We need more managers

With recent news that Agency spending within the NHS has pushed through £3.5bn (from £2.5bn in 20/21) whilst non-clinical Healthcare spend is 21% lower than last year (as per the CCS framework), although these are not precisely comparable measures, the pattern is certainly relevant, I thought it was a good time to put pen to paper on the unpopular topic - That Management in the NHS is desperately underfunded, under-valued and mis-understood.

To give this article a bit of clout, I interviewed Steve Black, Data Scientist and HSJ columnist. Steve brings the sense & data to my “gut feel” & experience. We come from different angles but seem to arrive at the same point.

It seems everyone from the general public, to politicians, through Civil Service and NHSE find “management (*)” a convenient scapegoat for the woes of the NHS, and I’m certainly not suggesting its blameless, not at all, I think, generally speaking, it is under-performing in many areas, but the key point is why is the NHS struggling to cope with the challenge?

The popular view is, organisations are under-performing, therefore cut management and we could save a fortune to spend on “front line” Doctors and Nurses. My view is to look at it from the other way - If performance is poor and management is struggling then shouldn’t we do something to support and improve it, to enable it to function more efficiently?

There seems to be a lot of evidence suggesting I might be right.

By some credible measures (most notably a Kings Fund report) NHS Management is about a quarter of what you would expect in similarly sized organisations, and less than half compared to the average spend in European Organisations (as the IFS wrote in 2018). By this comparison, you might be forgiven to believe that it has little chance of being effective, and you might be correct.

Between 2019 and 2022, there has been an increase of 17,000 Doctors and 26,000 Nurses and the rate of Hospital Managers has not kept pace with other staff growth and overall performance & efficiency has dropped. Ask anyone in Corporate, NHS life and you will quickly find yourself on the topic of finances and the genuine fear of not being able to keep the lights on within budget this year. Ask a patient and it is most likely access to services that will be their major gripe. As one Director put it to me “Trusts are faced with 1 of 2 options, either; do more with current resources or cut staff numbers all together”. Faced with these two choices then a management team with capacity to look at efficiencies and implement improvements as opposed to 24/7 firefighting, would be your best tool for the job. So, why then have we paid insufficient attention to a major lever in our arsenal to fight-off the challenges the NHS faces?

A timely and clear example is from the recent Times article on Guys & St Thomas’s Trust seeing an entire week’s operations in a single day. This wasn’t primarily due to having more clinicians, it was about being better organised and more efficient with the resources they had. This is exactly the point, doing more with the resource we have.  The best way to do this is to invest in Management who do precisely this. Ideas like this aren’t new or particularly difficult, they just take bravery and collective support to implement. Indeed, many ideas to improve Operations already sit within the current teams, they just require the time and backing to implement them. Which leads me to my next topic of supporting management to provide more collaborative environments, but that’s for another day…..

Matthew Trainer, CEO at BHRUT wrote an article for the HSJ in 2023 about lifting his Trust out of the bottom realms of National A&E performance rankings and this was only possible with good people and good managers. Indeed, in one NHS Confederation report from 2022 a central conclusion was “Efficiency, quality and patient satisfaction improve with an increase in management-to-staff ratios” and even a rise from 2% to 3% of Managers, as a proportion of workforce, has a marked increase in productivity. Therefore, the best run Hospitals have a greater proportion of Managers as percentage of overall workforce.

The data, reports and analysis I outline certainly supports what I hear speaking to Managers up & down the country, day in, day out for the last 15 years. It is, of course, a two-way street and there is no silver bullet to solve the problems, but I firmly believe the current situation regarding NHS management could be vastly improved.

In summary, should we employ more Managers? Yes, yes we should. Managers will ensure services are more effective, that front-line staff are seeing the relevant patients, that patients have the right access, that the whole system is more efficient. They’re not miracle workers, they may not even be the most significant part of the chain, but they currently underutilised.  If the problem is, you feel management isn’t giving the required support right now, then help them, give them a fighting chance to do their job, give them the resources to be successful and judge them then. If you were drowning, would you want someone to cut your arm off or throw you a life jacket?