The NHS lacks strong leadership and does not develop and support its middle managers, an NHS Confederation report has warned.

Over two-thirds of managers strongly agreed or agreed that the NHS 'lacks a strong leadership and management development programme'. A further 46 per cent said middle managers suffer most from a lack of leadership and management support.

The report, The Challenges of Leadership in the NHS, the result of a series of interviews with senior managers, found middle managers are 'sandwiched between clinicians and senior managers, are often disempowered and need more support'.

And nearly 60 per cent said they believed the NHS was driving out talent by failing to value and back up its leaders.


Those surveyed said good managers were often hampered by 'negative drivers within the system' and that financial pressures and targets 'encourage short-term thinking'.

'Managers felt that they often spend too much time fire-fighting rather than making fundamental changes which can contribute to long-term improvements,' it says.

The NHS managers surveyed said they were 'acutely aware that their performance in some areas could improve'. The report also found:

  • 'managers are forced to focus upwards to the Department of Health and not across their trusts towards the interests of patients and staff;
  • some policies, in particular payment by results, encourage trust boards to think about the survival of their own organisation rather than the wider health community;
  • the role of the chief executive, and how the success of the organisation should be measured, is not always clear;
  • training can be inadequate or non-existent at all levels of. management.

'Clinical engagement and managerial engagement with clinicians is key to success and often falls short at every level,' the report says.

Culture of bullying

There is also a 'culture within the NHS which encourages bullying, and this stifles leadership potential'.

The report says bullying came in the form of 'direct threats, described as 'insultingly brutal' by one external observer, and 'distressingly macho' by another.'

While there are good, 'even exemplary', leaders, the report states 'there are not enough of them', particularly among commissioners. It says 'many managers stay in post for only two or three years while clinicians tend to remain at the same hospital for many years'. This has 'implications for the way in which trust develops between the two groups'.

Non-executive directors, however, had improved.

Stuck in the middle

NHS Confederation policy director and report author Nigel Edwards warned that the role of middle managers was in trouble.

'We need to look at how we can help them. It doesn't matter how good the leadership of an organisation is, if you don't have happy middle managers you can't deliver anything'.

NHS North West chief executive Mike Farrar said managers needed to pay much more attention to developing the 'softer' people skills of middle managers.

'These skills are essential if we want to create sustainable leaders and they are what differentiates the great from the good because they require people having honest conversations about really difficult issues'.

Mr Edwards said it was imperative that managers had 'much better evidence and research available to them' to make changes, inform decision-making and get the support of clinicians.