Middle managers feel stressed. Constant firefighting and balancing conflicting demands of senior management and junior staff are just two of the reasons - but most still enjoy their jobs. Nigel Edwards and Claire Mallett analyse an HSJ and NHS Confederation survey

In the discussion about how to change the NHS a lot of weight has been placed on leadership and clinical engagement. But national policies, board strategies, clinical improvement projects, day-to-day problem-solving and creating and maintaining flawless systems that deliver the patient experience we want will all at some point rely on the skill and judgement of a middle manager. Indeed, the government's recent infatuation with the idea of matrons is, in a perverse way, recognition of the value of supervision at the clinical front line.

But what is a middle manager? Although this is an important group, not much is known about them and there appears to be little systematic opportunity for the development of their skills and capability. The NHS Confederation has teamed up with HSJ to survey people who describe themselves as middle managers, getting 559 responses.

The popular stereotype of an NHS middle manager is a young man in a suit who knows little about clinical care. Yet our survey shows that more than 70 per cent of middle managers are female, more than 35 per cent have a clinical background and 60 per cent are over 40. Our sample and other surveys also suggest that they are significantly less ethnically diverse than the general population and the staff they manage.

Pinning down a definition

If we cannot define something the chances of developing a plan for improving it are limited. One problem with the term middle management is that, while everyone thinks they know what it is, in fact the definition is quite unclear, even to some of those who call themselves middle managers. Their level and responsibilities are quite diverse: 56 per cent of our sample said they are responsible for managing staff; 12 per cent manage more than 50 staff; and 76 per cent manage budgets, with 25 per cent responsible for more than£1m.

One concern, evident in the management literature and previous surveys, is the difficult balancing act at the heart of middle management roles - these managers must pass on top-down instructions to staff, while maintaining good relationships with them. The imbalance in power with clinical staff is also a cause of stress and anxiety.

In the survey, 69 per cent reported that they enjoy their job and 20 per cent are neutral. Middle managers who manage clinical staff are more likely to enjoy their role. Sixty per cent reported that they often work longer than their contracted hours - though there is little relationship between hours worked and levels of enjoyment. Managers in mental health were less likely to be positive about their jobs.

Forty per cent of the managers we interviewed said that teamwork and the 'skilled' people or teams they work with are positive and enjoyable parts of the job, including 'volunteers, patients and clinicians'. This was closely followed by the variety and diversity inherent in the post (34 per cent). Participants said they enjoy the 'buzz', considering their job exciting, and 'never dull'. Many mentioned making a difference to patients as very important to them.

There are of course many frustrations including convoluted decision-making processes, the pace of change, frequent reorganisation and changes in priorities. For those with operational roles, constant firefighting gets in the way of more careful strategic planning which might solve the root cause of problems, rather than just dealing with the symptoms.

Despite enjoying their jobs, more than 30 per cent feel stressed 'usually' or 'all the time', a figure in line with previous research and a significant cause for concern. There was little difference between types of organisation, professional background or whether clinical services were in their portfolio. Most felt they had the knowledge and skills to do their job and so this was not a factor. Those managing staff were slightly more likely to be stressed.

The survey raises question about whether the organisation is clear about what is expected of managers and whether an appraisal had taken place. Forty per cent of respondents had not had an appraisal and these managers were much less likely to understand what the organisation wanted. Our interviewees who had been appraised were often critical of the quality and value of the process and not always clear that the process linked to the wider objectives of the organisation.

Technical problems

The comments in the survey seem to suggest that some of this lack of clarity stems from recent reorganisations (particularly in primary care trusts), where the implications for individuals have not been clearly spelled out.

In some cases the problem is that the organisation itself is not clear about its own objectives. Unclear job design and overlapping roles also appear to be a source of confusion.

The comments also suggest a particular problem for managers in specialist areas such as medical records, coding and learning and development. Senior managers often do not understand the technical content of such roles and so are not clear how to specify success or bring these functions into the mainstream. Comments from specialist staff included: 'My role does not relate to the top targets that the PCT worries about (eg 18 weeks) and I am just left to get on with it,' and 'I sometimes feel that the "organisation" does not know what I do.'

Being clear about what is expected needs to be accompanied by the authority to do the job, appropriate support and the right level of skills.

The results here were encouraging, although better support for middle managers would clearly be helpful. Middle managers did highlight this as an area where senior management could do more to help them but highlighted listening more, communicating more often and effectively and making major decisions more quickly as even more significant in helping them in their roles.

Our interviewees also mentioned risk-taking and innovation - and their concern that this is not adequately supported.

Colleagues can also help with stress and uncertainty as well as providing support, guidance and the environment for testing ideas. In our interviews the problem of geographical isolation was an issue for a number of middle managers - particularly in PCTs, and this was a barrier to creating helpful networks for mutual support.

Respondents seemed to be satisfied with their pay and prospects for development although the number who thought these were good or excellent was disappointing. Job security was a concern for more than 30 per cent of respondents and unsurprisingly this group was much more likely to feel anxious.

Relations with doctors

The relationship between middle managers and clinicians is frequently mentioned as a cause of concern.

Of those who had an opinion, 16 per cent thought relationships were deteriorating while 34 per cent thought they were improving. Only 15 per cent thought that they had a less than satisfactory relationship with doctors, although this was notably less good than relationships with nursing staff or senior managers - where almost 50 per cent of respondents described their relationship as being very good or excellent; the figure for the relationship with doctors was 32 per cent.

Middle managers with a clinical background and those from mental health organisations were more likely to say that they had a very good relationship with clinicians; PCT managers were least likely to say that they had a good relationship (23 per cent).

Overall the picture is rather more encouraging than expected, although the level of stress and the lack of clarity about roles is a cause for concern. The question we will be investigating next is whether clinical colleagues and senior managers share middle managers' confidence.

There are a number of positive actions that senior managers can take in terms of listening, communicating and being clear about what is expected. Improving appraisal and the associated processes of review throughout the year would also help.

One thing is clear: we need a better understanding of this heterogeneous group and a much better way of defining what is expected, how they can develop and how they can be supported.