Reforming management and leadership in the NHS: Does the Messenger review go far enough?

The Messenger review into health and social care leadership in England has been published along with a set of seven recommendations. Led by Dame Linda Pollard and Sir Gordon Messenger, the review is a promising start for health and social care leadership reform, although many hurdles to its implementation remain.

It is essential government avoids falling into the same trap seen following previous reviews – of repeatedly committing to change without following through. That means the response to Messenger will need to be backed up with concrete resources and action.

A welcome focus on culture

Messenger’s focus on the underlying cultures and behaviours that drive organisational performance is hugely positive. Equally welcome is the tone of the review itself, which is supportive of managers, and sensitive to challenges they face. Indeed, the review is far from being punitive toward managers as feared by some following the review’s announcement in the autumn. The supportive tone and recommendations bring to life the values suggested by Don Berwick in his 2013 review into patient safety, to learn not blame, in contrast to recent media negativity about management in the NHS.

The inclusion of consistent standards for managers to be delivered through accredited training is another welcome recommendation and begins to pave the way for greater quality assurance and strengthening capability in the workforce. Although Messenger does not recommend a leadership and management Royal College equivalent – as some of our long read interviewees had suggested – consistent standards will be beneficial in working towards greater parity of esteem with registered colleagues, such as doctors and nurses.

Ensuring the recommendations are implemented

Unlike many of the previous reviews, there is significant emphasis in the report on implementation of the recommendations, including the creation of the Review Implementation Office with clear lines of accountability. This multisector group – with representatives from the NHS, social care, local and central government – signals a strong commitment to working with all sectors in implementing the recommendations, and hopefully a positive sign of more joined-up working to come. While the Messenger review focuses primarily on acute care, careful thought will be required to ensure learnings are applied across the sector – including in primary care, social care and mental health services.

The important thing now is to capitalise on current momentum and begin work on implementation at pace. The review’s stakeholder engagement has prompted an increased desire for reform in management practices, as well as increased recognition of the work managers do. There is never a good time for wide scale change in health services, as you cannot simply stop the ‘production line’ or shut down the servers as in other industries. Yet the prospect of greater integration, both within integrated care systems (ICSs) and the recently reconfigured NHS England, provide perhaps the best opportunity in recent history to refocus the NHS’s relationship with its leaders and managers in England.

A significant risk to implementation appears to be lack of additional investment in the management workforce, instead focusing on resource rationalisation and reallocation. UK spending on health care administration is significantly lower than in similar countries – 1% of UK public spending, against an OECD average of 2.4%. Meanwhile, in their work Malby and Kirkpatrick estimate the NHS is significantly undermanaged compared with other areas of the UK workforce. Managers and leaders we interviewed also described the low number of managers in post as a significant limiting factor in their own personal development and wider service improvement.

In saying this, the available data on management staffing levels could be stronger, making it challenging to show exactly where extra resources are needed. For example, many NHS managers also have clinical roles. Yet reliable statistics on how many clinicians hold management responsibilities, and what proportion of time they spend on management tasks are hard to find.

Similarly, while some of our interviewees suggested that many of the more recently created management roles are located in national bodies or in ICSs, rather than in front-line services, there is a dearth of accurate data on this question. The fact that the review calls for improvements in the way management workforce data is collated and exploited is therefore extremely welcome. Better data on managers will give us the means to determine where current gaps in the management workforce lie, and what the priorities for future investment are.   

Including managers in an NHS workforce plan

Nonetheless, to keep up with the pace of change in the NHS management workforce, there will need to be more than just improved data. For this reason, it’s important that managers are included in a robust, long-term NHS workforce plan. If the debate is centred purely on the NHS’s clinical workforce capacity, then a crucial opportunity to shine a light on the recruitment, retention and development challenges facing the NHS’s management workforce will be lost.

We welcome the government’s acceptance of the review recommendations in full. However, as we have seen from recent reviews, acceptance is merely the beginning if the review’s work is to lead to real change for managers working in services. Government needs to get on with the job of implementing the recommendations and invest the resources required to allow managers to do what they set out to when they walk into work each morning: deliver great services for staff and patients.

Joe Home is a clinical fellow in the improvement team at the Health Foundation. 

Bryan Jones is an improvement fellow in the improvement team at the Health Foundation.

Tim Horton is an assistant director in the improvement team at the Health Foundation.