Middle managers are at the front line in delivering effective care, yet they are often neglected and undervalued

Much of the change in the NHS in the past 20 years has been about structures - the creation of government agencies, foundation trusts, internal markets and outsourcing. With these have come target setting, performance measurement and debates about positive results, unintended consequences and whether or not patients really benefit.

These structural changes have firmly put accountability into the hands of senior management and changed the way in which public sector organisations operate, achieving a stronger customer and commercial focus. However, it has been much harder to deliver productivity improvements.

This latest challenge to drive efficiency can either be seen as more hassle for embattled managers or an opportunity that will re-energise organisations. By getting rid of wasted time and effort, improvements in productivity will be better for patients and will make life easier for staff and their managers.

So why do we need special initiatives and programmes to improve performance and productivity? Why isn’t it a matter of course? How will the challenges of reducing budgets and increasing costs be met?

Middle managers are at the front line in delivering safe and effective care, so they have a key role to play. Yet they are often a neglected and undervalued group. They can be seen by senior managers as a barrier to achieving change, rather than an enabler.

This is a hard group to support. Middle managers are very much part of frontline delivery and the daily achievement of safe and effective care. They have often grown into their roles and may not have had training in management skills. They also often feel disempowered by the rules, regulations and bureaucracy of the working culture.

Senior managers tend to see middle managers as obstacles that resist their plans and who struggle to put in place what is asked of them. Senior managers get frustrated when middle managers seem incapable of handling issues such as sickness absence and poor performance.

Bearing the brunt

In one organisation of 3,000 staff in 14 locations, the staff survey showed that middle managers were particularly demotivated. Dedicated lunchtime meetings revealed their issues.

They were unequivocal that communications and engagement were getting stuck. They took the brunt of the issues around service delivery and staff, but were not able to get access to senior managers, who were being brought together in conferences and other meetings to discuss the organisation’s strategies and plans in isolation from their junior colleagues.

It really helps to reach out to middle managers, engage in some active talent spotting and allow innovation to develop within teams, rather than be pushed down from above.

In one organisation, we had a manager who was keen to apply lean techniques to the way his department operated. So we let him get on with it. His enthusiasm was infectious and his teams quickly found a number of ways to make their lives easier and so provide a better and more effective service and at reduced cost.

This “pocket of good practice” was then presented at senior management meetings and other forums. Other managers soon wanted a part of this action.

Finding ways of doing more for less should not be about making staff run faster, but about getting rid of the hassle in their day and genuinely making a positive difference to patients’ and staff’s lives while reducing costs along the way.

But if we cannot engage our managers in our vision and provide them with the skills, tools and understanding our efforts will be doomed to failure. We will find ourselves left asking what went wrong.

If you are wondering why your managers are resistant to change, then ask yourself these questions:

  • Have I genuinely engaged my band 7 staff in my organisation’s vision and plans for the future? l Am I listening to their concerns and giving them opportunities for feedback?
  • Am I finding ways to enable them to network and exchange ideas with their peers in other units, despite the challenge of pulling them out of the day to day operational delivery?
  • How am I helping them to deal with their own uncertainties and issues with the change?
  • Am I investing enough in developing their skills as managers?
  • Do I know who my most talented managers are and do I have plans for the development of all my managers?