Good managers: the workforce the NHS most desperately needs

Over the last two years, IPPR have been running deliberative workshops with an assembly of health and care staff. Our ambition was to understand what a sustainable and hopeful future looks like, as the government considers its own long-term workforce plan. 

The assembly identified no shortage of problems – and had powerful ideas about the future. They wanted fairer pay, more equality at work, better standards for people returning from maternity leave, targets for a sustainable approach to unpaid care, and a vested stake and voice in innovation.  

But one demand stood out: more and better managers. 

Throughout the last decade, as politicians have focused on waste and efficiency, managers have been an easy target. Cut the bureaucrats and invest in the frontline has become a common refrain. 

But our conversations with frontline staff identified two key consequences of this approach. First, a real frustration at how hard this makes it to shift to system working. NHS staff want to work in collaborative, integrated workplaces. Without leaders to build relationships and partnerships, this is all but impossible. 

Second, and perhaps most important, a shift in the burden of management to clinical staff. An organisation as big and complicated as the NHS comes with an inevitably high burden of administration, bureaucracy, project management and leadership needs. Without managers, this work falls on clinical staff – at the expense of the time they have for patient care.

The NHS has long struggled to consider management a science and an art in its own right. Too often, the assumption is that good clinicians will make good managers 

In identifying a dangerous shortage of managers, our workforce assembly identified a trend also observable in the data. Between 2010 and 2019, manager numbers in hospital and community settings actually fell. Indeed, had managers grown at the pace required, we’d have up to 10,000 more managers in hospital and community settings today.  

What would they be doing? The hard work of making the NHS fit for the future, as it approaches its 75^th anniversary. They’d be delivering the partnerships needed to make outcome-based, integrated and system working a reality. They’d be providing the capacity for research and innovation within the NHS. And they’d be freeing up the frontline to get through the severe backlogs plaguing the NHS. 

Without them, the NHS is forced to bring in external capacity. Not only is this expensive – the management equivalent of high agency spend to cover clinical shifts – but it’s not as effective. One study even found external management capacity is associated with an actual decrease in hospital efficiency. 

But as well as more managers, our assembly had a second point: we also need better managers. The NHS has long struggled to consider management a science and an art in its own right. Too often, the assumption is that good clinicians will make good managers. 

International evidence suggests this isn’t quite right. A recent study of public hospitals in Chile showed that the best managers were associated with a statistically significant reduction in management, compared to the worst managers. Those good managers tended to have a more modern, evidence-based approach to good leadership. 

So it is worrying that the NHS has such limited scope to create good managers. As has recently been argued in the HSJ, the graduate management scheme has significant limitations. Other initiatives like the NHS Leadership Academy seem to be having limited impact. And the NHS does too little to create pathways for its leaders to get experience in other parts of the health ecosystem: social care roles, local government, charities, or business secondments, for example. 

Ultimately these findings should be seen as an endorsement of a range of independent reviews – not least, the Hewitt reviews findings that the NHS has too few managers. But it should also be a call to action ahead of the long-awaited NHS Workforce Strategy. Taking our results seriously would mean really integrating long-term management projections in independent assessments of workforce needs; pushing integrated care systems to publish plans to increase management numbers; and reallocating spend on external capacity on in-house staff numbers. 

Got right, it would provide the NHS with a new foundation to be more productive, to get through the backlog, and to let clinicians focus on the job they want to do: delivering high-quality patient care.