Shrink the centre to boost local management, Darzi concludes

The review, commissioned by health and social care secretary Wes Streeting, points to the significant increase in the number of people employed by bodies such as NHS England, the Department of Health and Social Care, and other non-provider organisations over recent years – and contrasts it with the sharp decline in operational managers.

The report also:

• Questions the basis on which trust chief executive pay is set;
• Calls for the responsibilities of integrated care boards to be clarified “at pace”; and
• Excuses NHS managers from any blame for the “critical” state of the service.

The report includes a table showing the number of people employed by NHS England and the Department of Health Social Care rose from 53.2 per provider trust to a peak of 109.2 in 2022-23, before falling back to 89.8 last year.

It also notes that “the number of people in regulatory roles for each provider trust has gone from 5 per provider to more than 35” over the last 16 years.

This growth in central oversight has imposed “a burden on boards and management teams of care-providing organisations”, says the report.

In contrast, the report records that the number of senior managers as a proportion of the total NHS workforce fell nearly 30 per cent between 2008 and 2013. The number of senior managers has recovered to 15 per cent below the 2008 benchmark, but the total for all managers is still 24 per cent down.

The report says “good management has a vital role in healthcare”, and its analysis “suggests that the NHS is not employing enough people whose primary responsibility is that its resources are used well, and the talents of its clinicians are focused on delivering high-quality care”.

It adds: “While a top-down reorganisation of NHS England and integrated care boards is neither necessary nor desirable, there is more work to be done to… ensure the right balance of management resources in different parts of the structure.”

The report states: “Accountability is important. But too many people holding people to account, rather than doing the job, can be counterproductive… NHS organisations should focus on the patients and communities they serve, but the sheer number of national organisations that can ‘instruct’ the NHS encourages too many to look upwards rather than to those they are there to serve.”

NHS management structures still ‘confused’

The report says the “scorched earth” approach of the 2012 health reforms created “institutional confusion” which has left the NHS “still struggling to reinvent its managerial line” over a decade later.

It describes a situation in which organisational structures are “in constant flux” and where – in the words of one trust chair – almost every senior manager is “living in their own reality of how the system works”.

The report also suggests incentives for senior leaders are not aligned with the service’s goals.

It claims: “The incentives for individual trust leaders are blunt. The only criteria by which trust chief executive pay is set is the turnover of the organisation. Neither the timeliness of access nor the quality of care are routinely factored into pay. This encourages organisations to grow their revenue rather than to improve operational performance.”

The arrival of integrated care systems and boards is broadly welcomed, but the report questions whether the permissive approach taken by NHSE to how they operate is the right one.

It says “the roles and responsibilities of ICBs need to be clarified” in relation to population health management work, and whether they are meant to “performance management” provider trusts.

The report concludes: “Given the scale of the performance challenge, it will be essential that this is resolved at pace.”

Managers not to blame

The report concludes: “The NHS is in critical condition.” However, it largely absolves NHS managers of the blame for this state of affairs.

It states: “The NHS is the essential public service and so managers have focused on ‘keeping the show on the road’. Some fantasise about an imaginary alternative world where heroic NHS managers were able to defy the odds and deliver great performance in a system that had been broken. They are wrong.

“Better management decisions might have been taken along the way, but I am convinced that they would have only made a marginal difference to the state that the NHS is in today.”