NHS leaders and managers can get a bad press. Blame for delays, waste and inefficiency in the health service tends to be laid firmly at their door, often without any real attempt to understand the pressures and constraints facing them. So it is refreshing to see Sir Gordon Messenger and Dame Linda Pollard, the chairs of the latest England-wide review of health and social care leadership and management, acknowledge the excellence of many leaders and managers in the NHS, as well as the strain under which they operate.

The fact that management and leadership are each receiving the same level of attention from the review is also encouraging. In recent years, the importance of good management has been somewhat forgotten in the policy debate at the expense of a focus on leadership. Given that the NHS employs over 30,000 managers (see Box 1), it is important this imbalance is addressed.  

What impact does management have on NHS performance?

Good management underpins the success of many high performing, ‘well led’ NHS organisations. It is key to the NHS’s ability to provide high-quality services and to maximise the impact of resources in the face of growing demand for care. Managers also play a pivotal role in improving the way services are delivered. Some evidence on the impact of management on health care providers’ performance is summarised in Box 2.

Our interviews highlighted a number of challenges to tackle for improving management practice in the NHS. In this section we describe some of these and suggest ways they could be addressed.

Rationalising managerial workload

A decade ago, the role of an NHS middle manager was described in an NIHR-funded study as having strong similarities to the highly paid ‘extreme jobs’ found in the world of international finance and management consulting. The financial rewards may have been very different, but the pace and intensity of the work, the long hours and the punishing delivery targets were largely the same. Little seems to have changed since then.

For many managers the pressure is every bit as intense as the NHS strives to tackle the care backlog in the wake of COVID-19, as well as the longer term pressures from increasing demand for care. According to our interviewees, finding a way to juggle an impossibly long and complex list of tasks, all of which are billed as urgent priorities, is still a constant challenge for a large proportion of NHS managers, especially for those working in front-line clinical settings.

It is important that managerial workload is feasible and management time is spent where it can add most value. All employers, as well as regional and national bodies, should reflect on how they can reduce the upward reporting burdens on managers and the volume of priority tasks they are assigned. Those organisations that have stopped ‘boiling the ocean’, or expecting managers to deliver everything at once, and focused instead on establishing a few clear overarching quality goals, have helped to establish a climate in which managers are able to function effectively. In these organisations, clarity of purpose and an emphasis on ensuring their core goals are aligned and interlocking creates a context in which managers at all levels can be much more strategic about how they use their time and what they focus on.

Ensuring managers have the licence, space and ‘air cover’ from their leadership teams to lead the development of creative solutions to quality challenges also matters. Management teams need to earmark time away from their usual activities to reflect on the way that their service is managed and identify ways to improve it. This is key for enabling managers to switch from a mode of ‘firefighting’ to one in which they are able to identify and tackle emerging problems, or avoid them altogether.

Addressing variation in management practice and training

The question of whether managers should be subject to a set of agreed professional standards and national regulation governing their conduct, responsibilities and development has been at the forefront of many national reviews of NHS leadership and management over the past decade (including the Kerr, Rose, Smith, Dalton, Berwick and Francis reviews). The debate has been highly contentious. Proponents have argued that regulation has the potential to reduce variation in management performance, as well as bringing full-time managers in line with the medical and nursing professions and, in doing so, raising the status and profile of managers. Meanwhile, critics have pointed to the costs and feasibility of regulation and questioned whether it is really an effective lever for tackling variation. Some have worried that it may just provide another stick with which to beat an already beleaguered profession.

While the prospects of achieving a consensus on regulation appear slim, there is general agreement on both sides of the debate that there is a pressing need to achieve greater consistency in a number of key areas relating to management. Here we look at two particular issues, which emerged during our interviews: addressing the style of personality led management found in many organisations and improving the training and development of managers.

Reducing the prevalence of personality led management

A strong theme that emerged in our interviews was the extent to which the style and practice of NHS management varies, not just between organisations but within them. In many NHS trusts, for example, a group of clinical service lines is led by a ‘triumvirate’ consisting of a clinical lead, an operational lead and a nursing lead. But if you look beyond this standard structure, at the way in which power and responsibility is divided between the triumvirate in different groups, even within the same trust, a more varied picture emerges.

In some places, longstanding governance conventions and practices mean that one of the leads has a higher profile and reach than their peers. Elsewhere, it is the personalities and preferences of the respective leads that shape their management style and approach. Sometimes there are engaged and assertive clinical and nursing leads with a wealth of management experience who take the time to form an effective and even-handed partnership with their operational lead. In other cases, the operational lead dominates management decision making and the main function of the clinical and nursing leads is to review and sign off decisions.

Each of these versions of the triumvirate may work perfectly well for the individuals in post at the time and allow them to manage the division effectively. But this style of ‘personality led management’ (that is, contingent on the personality, style, interests and preferences of the individual) presents some risks. Chief among them is the inherent instability it can cause. If one person moves on to a new post and is replaced by someone with a different style, or a different set of priorities and preferences, then an entirely new working relationship needs to be struck, and staff are forced to adapt to a new management approach and set of power dynamics.

While ‘personality led management’ can be seen in the senior and middle management tiers of many NHS organisations, our interviewees suggested that it is not entrenched everywhere in the NHS. Some organisations have developed a consistent management culture and standardised way of working that is sufficiently well embedded that new appointees fit seamlessly into the team. As well as seeking to embed the right values and behaviours, leaders and managers of high-performing services have created management structures and processes geared towards ensuring consistency, clarity and stability. They have created standard job descriptions, and established managerial protocols, procedures and competency frameworks at each level to ensure that there is clarity about what each role involves, the skills and experience required and where the boundaries between specific roles lie. Underpinning them is often a transparent training and development pathway to ensure that prospective managers know what they need to do to progress their career, and what support they will get to do so.

The priority now is to ensure that good practice of this kind is the norm, rather than the exception. There is no single way of doing this. In large provider organisations it may be a question of gradually building on the success of high-performing, well-managed divisions and services as part of an organisation-wide strategy. In some areas, it may be appropriate for provider collaboratives and integrated care systems to pool resources with a view to driving change on a collaborative basis. Whatever path is chosen, it is important that organisations and systems are prepared to allocate sufficient time, resources and priority to planning and implementing their chosen approach.

While improving management practice is sometimes discussed as a route to tackling variation in performance between providers, it is important to remember that there can also be huge variation in performance within individual providers. Ensuring greater consistency in the approach to management within an organisation, and replicating good management practice across the whole organisation, can therefore be important levers for addressing this type of performance variation.

Improving access to training and development

A common complaint from the managers we interviewed is that they have had to work out for themselves how to be a manager. Sometimes there is training available, but they have not had the support to take time away from their day job to take advantage of it. Sometimes there is nothing suitable on offer at all. But what virtually all managers find is that the onus is firmly on them, unless they have a supportive supervisor, to find relevant training and then justify why it is necessary. Few it seems have access to a structured development programme in which they are expected to participate. As a result, there is significant variation in the training and skills of NHS managers.

There has been some progress over the past decade in increasing the availability of training programmes. According to our interviewees, for those who want it, it is often now easier than it was to find training in specific management skills, such as how to manage a budget or a team. Meanwhile, an increasing number of NHS trusts have understood the value of creating a standardised development offer for their managers and leaders (for example, Sheffield Teaching Hospitals NHS Foundation Trust). There are also a plethora of national schemes open to managers (see Box 3). And the importance of making line management training more readily available was recently acknowledged in the NHS People Plan.

Nonetheless, evidence that structured training for managers is widely recognised as important is elusive. The persistence of certain stereotypes about what it takes to become a manager may be partly to blame for this. In the case of clinicians, many of our interviewees drew attention to what they felt was an unhelpful assumption that clinicians’ medical training and clinical decision-making expertise provides them with the requisite skills to take on leadership and management responsibilities. As a result, they argued, many clinicians find themselves in management roles without any grounding in the theory and practice of management, and are then forced to play catch up for the rest of their careers. According to our interviewees, the presence of very senior NHS managers on management training modules, designed for far more junior colleagues, is much more common than it should be – testament to the lack of a structured development pathway earlier in their careers.

A clinical background offers many advantages for prospective managers, and it is clear that more needs to be done to encourage clinicians interested in leadership and management to take on responsibilities in this area. After all, clinical leadership at NHS trust board level has been associated with a range of performance benefits. But, in the view of our interviewees, the NHS lags behind other  health care systems in Europe and North America in terms of preparing clinicians for a management and leadership career.

Much of the responsibility for tackling the challenges outlined above lies with local leaders. The task of ensuring that pockets of good management practice are replicated across organisations and wider systems, for example, lies predominantly with organisation and system leaders. Local leaders can also help to ease the burden on managers of front-line services by stripping back the number of delivery targets and reporting requirements they face. However, national policymakers have several critical roles to play.

First, it is important they champion the cause of managers and celebrate the contribution they make to the delivery of quality health care. NHS England and NHS Improvement’s new 10-year strategy for NHS human resources and organisational development does underline the talent and ability present within the NHS’s managerial ranks, but these sentiments need to be echoed across the whole of government.

Second, and related to this, particular attention needs to be given at national level to attracting and retaining good managers and leaders, especially in organisations with performance challenges. Given that the median tenure of NHS trust chief executives is reported to be only 3 years, and that many of our interviewees cited a high level of managerial turnover in their trusts as a particular challenge for improving performance, it is clear that more work is required in this area. Financial incentives, such as relocation allowances, performance-related pay and loyalty bonuses probably have a role to play here, but they will need to be accompanied by efforts to boost the professional kudos associated with turning around struggling organisations. As long as leadership and management roles in large metropolitan teaching trusts continue to be seen as far more prestigious than those in other trusts, including in smaller urban centres or rural areas, then the latter will find it harder to recruit and retain talented managers and leaders. Recruitment and retention are not the only reasons why trusts in smaller urban centres or rural areas sometimes face performance challenges, but they certainly play an influential role.

Third, policymakers have an important contribution to make in creating a climate in which leaders and managers can flourish. Providing long-term strategic clarity, while avoiding overly prescriptive interventions and disruptive reorganisations, helps give organisations the security they need to set long-term objectives aligned with national goals. And by cutting the upward reporting burden, tackling ‘priority thickets’, and avoiding a punitive culture, national policymakers can help provide leaders and managers with the space they need to focus on improving services. Indeed, punitive policy and regulatory measures may have the effect of deterring innovation by leaders and managers, and encouraging a focus on compliance with short-term targets, rather than on long-term transformation.

Finally, policymakers need to consider the question of how to fund any increase in training provision. Ensuring that there are sufficient resources available to train and support senior leaders is relatively feasible given the modest size of the health and social care leadership population (and there are some excellent programmes already in place). Providing high-quality training for the NHS’s army of junior and middle managers is a more significant undertaking. Yet it is important that funding is made available if local organisations and systems are to have the resources they need to address their training and development priorities. After all, a lack of resources is one of the reasons why the recommendations of previous reviews to strengthen the management training offer have not been realised. So policymakers need to ensure that extra investment is made available over the next decade.

In summary, we have highlighted several important areas for the Messenger review to consider:

1. Support providers and systems to tackle variation in management practice. Management practice and culture varies considerably across the health and care landscape, including within individual providers. Such variation is unlikely to be resolved through a one-size-fits-all intervention. Instead, local leaders need to be encouraged and supported to develop strategies tailored to local needs and context to ensure good practice is replicated across organisations and systems.
2. Improve access to training and development opportunities. Training and development opportunities are currently patchy and hard to access for many current and prospective managers and leaders. Significant resources need to be earmarked to strengthen the infrastructure for training, development and talent management. It could make sense to develop new accredited training offers and programmes on a regional basis, while ensuring these complement existing local programmes and are tailored to local needs.
3. Ensure training equips managers and leaders with the skills they need today. Training must include the knowledge and skills managers and leaders need to flourish in today’s landscape, which is networked, place-based, data-driven and improvement focused. This includes more emphasis on collaborative leadership skills, so that managers and leaders can work effectively with their peers across the local health care system, as well as on performance measurement, quality improvement and technology appraisal and implementation skills.
4. Tackle the reporting burden and ‘priority thickets’ facing managers. Employers, and regional and national bodies have a responsibility to help ensure management workloads are feasible and that management time is spent where it can add most value. They should reflect on how they can reduce the upward reporting burden, tackle priority thickets and avoid unnecessary reorganisations – all of which can consume management capacity and make it harder to manage effectively.
5. Ensure the role of managers and leaders is better understood and valued. Employers, regional and national bodies should work collaboratively to shift perceptions of NHS managers and leaders and to challenge negative stereotypes, as well as ensuring that remuneration supports effective recruitment and retention. This will be particularly important to help employers recruit and retain good managers, particularly in those parts of the country facing recruitment challenges.

Arguing that we should better value NHS managers and leaders, and increase the support available to them, might not be the most politically popular case to make given some of the myths and negative stereotypes that have been allowed to take root. But it is the right thing to do – and indeed will be essential – if the NHS is to improve the quality and efficiency of its services, and meet the growing demand for care as it recovers from the pandemic.