

Waiting time targets, patient and staff surveys, data transparency and patient choice as well as private sector involvement and increased regulation had all been more prevalent in England, the commission said. “All that requires much administration and some management,” it said.

The policy of replacing single waiting time targets with multiple performance measures “can only add to the NHS administrative and possibly management costs”, the report said.

Some money could be saved through sharing back office functions, but the policy was “more likely to lead to financial failure than an improvement in patient care”.


Readers' comments (26)

  • "much of the administrative burden was due to “targets and terror” and demands from government."
    This analysis is spot on.
    "creating new bodies, such as consortia and health and wellbeing boards, “is likely to be an increase in management and administrative posts, not a reduction, and not necessarily an improvement in either management or leadership."
    Is apt warning.

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  • Rational thought based on actual evidence. Hopefully this will have significant influence on the listening exercise currently underway.

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  • Ahhhhh. Fantastic. Finally the KF takes up the mantle.

    Now that it influences the finances at their disposal we might even see the GP professional bodies line up with the evidence on this for once, but I wont hold my breath.

    See also the excellent article from Leeds business school which states:
    - required management costs likely to go up under reforms
    - NHS management costs way below peers anyway.

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  • David Hooper

    I cannot but agree with Chris Ham's analysis. Anti-managerialism has been a stance of the party of this government for a decade or so now. It also conflates the concepts of bureaucracy and management, and fails to distinguish between management and administration.
    The analysis rightly points out that much administration is created through the demands of politicians (of all parties). This does not mean that there is not waste nor that the status quo should be preserved. A bit of rigorous and non-dogmatic thinking is required by those in government - but that might be too much for even the most optimistic of us to expect.
    The notion that must be abandoned is that which holds that if a person does not hold a scalpel in the hand, or wear a fob-watch on the uniform (for the literal minded, these are metaphors) then that person must be unproductive - and doubly so if they wear a suit.
    But then I live in hope for an increase in rationality, even amongst politicians!

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  • Diane Ridgway

    Trust Chris Ham to talk sense and back it with data unlike the 'finger in the wind' guessing of a government trying desperately to reassure and convince the public that after all this time waiting Mr Lansley did not draw his plan to dismember the NHS on the back of a fab packet over a pint of the local brew. Ditto 8.04 - let's hope they listen - Chris Ham for the next health secretary- nah - he tells it as it is and unlike the government actually talks sense!

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  • Imagine if there was an abundance of management support available. I wouldn't have to work 12 hours+ every day......

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  • Fantastic, NHSLondon have already implemented the the cost savings in a most brutal way losing some new young and bright managers , Ms Carnage trying to be best in class and please teacher.It has been too fast and insufficient little thought has been given to what jobs need be done, some were left out altogether our cluster ommitted to include LD and part of the IT team. We already have replaced previous interim managers with new interim managers post re- organisation. No doubt this will enable NHSL to spend the money saved on management consultants to come up with lovely new ideas to impress teacher again without actually delivering anything.

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  • You administer great institutions and systems; justice and the NHS.

    You manage banks.

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  • David Hooper - bang on, sir. Unfortunately, if the DH continues to label NHS management as "adminsitrators", as they have done recently, then your hopes, although laudable, will be ultimately undelivered!

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  • Excellent report and evidence-based conclusions. Just one small problem - it's a year too late.

    So many good managers have already gone, the political direction is set (listening aside) and the public perception that managers are the problem not part of the solution has been reinforced.

    Still, made us all feel better for a moment I'm sure.

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  • Agree with the last post 11.39. too little, too late. Wouldnt have made much difference a year ago though, if you wanna lose NHS staff, who you gonna cull ? The public know what doctors and nurses do, but management have always been the bad guys.

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  • perhaps one way for the private sector to make significant inroads into the NHS will be the need to replace experienced NHS managers with people from the private sector.
    It is clear this government are hell bent on transforming the NHS, and it's ethos, toward a market system.
    The current travails of the progress of Lansley's bill is merely a reflection of growing concerns within all professional groups as to where the NHS is going.

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  • Some great posts here..David Hooper were it in my gift I would knight you! Ever thought of standing for Parliament? You should, you'd be great.

    Unfortunately, I too think it is too little, too late. What this horrid gov is doing to public services is wholly wicked and bodering on criminal. They have indeed 'forced out' some great people not prepared to be the last one saluting whilst the good ship NHS sinks below the waves. And who can blame them? But they have learnt nothing from the plethora of previous ill-thought out re-structures remember CaPLNHS or StBOP?

    We the people are standing by and letting this bunch of unmandated wreckers destroy our public services. Good on the KF for challenging this plank of Tory wisdom. Let's hope that others follow suit.

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  • I am not sure this report makes a very compelling argument, probably because the question posed if the wrong one. The question of whether the NHS is over or under managed is almost irrelevant. The question ought be is the NHS well-managed. And we have to be honest and say that in many parts its not. If the NHS had the number of managers it does and it delivered strong outcomes, no-one would be complaining. But the sad fact is that day in and day out people continue to have frustrating experiences of care - jammed GP lines, poor access, cancelled appointments, lost medical notes, re-referrals from one place to another, delayed care due to CAS systems with no evidence base. Instead of looking to the centre and criticising, perhaps its time we looked at ourselves as a profession and asked if we really are up to scratch.

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  • Steven Burnell

    £20Billion will only be sustainable if it comes from evidence-based, consensual, intelligent, patient-focused Design. This requires greater Investment in strong Leaders & competent Managers, & better Tools to support decision-making particularly as the £20Bn is not about simple Cuts but must include optimal Resource re-Allocation Decisions & better Investment Choices. More than anything, you have to Invest the time & energy & get the data if you want to deliver sustainable QIPP & to do this there must be a level of "productive administration" because even the people in the 'back office' can & must make a big, positive impact on Delivering Optimal Care, by Design.

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  • Well done on this report. Much of the management structures and "bureaucracy" have been generated in response to meeting the demands for information and assurance from on high. Each time there's a systems failure we're required to give yet more assurance by filling in more and more paperwork and processes but in reality this will not stop systems failures happening in the future because this is not the answer; it's the culture and quality of leadership that matters. Over the years we've seen many reviews on reducing the burden of bureaucracy from above but seen a very limp response if we've seen a response at all. I really hope the high profile and timing of this report means that this time things may just be different, but it will be a triumph of hope over experience

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  • How much management time and effort is wasted on spruious assurance processes.

    It was when I, in the PCT, was asked by the SHA because they had been asked by the DH to provide the data that formed the evidence of how we had assurred ourselves that the data we had supplied to confirm that we had assured ourselves that the data we had requested from the Acute Trusts to support the Stroke Assurance Framework which assured everybody the the stroke strategy was being delivered was correct that I gave up fighting and just got them the data as best I could and started looking for a more meaningful job!

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  • Anon 6:14pm "But the sad fact is that day in and day out people continue to have frustrating experiences of care - jammed GP lines, poor access, cancelled appointments, lost medical notes, re-referrals from one place to another"

    All these parts of the system are run by the clinicians not the management structure. And their in lies the problem. Clinicians have got too used to been a law until themselves and until there is proper collaboration between the clinical and managerial sides of the Trusts not much will change. You only have to go back and watch the Gerry Robinson series when he failed to get the clinicians to engage and work properly with the management of the hospital how disjointed it all is

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  • anon 12.39pm makes the critical point in response to anon 6.14pm - these are most definitely clinicians and in the case of jammed GP lines the very clinicians we are entrusting with £80billion of public money! Often many of the ill's in the NHS are caused because we are trying to cope with ever increasing demands and expectations with antiquated systems. So what do we do in response? Rubbish the idea of a national NHS IT system and dump connecting for health. Only in the UK would we be so short-sighted - we reap what we sow.

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  • There is a big irony in the current direction of travel. The dogma of the Conservatives is for further marketisation of health. This creates more transactions and inter-relationships that need to be managed. A health market can't be allowed to fail because people die. So the irony is that you would be stripping back management at exactly the same time as you need it to manage the new system as it becomes more complex and produces unintended consequences. It's time to listen to facts and not simple headline narratives! But remember the Milton Friedman economics of the Neocons is all about deliberately creating instability/panic/chaos to drive change!

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