NHS managers could do with a facelift. Cure the NHS with far fewer managers and It is nurses working at the coalface of the NHS that we need, not more bosses are commonplace headlines. And cynicism about NHS managers is not limited to the media. Two years ago, the then minister for health, Jeremy Hunt, wondered whether the NHS had made a mistake in the 1980s “by deliberately creating a manager class who were not clinicians”. Both Labour and Conservative governments have tried (unsuccessfully) to reduce their number.
However, our latest research suggests that this negative view of managers is unwarranted. Far from representing a “bureaucratic burden” on the NHS, we found that having more managers increases performance.
To investigate this issue, we used data from 160 hospital trusts in England from 2007 to 2012. We selected those years because it was easier to collect and combine data on managers and the performance of hospital trusts for this period as the data was consistent and hence easier to collate and compare.
We wanted to know whether the proportion of managers in a hospital trust affected hospital efficiency, patient experience and the quality of clinical services. The NHS reports these measures consistently across all trusts, making comparisons easier.
To measure efficiency, we used a method called a “data envelopment analysis” which uses several indicators to compare hospital trusts’ ability to increase their outputs relative to their inputs. For patient experience, we gathered data from the NHS Adult Inpatient Survey, collected annually for each trust by the Care Quality Commission since 2001. Finally, to assess clinical quality we used one indicator: hospital infection rates. Specifically, we looked at the rate of infection for Clostridium difficile.
We analysed the data using a statistical technique called regression analysis. The technique allowed us to explore the relationship between the proportion of managers in a trust and the outcomes we were interested in while ruling out the influence of other factors, such as the size of a trust or previous levels of employment or performance.
The results showed that, across all trusts, having a higher proportion of managers had a statistically significant impact on performance. Even a small increase in managers, from 2% to 3% of the workforce, led to a marginal improvement of 1% in patient satisfaction scores, a 5% improvement in hospital efficiency and a 15% reduction in infection rates.
We further estimated, across all hospital trusts in England, that raising the proportion of managers in the workforce by one percentage point could cost less than £500m, annually. This seems like a small price to pay, given the size of the NHS budget (£130 billion, annually) and the benefits reported in our study.
This one percentage point increase would not mean that the NHS would be overmanaged. Currently, there are only 31,000 managers in the NHS. About a third are doctors or nurses who work part-time in leadership roles, while the rest are general (non-clinical) managers. This may seem like a lot, but in an organisation of 1.36m employees, it is less than 3% of the workforce. It also contrasts with the UK economy where managers make up 9.5% of the workforce.
So why has bashing managers been such a popular pastime for policymakers and the media? There have been high-profile scandals that have added fuel to the fire, most notably the case of Mid-Staffordshire NHS Foundation Trust, where it was estimated that between 400 and 1,200 patients died as a result of poor care between January 2005 and March 2009. The Francis report on the scandal highlighted the remoteness of managers from the frontline and their fixation on meeting financial targets as important factors contributing to the trust’s failure.
Doctors, meanwhile, have a growing amount of paperwork to deal with, much of it generated by national policies and regulatory demands. By association, they blame this on managers as it takes them away from doing their real job of caring for patients.
And yet, by any metric, the NHS appears to be undermanaged at the operational level. Managers are not well paid relative to the private sector, while the intensity of work and stress is probably higher.
This is not to ignore the fact that managers can sometimes make mistakes. Instead, our research suggests that as a complex organisation – now the fifth biggest in the world – the NHS needs more managers. Strengthening management is not about wasting money and nor does it mean privatising the NHS, it is about making the NHS work better as a public service in the public interest.