Comment / In defence of our managers

It makes me cross – and I’m no NHS manager.  So I can’t imagine how it makes you feel. It only takes a few headlines about service pressures and financial problems to get someone suggesting we could address at least some of the current challenges by sacking a few managers and replacing them with various coloured scrubs.

The question of management costs came up again in a recent special debate on Radio 4, examining what needs to give to enable the NHS to cope with its current pressures. There are plenty of examples in recent national and international politics where people want to grasp overly simple solutions to complex problems, but this one just never goes away.

The late Tony Benn famously riffed on the topic in a debate in the House of Commons in 1995, when he referenced a mythical boat race between the NHS and Japan. All you need to know is that NHS managers didn’t come out well from the anecdote. It was a clever way of getting across his view that the NHS was over-managed – you’d expect little else from the distinguished parliamentarian. But for those in the service, the constant brickbats must get beyond a joke.

Back on the BBC debate, NHS Providers’ Chris Hopson mounted a sterling defence of current management levels in the NHS, insisting NHS management and administration costs were a third of those in the US and half of those in ‘efficient Germany’. 

Given 1.4 million staff and a £115bn budget, wouldn’t you want good HR and finance departments? With the NHS seeing one million people every 36 hours, wouldn’t you want people ensuring effective flow? When operating theatres are so expensive to run, don’t you want people ensuring they are as efficient as possible? If anything, he argued, the NHS was undermanaged. 

It is a point made previously by the King’s Fund. It is six years since the respected research body’s commission on NHS management. It recognised the difficulty in defining management but suggested ‘best estimates’ put the cost of management and administration at about 8%. Its analysis also concluded that, given the complexity of healthcare, the NHS was more likely to be under- rather than over-managed.

To be fair to the clinicians involved in the BBC debate, they mounted their own defence of management – a surgeon suggested her surgical team couldn’t operate without the management skills that get people to the right place at the right time. Where there were concerns, it was more about what managers were being forced to spend their time on. 

For example, there are plenty of people (managers and clinicians alike) who see waste in the continued operation of an internal market – though many functions would still need to be undertaken (such as understanding local population needs) whatever the system architecture. And there remains open hostility to the money spent on external management consultants (although the alternative would presumably involve more internal management resource).

Politicians over the years have often encouraged the simplistic perception of ‘frontline good, management bad’. There remains a push to examine shared back-office services and there has been no mention of not pursuing Lord Carter’s recommendation for acute trusts to cap corporate and administration function costs at 7% of income by April 2018. 

But in general, there seems to be a greater central appreciation that the challenges facing the service won’t be addressed without a support function that has the right skills and the right numbers.

However, it must be hugely demoralising to hear the same accusations trotted out again and again – effectively questioning the contributions of important support services.

Doctors, nurses and allied health professionals do fantastic jobs. But ignoring the important contributions of all the other health service workers is at best naïve. And at worst, it will demotivate a crucial part of the workforce when we most need them.