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Thursday 07 February 2019

Managers in the NHS: part of the solution, not the problem

By Ian Kirkpatrick

A guest blog by Ian Kirkpatrick, the Monash Warwick Professor of Healthcare Improvement & Implementation Science (Organisational Studies) at Warwick Business School.

Employing managers to help run health and care services continues to be controversial. In the NHS, since the early 1980s the recruitment of managers to executive roles in hospitals, has often been resented by the medical profession. Even today, after three decades of reforms, there still remains a pressing need for ‘dialogue and conflict resolution’ to improve ‘doctor–manager relationships’ [1]. This level of cynicism about managers in the NHS has also spilled over into public debate. In the UK, media headlines, such as ‘death by bureaucracy’, ‘greed of NHS fat cats’ or ‘cure the NHS with fewer managers’, are increasingly commonplace [2]. Most recently, Max Pemberton (himself a doctor), writing in the Daily Mail, has criticized the recruitment of managers at the expense of front line clinical staff (nurses and doctors). Managers, he suggests, have proliferated in the NHS and add little or no value: ‘Put a manager in a room with a clipboard and they will find work’. [3]

This cynicism about managers has spilled over in to public opinion. A poll published in January 2015, for example, found that ‘too much being spent on management and bureaucracy’ ranked first amongst public concerns, ahead of (arguably more pressing) issues such as hospital closures, staff shortages and access to drugs and treatments [4]. Even politicians have got in on the act. While the current Secretary of State for Health (Matt Hancock) has been more upbeat about managers, his predecessor, Jeremy Hunt, famously declared: “We should today ask whether the NHS made a historic mistake in the 1980s by deliberately creating a manager class who were not clinicians.” [5] 

But my research with Gianluca Veronesi at the University of Bristol and other colleagues suggests that this negative view of managers is both misleading and worrying.
Currently there are around 31,000 managers employed in the English NHS. About a third are doctors or nurses who work part time while the rest are dedicated managers. However, as our research showed, while this may seem like a lot, but, in an organization of 1.36 million employees that amounts to less than three per cent of the workforce. It also contrasts with the UK economy as a whole, where managers make up 9.5 per cent of the workforce [2].

In a more recent study, published in the Journal of Public Administration Research and Theory we discovered that having more managers increases performance [6]. In fact, our analysis of 150 acute hospital trusts in England from 2007 to 2012 showed that even a small increase in the proportion of managers (from two to three per cent of the workforce in an average hospital trust) has a significant impact. Larger numbers of managers led to improved patient satisfaction, a five per cent improvement in hospital efficiency and a 15 per cent reduction in infection rates.

Across the NHS, raising the proportion of managers by one percent would cost less than £500 million. While it may be unpopular to say, to us this seems like a small price to pay given the size of to the NHS budget (£130 billion annually) and the benefits reported in our study.

Spending more on managers could also help to reduce the use of management consultants - another bugbear of the media. On average, £1.2 million a year is spent on consultants per hospital trust. However, our study of 120 hospital trusts in England, showed that more spending on management consultants lead overall to a significant rise in inefficiency, ultimately worsening services [7].

So why has bashing managers been such a popular past-time for policymakers and the media? There have been high profile scandals that have added fuel to this belief, most notably the case of Mid-Staffordshire NHS Foundation Trust. Clinicians, meanwhile, face growing work intensification with increasingly dire labour shortages and a rising amount of paperwork, much of it imposed by government and regulators. By association, they blame some of this on managers, as it takes them away from doing their real job of treating and caring for patients.

Academic research has also reached the same conclusion, albeit from radically different starting points. On the one hand are critical accounts from public administration academics, which depict managers as motivated only by a desire to cut costs and control the work of doctors and nurses, limiting their freedom. Another influence is public choice theory. Originating in the US, this theory argues that bureaucrats have no real public service ethos and their only motivation is ‘rent seeking’ and building up their own empires. In the UK, NHS managers have also been tarred with this anti-bureaucrat rhetoric.

And yet by any metric the NHS appears to be under-managed at the operational level. Managers are not brilliantly paid relative to the private sector, while the intensity of work and stress is probably higher [8].

This is not to ignore the fact that managers can sometimes make mistakes. Instead, our research suggests that as a highly complex organization - now the fifth biggest in the world – the NHS needs managers to survive and adapt. Strengthening management is not about wasting money and nor does it mean privatizing the NHS. It is about keeping the ‘show on the road’ and, as important, supporting what Richard Bohmer describes as ‘the hard work of healthcare transformation’ [10]. Ultimately having managers is about making our cherished and often maligned NHS work better as public service in the public interest.


[1] Powell, A. and Davies, H. (2016) Managing Doctors, Doctors Managing, London: Nuffield Trust.
[2] Kirkpatrick, I., Veronesi, G. and Altanlar, A. (2017a) ‘Corporatisation and the emergence of (under managered) managed organizations: the case of English public hospitals’, Organization Studies, 38: 12.
[3] Pemberton, M. (2017) ‘Dr Max the mind doctor: It is nurses working at the coalface of the NHS that we need, not more bosses’, Daily Mail, 3 March. 
[4] Lord Ashcroft KCMG (2015) The People, the Parties and the NHS, London, UK: Lord Ashcroft KCMG PC.
[5] Guardian (2016) ‘Why would doctors and nurses put themselves through the ordeal of NHS management?’, 2 December.
[6] Veronesi, G., Kirkpatrick, I. and Altanlar, A. (2019) ‘Are public managers a bureaucratic burden? The case of English public hospitals’, Journal of Public Administration Research and Theory [On-line first].
[7] Kirkpatrick, I., Sturdy, A., Reguera, N. and Blanco-Oliver, A. and Veronesi, G., (2018) ‘The impact of management consultants on public service efficiency’, Policy and Politics [On-line first].
[8] Hyde, P., Granter, E., Hassard, J. and McCann, L. (2016) Deconstructing the Welfare State, London: Routledge.
[9] Bohmer, R.M.J. (2016) The hard work of health care transformation, New England Journal of Medicine, 375, 8, 709-711.

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