In June 2023, then prime minister Rishi Sunak announced something that he said “governments from all parties have ducked for decades”—a national, long-term workforce plan for the NHS. The Long Term Workforce Plan, produced by NHS England and backed by the government, was described by Sunak as the “most ambitious transformation” in NHS staffing in its history.

It was ambitious in many respects—so ambitious that less than two years later the new Labour government called its workforce growth projections a “fiction” and committed to publishing a revised plan. After being delayed last year, ministers have now promised to publish that plan sometime this spring.

Few disagreed with the need for a comprehensive workforce strategy. But the original plan was squarely focused on increasing clinical headcount rather than looking at the entire NHS workforce. The previous government lacked a vision for fundamentally reshaping how the NHS delivered care—it simply wanted to keep the status quo but increase activity through more clinical staff.

The current government insists it wants something different. Its message to the NHS has been blunt: “reform or die”. Any increases in funding or staffing, it says, would be conditional on the NHS changing the way it operates.

Those changes were outlined in last year’s Ten Year Health Plan, centring on three major shifts: from hospital to community, from analogue to digital and from treatment to prevention. These shifts, if the government is serious about realising them, will have major implications for where and how staff work. It makes sense then to rework the current workforce plan to reflect this change of direction.

When MiP surveyed its members, we found overwhelming support for these shifts and backing for the broader aims of the Ten Year Plan. But members noted that these three shifts were nothing new and successive governments have promised similar transformations. The challenge has never been to the vision—it has been about delivery. And delivery depends on having the right people, with the right skills, in the right parts of the system.

That has been made much harder by the government’s decision to significantly reorganise the NHS and embark on significant cuts to management capacity across trusts, integrated care boards and arm’s-length bodies. The decision to cut large swathes of the workforce was made before the Ten Year Plan was even published. And those cuts are already taking place, with staff leaving the NHS while the workforce plan remains in draft.

If the NHS is expected to reform, it cannot afford to hollow out the very capacity required to drive those changes. These cuts have undermined the government’s reforms before they have had a chance to get started. The upcoming workforce plan may be the last chance to get the right staff in place to deliver the government’s ambitions. NHS managers must be part of that conversation.

There is an abundance of research that highlights the positive impact good management has on health services. The Institute for Government found that growing management capacity can have tangible benefits for patients as well as the wider workforce: a increase in managers from 2% of staff to 3% has been associated with a 1% increase in patient satisfaction scores, a 5% increase in hospital efficiency and a 15% decrease in infection rates. These are not marginal gains—they represent thousands of safer treatments, shorter waits and better patient outcomes.

The Health Foundation has similarly concluded that sustained productivity improvement depends not only on clinical expansion but on investment in management and leadership. Likewise, analysis by the Institute for Fiscal Studies also suggested that management shortages may be contributing to weak NHS performance. Lord Darzi’s review of the NHS, commissioned by this government in late 2024, found that many of the NHS’s ills in recent years can be linked directly to the reduced number of managers over the period.

Even clinicians themselves are pleading for more managers. The Institute for Public Policy Research’s workforce assembly—a two-year consultation with frontline health and care staff—found that the most common request was for “more and better managers”.

Why? Because when management capacity is stripped out, the work doesn’t disappear. Someone else has to pick up the slack. As management capacity is squeezed, more administrative and operational tasks fall on clinicians.

When doctors and nurses spend hours resolving gaps in rotas, managing procurement, chasing estates repairs or navigating HR processes, it means less time treating patients. It contributes to burnout and makes little financial sense. There is nothing efficient about paying highly trained and highly skilled clinicians to plug managerial gaps.

Management in a £180 billion public service is not an optional overhead. The NHS is one of the world’s largest and most complex employers—it needs managers to ensure it operates smoothly and effectively. Good management allows clinical care to happen safely and at scale.

Managers are crucial in driving down lists, improving patient flow in hospitals, ensuring services are delivered safely and making sure hospitals have enough medicine and equipment. They are the technology experts, the people who will make AI work well for patients and make sure the NHS uses data-informed decisions to increase activity and improve services. They commission the services patients interact with each day, lead transformation programmes, and co-ordinate multi-agency working. Managers translate policy into safe, functioning services on the ground.

Despite all the evidence to the contrary, we hear persistently that the NHS is over-managed. But the reality is the NHS employs a lower proportion of managers than many comparable health systems and far fewer than the average UK private sector firm.

Managers make up a small share of the workforce and an even smaller share of overall spending. Yet they are consistently first in line for cuts. This is politically motivated—managers are an easy target—but the evidence above shows this is clearly counterproductive.

The public want a health service that delivers high quality, timely care, free at the point of use. Achieving that requires the whole NHS to work together as one team.

A credible workforce strategy would recognise this and go beyond simply boosting clinical headcount. It would factor management into its projections, recognising the link between good management and performance. It would identify the skills needed to deliver the government’s three shifts and plan accordingly, and it would invest in management and leadership development just as it does for clinicians. Crucially, it would stop treating management as a cost to be squeezed and start recognising it as an investment in performance and productivity.

This is not about administration versus treatment. It is about aligning the workforce with the government’s own priorities. Right now, ministers are asking the NHS to fundamentally transform how it delivers care, while cutting the very people needed to make that transformation happen. The workforce plan when published this spring offers a chance to correct that contradiction. //