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Friday 18 March 2016

The NHS needs managers as well as leaders

By Nigel Edwards

Leadership may be exciting, but the unglamorous job of making things work is where the real action needs to be.

Nigel Edwards
Leadership has received a lot of attention and it’s become a cliché to say it’s an important part of any change programme. We have also been told that we need to move from management to  – rather as the celebrated management thinker Peter Drucker said we needed to shift from administration to management 30 years ago. I do think leadership is important, but I’m concerned that the obsession with it has obscured the very important task of effective administration and management. 

There is no point in being a great leader if you do not have the ability to execute your ideas, especially if you are trying to change a system which is not stable or performing reliably. Research also tells us that the quality of one’s immediate line manager is an important determinant of staff wellbeing and morale.

Management has a much less clear definition than leadership. Management tasks and roles may be carried out by non-managerial staff, and some people doing managerial jobs may not even see themselves as managers.

Support middle managers

The term ‘middle manager’ covers a very wide range of responsibilities and budgets. What they do and how they spend their time at work is similarly diverse. So too are the pathways to management, with many people finding their way from clinical roles, others working their way up from clerical or admin jobs, and some coming in through more formal routes. This may partly explain why middle managers have received less attention than the more glamorous area of leadership. I think we need to do more to support and develop this important group of people. 

Firstly, there is not enough recognition that technical knowledge is important. Interestingly, people who lead hospital groups tend to be experts in running groups of organisations but take great care to ensure that the hospital managers are real operational experts. I think the myth that management is a generic skill, which does not require deep knowledge of the functions, processes and people issues involved, is a result of over-emphasising the importance of leadership. Leadership stresses personal competences and behaviours, and tends to down-play technical knowledge. 

From this it follows that training and development for management roles is vital. Many skills do have to be acquired on the job, but that requires appropriate supervision, time for reflection and peer support, which many people in management roles don’t receive. 

We also need to consider the design of jobs and how they fit into the organisation’s structure. Research has shown that many job roles are poorly defined, overlap with others and do not have clear objectives. When combined with poor appraisal, this is not a good recipe for an effective organisation.

I have been involved with work on the emergency care system for many years and one of the things I’ve learned is that performance is the result of rigorous attention to detail to ensure the continuous, flawless operation of a large number of different interlocking systems. Fire fighting and crisis management are exciting and NHS managers are very good at them, but the unglamorous job of making things work is where the real action needs to be. 

The final area I would highlight is what I would call the ‘epidemic of assurance’. Checking, ensuring someone (preferably someone else) can be blamed when things go wrong, and diverting people from the job to complete forms, join conference calls and engage in other non-value-adding work, is a feature of NHS life we take for granted. Viewed from the outside, it looks strange, dysfunctional and irrational.

I think supporting middle managers – whoever they are – is a key priority. Creating more peer support and a conversation within and between organisations could achieve some of this, but we will also need to invest in development and support. Without this, leaders can lead but it will be difficult to follow them effectively.

Nigel Edwards is chief executive of The Nuffield Trust.

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