The growing management crisis risks undermining NHS reform

When the first NHS Long Term Workforce Plan was published in 2023, it met with a distinctly lukewarm reception. One of the most glaring and consequential gaps in the plan was the absence of any concrete plan for the NHS’s management workforce. 

As highlighted in our new briefing, the new NHS workforce plan provides an opportunity to remedy this mistake. With ongoing research by York University and the Health Foundation suggesting that managers play a central role in innovation and improvement, failure to fill this gap in workforce planning is likely to make it harder for the NHS to achieve its reform ambitions. 

So what would a good workforce plan look like from an NHS management perspective? It should first acknowledge that the NHS is very likely to be undermanaged at present, certainly if national workforce datasets are anything to go by. 

These national data are backed up by our research at the NHS trust level. That research is finding many examples of all too thinly managed services, where the job of keeping the show on the road is a constant struggle. 

Worryingly, recent cuts to the so-called administrative overhead of the NHS seem to be targeting exactly those management support functions most needed to deliver improvements. Meanwhile, the reorganisation and cuts experienced by integrated card boards and a host of other bodies are also depleting the NHS’s collective management capacity. Addressing this management deficit must therefore be a priority for the workforce plan. 

Ensuring a sufficiency of managers must also go hand in hand with action to create workplace cultures in which managers at all levels feel trusted and empowered to take decisions. Further research by the Health Foundation and York University has found some NHS settings that have succeeded in embedding such cultures. 

But we also encountered organisations in which core managers either routinely push operational decisions upwards for approval, for fear of being blamed if their decisions backfire, or are denied even the chance to take such decisions – effectively reducing their roles to that of administrators. 

This is exacerbated by the top-down political culture of the NHS, which does little to encourage local providers to drive change. Policymakers also need to face up to the consequences of endless rounds of restructuring across the service that are making it ever harder for managers to focus on the job of improving patient care. 

Another priority is improving access to management training. This is highly variable across the country, not least because of training cuts made by some providers during the pandemic that have yet to be fully reversed. The workforce plan can help to address these challenges by setting out an ambitious vision of what managers with sufficient autonomy, stability, support and training can bring to the NHS and identifying the steps needed to achieve this vision. 

One important step all NHS provider organisations should take, especially the largest ones, is to examine how their core functions are managed and what ‘management dose’ is required to run them effectively. Beyond improving their understanding of their current organisational operations and needs, doing so will have three further benefits. 

First, by making the hitherto intangible management function of organisations more visible, it becomes easier for people within and beyond the NHS to recognise the value good management offers the service and to defend it from attrition. 

Second, it shines a light on critical corporate services such as HR, finance and improvement, which are often vulnerable to cuts but essential to the delivery of front-line care services. Knowing the management dose that such services require can help reveal the consequences of stripping out their management capacity. 

Third, it helps shift the focus from individual managers to the broader organisational management function – the interrelated set of processes and activities needed to plan, organise, deliver and improve services. This is important because the best performing health care organisations think about management in this more holistic way. It leads them to see management as an organisational system in which many staff participate and for which everyone bears some degree of responsibility. 

At a time when plans are underway to regulate managers and introduce a set of professional standards and a code of practice for the profession, the absence of an underpinning workplace plan for management makes little sense. In any other sector, it would be unthinkable for a service of the NHS’s size to operate without a workforce plan for managers. 

Such a plan would be an important statement of intent, especially if it has consistent political backing, and could go a long way towards dissolving the practical and cultural barriers that have stymied the NHS management profession in recent decades – and, with it, the NHS’s ability to respond to the urgent productivity and transformation challenges it faces. 

Bryan Jones is a Senior Improvement Fellow at the Health Foundation. Ian Kirkpatrick is a Chair in Public Management, University of York.

This blog was first published by HSJ on 21 May 2026.