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Tuesday 25 October 2022

Managers make a difference – let's make the most of them

By Geoff Underwood

By any standards, the NHS lacks management capacity despite clear evidence that managers improve efficiency and service quality. If we can’t have more managers, let’s at least make the most of the ones we have.

Geoff Underwood 2019

As a budding young manager in the mid-noughties, I was shown around a local hospital by a friendly deputy director. Afterwards, we went back to his office for a chat. It was a classic health service office of the post-war, pre-PFI era. Building circa 19th century. Five desks in a room with adequate space for three. Chunky, creamy-beige computers from the 90s, collections of papers going back to the 80s, all piled on, under and around sagging chipboard furniture from the 70s. Scrawled notes of extension and bleeper numbers covered the shared telephone. And on one of the noticeboards, half hidden among the faded structure charts and health and safety notices, was a printed poster that someone had made which said, “NHS = Never Having Sufficient”.

Ever the optimist, I remember thinking that poster was a bit too cynical. After all, in the noughties, budgets and workforce numbers were very much on the up and waiting lists were coming down fast. Skip ahead to 2022 and with all the challenges we are facing – close your eyes for a moment and visualise your own to-do list scrolling by – it might be worth searching the collective shared drive to see if someone still has that poster so we can print it off again.

We're short of managers too

In July 2022, the House of Commons Health and Social Care Committee published their latest workforce report and it isn’t fun to read. In autumn 2021, there were over 200,000 advertised vacancies in health and social care. Analysis provided by the Nuffield Trust, “suggests that the NHS in England could be short right now of 12,000 hospital doctors and over 50,000 nurses and midwives.” The report includes a depressingly long list of healthcare professions facing shortages, but I think there was an important profession missing. It isn’t a popular thing to say out loud, but it needs to be said: we are short of managers too.

According to figures published by the NHS Confederation in January this year, the NHS is already under rather than over-managed. Managers make up approximately 2% of the NHS workforce, compared to 9.5% of the UK workforce as a whole. Our numbers have decreased from 29,940 in 2007 to 25,119 in 2018 – a fall of roughly 16%. Recent announcements from NHS England about planned job cuts suggest that numbers are likely to continue to fall.

Maybe it’s a good thing that the NHS has relatively few managers? That doesn’t seem to be the case. Further work from the NHS Confederation suggests that increasing management-to-staff ratios in NHS organisations can improve efficiency, quality and patient satisfaction: “Even a small increase in the proportion of managers employed (from 2% to 3% of the workforce in an average acute trust) has a marked impact on performance.” General Sir Gordon Messenger makes a similar point in his independent review of management and leadership. “In every way, investing in leadership and team-building makes economic sense,” he found.

Black hole

So we probably don’t have enough managers and there is a good case for having more managers. But we’re unlikely to get more managers, so what can we do?

First, I think we could make better use of the capacity of the fantastic managers we already have. I am reminded of a story that a colleague told me about joining a Teams call with a senior commissioning manager. “How’s your day going?” asked my colleague. The senior commissioner said, “If I get one more [expletive] template from NHS England, I’m going to [expletive] explode!”

We certainly do a lot of planning, reporting and assurance, and I’m not convinced it is all necessary. There is a lot of resource in central and regional teams and sometimes the centre can create its own gravity, like a black hole formed from super-dense spreadsheets sucking in energy from the rest of the NHS. This is something that Messenger recognised and described in his report: “The sense of constant demands from above, including from politicians, creates an institutional instinct, particularly in the healthcare sector, to look upwards to furnish the needs of the hierarchy rather than downwards to the needs of the service-user.”

A wider sense of belonging

I am here to argue that we need more managers, not fewer, and I am not saying that colleagues in regional and national teams have no role to play. I certainly don’t think it’s a good time to lose highly skilled, highly experienced managers from health and social care. But what if we could focus all that expertise on delivering services and delivering transformation more directly, rather than providing assurance that others are delivering?

With that in mind, let’s get squarely behind Messenger’s recommendations on standard inductions, mid-career interventions for managers, and career and talent management. You only have to look at how many Integrated Care Board leadership posts were left vacant after the first round of recruitment to realise that we aren’t doing career management as well as we need to.

As Messenger puts it, we need standardised inductions to, “foster a sense of belonging wider than the immediate organisation,” and we need great career management to help people to move around more freely. We need to be better at matching people and skills to challenges and resource gaps. There could be a great opportunity now – with Integrated Care Boards needing more resources to deliver the huge asks of them, and NHS England about to go through a major restructure. What if we could reassign people from assurance and reporting functions nationally and regionally to delivering a direct impact in our integrated care systems? Could Messenger’s recommended career and talent management functions be implemented in time to help with this?

Management is a profession

Finally, let’s support greater professionalisation of management. One of the reasons that management was missing from that list of healthcare professions in the Health and Social Care Committee’s report is that people don’t really count management as a profession. Messenger was spot-on in recommending that we develop a single set of consistent management standards, delivered through accredited training. It would put us on the same footing as our colleagues with accreditation from professional bodies like the royal colleges. How many of us have been asked to lead projects, without any project management training? Or to estimate bed numbers and room requirements, without any capacity and demand management training? Or to undertake a risk assessment, without any risk management training? Let’s get professional.

I am still an optimist. Even though there may not be enough of us, managers in health and social care will make a vital contribution to solving the problems we face over the coming years. If we take on and make happen some of the recommendations that Messenger has made, we may punch even more above our weight.

  • Geoff Underwood is a senior NHS manager and chair of MiP’s National Committee.

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