Celebrate, don't denigrate: the case for management is clear

“Denigration of managers and the role they play in delivering high quality healthcare will be damaging to the NHS and to patient care in the short and long term.”

The Future of Leadership and Management in the NHS, the King’s Fund report from which these quotes are drawn, is a seminal intervention in one of the longest running health service debates. It should skewer once and for all the lie that NHS management has no positive contribution to make or that the service has too many people involved in management. Its conclusion is unambiguous: “There is no persuasive evidence that the NHS is overmanaged and a good deal that it may be undermanaged”.

The report’s power comes from the weight of evidence it is able to bring to support its argument. Over recent years the idiocy of trying to run an enormous and complex public service with levels of a management that the most frugal charity would look askance at has attracted increasing scrutiny. The work by the Centre for Innovation in Health Management arguing for more investment in management capacity, which HSJ publishes this week, is another powerful contribution.

The prime minister’s underwhelming speech on NHS reform earlier this week did at least pay tribute to the “important and valuable work” undertaken by managers. But he then immediately qualified his comments by saying: “But they’re not on the front line so sometimes they don’t know precisely what local patients need.”

Indeed, the shine was almost completely taken off the PM’s fainthearted support when, immediately after receiving the speech transcript, HSJ got an email from the Conservative Party claiming the reforms would make “the NHS work for patients, not bureaucrats”.

As the King’s Fund explains, such statements not only damage the morale of existing staff, but discourage clinicians, talent from outside the service and the best graduates from seeking a role in NHS management precisely when it faces its biggest challenge for a generation.

The most telling and urgent recommendation from the report is that the government should revisit its plans “to cut the number of management posts by 45 per cent”. It stresses that this target is “simply arbitrary” and “backed by no published analysis whatsoever”.

The playground politics that affects the debate over NHS management makes it very unlikely the government will climb down from this commitment, but it could simply lessen its oversight on this matter and let local organisations make the appropriate decisions. As the think tank’s report says: “While administration and management costs will have to take at least their fair share of the pain as real terms growth in NHS spending ceases, a more sophisticated approach to the reduction is needed.”

The government can also help itself by noting the report’s finding on how “extensive, overlapping and duplicating demands” by regulators have driven up administration costs.

But the report also places an obligation on those holding NHS management positions. We are doomed to repeat the sterile debates of the past unless all concerned take personal responsibility to challenge the urban myths surrounding NHS management.

HSJ suggests two tactics.

First, stop slagging each other off. Junior vs senior, commissioner vs provider – the generic denigration of any NHS “bureaucrat” simply gives more grist to the populist mill. 

Second, the King’s Fund report – independent, evidence based, clear – can be a powerful tool in changing minds. So download it and the next time a colleague, local newspaper or politician or anyone else trots out the easy lie that “the trouble with the NHS is that there are too many managers”, you can simply say: “You’re wrong, read this.”