This HSJ feature, in association with the Chartered Management Institute, discusses how strong and consistent management and leadership can improve retention, technology adoption and productivity across the NHS
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The NHS workforce is facing several pain points, which highlight the need for a more structured approach to management and leadership development, to better support both people and performance.
Among the issues faced is retention. The 2025 staff survey revealed that 29.6 per cent of staff often think about leaving their job (up from 28.4 per cent the year before) and 16.8 per cent would leave their current organisation as soon as they could find another job (again up on 16.1 per cent the year before). Meanwhile, NHS Digital Workforce statistics reveal the leaver rate was 9.6 per cent in January 2026, and the vacancy rate was 6.7 per cent in December 2025.
Andreas Marcou, Great Ormond Street Hospital Foundation Trust’s associate director of organisational and employee development, describes the link between management and leadership and retention as “strong and direct”, adding: “People usually don’t leave because the work is hard – they leave because the conditions around the work make it unsustainable.”
The NHS employs nearly 40,000 full-time equivalent managers and senior managers, as of January 2026, and this does not include staff who are, for example, predominantly in a clinical role but have at least some management responsibilities.
However, NHS management has also faced a tough few years. Lord Darzi’s 2024 rapid investigation into the NHS stated the health service’s “managerial capacity and capability have been degraded by disastrous management reforms”, namely the Health and Social Care Act 2012.
Lord Darzi went on in his report: “Good management has a vital role in healthcare: it exists to ensure that the maximum healthcare value is created with the resources that are available… The problem is not too many managers but too few with the right skills and capabilities.”
That same report also noted that the NHS spent comparatively less on management than other international systems. “This has often been observed as [a] source of pride,” Lord Darzi wrote. “But it may well be a failing, since it 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. We need to invest in developing managerial talent and creating the conditions for success.”
Meanwhile, research by the Institute for Government from 2023 highlighted concerns that management capacity and capability had not kept pace with that of clinical staff. This, in turn, meant clinical staff could not be deployed to their full potential.
But managers do not exist in a vacuum, and strong leadership also has a role to play in retaining staff – 2023 research by the Chartered Management Institute and the Social Market Foundation found 32 per cent of managers said leaders were “poor” at motivating staff.
“Line managers are only part of the picture,” says Bryan Jones, senior improvement fellow at The Health Foundation. “So, you can have a great line manager, but if the culture around you within the organisation is restrictive… that’s obviously going to create some challenges. So, line managers [are] obviously critical to this, but it’s the broader culture within an organisation that really matters.”
Paula Bednarz-Withers, deputy head of department at Teesside University’s School of Health and Life Sciences Allied Health Professions, adds: “Within healthcare, we can struggle with retention and wellbeing… The leaders are absolutely pivotal in being able to work with their staff to ensure that their environments are positive, that their wellbeing is put at the forefront of what we do, because we absolutely know that if we have happy staff, we have happy patients.”
This HSJ feature, in association with the CMI, explores how strengthening leadership and management capability has a knock-on effect on retention, technology adoption and productivity.
Strong and consistent line management can improve retention. Corporate Leadership Council: Managing for high performance and retention – an HR toolkit for supporting the line manager, from 2006 and cited in The King’s Fund research, found that a good line manager can reduce the risk of losing talent by more than 80 per cent.
But the CMI has identified that management and leadership quality can vary across teams and services.
Mr Jones explains this could be because there is a lack of “parity of esteem” for NHS management roles compared to more frontline or research-based positions for clinicians. “It’s often a poisoned chalice sometimes,” he says. “It’s not seen as a job people necessarily want. And in organisations like that, where management becomes devalued or isn’t seen as important, it isn’t seen as how you develop your career, then inevitably you’ve got this concept of people becoming unwilling or accidental managers.”
He adds: “Culturally, we have to work in a way on actually making management of an equal status… so people actually want to take part in management training because they see this as important, not because it’s something they have to do.”
A King’s Fund long read, published in November 2025, noted: “For too long, the NHS has survived on a culture of leaders learning on the job and ‘muddling through’.”
Meanwhile, 2022’s Messenger Review described much of management and leadership training as “piecemeal, partial and isolated”, adding that the “whole landscape needs tidying”. Among its recommendations, the review called for “consistent management standards delivered through accredited training”.
The Review also noted that there are “excellent examples of talent management within organisations, but they are too widely scattered and are rarely completely inclusive”, and this “lack of structure means career opportunities can appear to be linked more to who one knows and the network one is able to create, than to one’s skills and experience”.
Crystal Akass, Guy’s and St Thomas’ FT’s chief people officer, adds: “One of the things that has impressed me most about the NHS [having spent a large part of my career in central government] is the real rigour brought to continuous learning and education in our clinical professions. That ongoing commitment to updating skills, to remaining current, as well as the desire to be at the cutting edge, is very visible and very well role modelled. We don’t yet apply the same degree of importance to our leadership and management practice – and we should.”
Ms Bednarz-Withers adds: “Within clinical and non-clinical roles, people are promoted because of their competence within their day job, if you like. And then what happens is you haven’t always had anybody really looking at or given the opportunity to look at themselves and say, you know, what are my core values? What is it that drives me? What are my strengths in terms of my personal effectiveness? What is my emotional intelligence actually like?… I think, increasingly, people recognise the importance of developing themselves and how important that is when leading others.”
Ms Akass adds: “[Management] is a teachable skill. It’s not something that you’re born with. It’s not aptitudinal. It can be invested in and developed in a really structured way.”
Ultimately, in busy NHS organisations, inconsistent management and leadership can have a negative knock-on effect for the people they care for. “In a complex, high-pressure environment like GOSH, consistency and clarity are essential for patient safety, staff wellbeing and fairness,” explains Mr Marcou.
“When managers operate to shared standards, staff know what ‘good’ looks like and how decisions will be made. Without that alignment, experiences become uneven, trust is lost and risk increases.”
NHS England is now addressing these inconsistency issues itself, through the NHS management and leadership programme and framework, designed in partnership with CMI.
The inconsistency in the NHS’s management and leadership becomes more problematic when viewed through the lens of technological change. The CMI has identified that managers and leaders need the skills and confidence to responsibly adopt new technology and to use AI to support productivity and service improvements, while balancing patient safety and ethics.
The NHS is already taking steps to adopt one of the biggest technological advancements of the last decade – AI. In late 2025, the government announced that more than 30,000 NHS staff had taken part in a pilot using Microsoft 365 Copilot for administration tasks. This found that the technology could save people 43 minutes per day, which equates to five weeks per year per worker.
Indeed, one of the three shifts in the 10-Year Health Plan is the shift from analogue to digital.
But are NHS organisations doing enough to support staff’s adoption of new technology? A 2024 study published in BMJ Open found that, although more than half (56 per cent) of the 211 doctors surveyed had used AI programmes, just 7 per cent had received training on AI, and only a third of those via their employer. And a 2026 survey by the Royal College of Physicians found two-thirds (66 per cent) of respondents said they lacked access to AI training.
What role, then, do managers and leaders have to play in technology adoption? “I think whatever shade of manager you are, there’s got to be something about technological literacy,” says Mr Jones.
The importance of managers and leaders in AI adoption is underlined by 2024 research from RAND. When interviewing AI practitioners about why AI projects had failed, 84 per cent cited a leadership-driven reason, ranging from using AI to solve problems that had little impact on the business to underestimating the time required.
The NHS is taking steps to give its managers and leaders the skills needed to implement AI projects. For example, the NHS Digital Academy offers courses ranging from short on-demand pieces covering various digital topics to the Digital Health Leadership Programme aimed at those in roles which are responsible for driving digital change in their organisation.
Mr Marcou adds: “AI is a powerful tool for processing information and removing friction, but it doesn’t replace human decision-making or values. The real productivity gains come from using technology to remove inefficiency and free people to focus on higher-value work. Leaders must understand where AI can help, where it can’t, and how to use it responsibly.”
Mr Jones stresses the importance of not getting “very excited by the shininess” of new technology, but actually taking time to think about implementation.
He adds: “You have to kind of think about how it lands in the service. So if you don’t have a good understanding about how to engage people, how to influence people around it, how to situate it in that context where people might have 1,000 other things to do, and they’re not necessarily going to be in the frame of mind where they’re going to think, ‘oh, great, another thing that’s come along’. So you have to think about its framing… thinking about all the steps that come around with implementing a really complex intervention in an already complex setting. So implementation skills… are really fundamental here. And the mistake would be if we forget about that in the rush to implement new tech.”
Ms Bednarz-Withers adds: “You are going to have a complete mixed bag in terms of what people’s skill sets are… when implementing any type of change, especially digital, it’s the human dimensions that are important… you could have the best strategy in the world, the best plan for implementation, but if you haven’t got your people on board, then that’s not going to happen.”
Supporting staff after technology has been adopted is critical, too. “Technology is already changing how we work, and our leaders must prepare for, adapt and respond to that change as well as support and empower others to do the same,” says Ms Akass. ”We need them to be curious about what is possible, ask good questions that help keep us safe and be impatient for improvement as well as attuned to the emotional aftermath and risk that colleagues are, or feel, left behind.
But where does developing managers and leaders sit in an NHS environment facing both financial and productivity pressures?
Ongoing financial constraints within the NHS mean organisations are under pressure to deliver value for money. The NHS is currently battling to improve access to services in both emergency and elective care. Latest data, published in April, revealed the NHS came just shy of hitting its emergency target to deal with 78 per cent of all accident and emergency patients within four hours, and, although it hit its elective care target for 65 per cent of patients to begin treatment within 18 weeks by March, experts have warned this was driven by a “record” spike in “unreported removals”.
But, arguably, this could mean that well-trained managers and leaders are more important than ever before – 2018 Warwick Business School research shows that an increase in the proportion of managers from 2 to 3 per cent of workforce can improve hospital efficiency by 5 per cent. Similarly, research from Portsmouth Business School found a “significant positive effect of leadership quality on hospital service quality”.
Meanwhile, a 2024 NHSE report cited post-pandemic levels of turnover in “experienced leadership and management” as one of the drivers behind the NHS’s failure to recover its productivity to pre-pandemic levels.
And the ability (or inability as the case may be) to retain strong staff is also a wider productivity issue. Research for the Institute for Government in 2023 revealed concerns that more senior staff were being replaced by more junior practitioners, who were not only understandably less experienced and less confident at helping patients flow through the hospital but also needed time to be trained.
“One of the problems with how productivity is framed is [it can be] framed as a cost improvement measure,” adds Mr Jones. “And sometimes that connection between the broader narrative around improving quality is lost.”
The 10YHP echoed this call for better framing when it addressed the need to “urgently resolve the NHS’s productivity crisis”, adding: “Our approach is not to ask for more, but to stop doing things that are not productive, or do things differently.”
Ms Akass agrees skilled management and leadership can be what unlocks productivity. “In an environment where we’ve got this triple challenge of the requirement to deliver a kind of once-in-a-generation reform, as well as significant here and now improvements to performance, in a context of genuine financial constraint, we need extraordinary leadership,” she says.
She adds: “If we lead people well, the results that we can deliver are immeasurably improved.”
Case study: Royal Berkshire FT
Alongside the national challenges facing the NHS – rising demand for services, workforce pressures, and a shift in the commissioning landscape – Royal Berkshire FT was dealing with a particularly difficult period when it started working with the CMI. The Care Quality Commission had downgraded it to “requires improvement”, and it had just emerged from increased supervision from the centre regarding both finances and quality.
Janet Lippett, the trust’s chief medical officer, recalls that, by the time former chief executive Steve McManus arrived, “there was a definite disconnect between the organisation and the leadership”.
The trust realised that, not only did this connection need repairing, “we needed to upskill our managers and our leaders to take us into the new future and address some of the challenges that we were experiencing”, says Dr Lippett.
Among the work the trust started early on, in 2017-18, was a leadership behaviours framework. This was one of the behavioural codes used to support the development of the new Management and Leadership Code for Health and Care, launching in 2026. The organisation will now look to map its existing framework against this national vision.
The trust also did a lot of work at the line manager level. “You’ve got to empower those managers throughout the organisation, because you can write your strategy at the top, but how it’s deployed and how it’s delivered and how it’s felt is so crucial,” says Dr Lippett.
Additionally, nearly 200 people at the trust have been through the management programme. As part of the course, apprentices are required to do a workplace-based project. Dr Lippett says some “great things” have emerged from these projects, adding: “Some of the things that have surprised me have been just how we’ve managed to… improve on our cancer performance targets, [and] reduce the turnaround time in our histopathology, for example. And that has a really tangible [outcome for] patients.” Another project focused on outpatient prescribing, enabling patients to collect prescriptions at a location closer to them.
Dr Lippett acknowledges that “the first thing to go when things get financially difficult, is often training and that kind of thing”, but urges senior leaders to “have that vision and that foresight that says it’s not a nice to have; it’s an essential part of what we do”.
The challenges facing the NHS have become part of the UK’s national conversation – often for the wrong reasons. With each story of surgery wait time targets missed, unfilled vacancies, or ambulances queuing outside emergency departments, it becomes increasingly clear that an acute workforce crisis cannot be resolved without addressing an equally acute management deficit.
As staff vacancy and leaver rates rise, we must heed the growing evidence that poor management, not the intrinsic difficulty of the work itself, is driving away precious talent. The health service’s reliance on “accidental managers” leaves people handed new responsibilities without the benefit of a level playing field when it comes to management training.
Through our support in developing the new NHS leadership and management framework, the CMI is actively working to dismantle this culture of “muddling through”. Our partnerships with forward-thinking NHS trusts, such as the Royal Berkshire FT, demonstrate the transformative impact of structured capability building. By investing in accredited management programmes, trusts are turning continuous professional development into a reality for clinical and non-clinical leaders alike. This isn’t a “nice-to-have” luxury; it is an operational imperative.
Establishing clear pathways to becoming a chartered manager provides a roadmap to consistent, high-quality leadership. Shared professional standards – when managers effectively speak the same language in their approach – creates accountable, supportive workplaces that translate into better retention, improved patient safety, and enhanced patient outcomes. Furthermore, professional management prepares trusts for the smooth adoption of AI and unlocks productivity amid growing financial constraints.
Cost-cutting alone cannot deliver the health service patients and staff deserve. Investing in the people who manage resources and lead teams is an essential investment in an effective future for our national health service.
