We don't know enough about what makes NHS managers effective

A research study seeks to understand what kind of management capacity the NHS actually needs and what makes for effective management capability, write Leo McCann, Ian Kirkpatrick and Kirsten Armit.

There has long been a tendency to denigrate and undervalue managers in the NHS. A widely-held view is that the NHS is 'over-managed' and over-regulated to the point where further investments in management would be wasteful and counterproductive.

However, refreshingly, Lord Darzi’s report on the NHS strikes a different note. It concludes that: 'Despite what some media commentators may say, good management has a vital role in health care: it exists to ensure that the maximum health care value is created with the resources that are available.'

The question of how to manage the NHS has, of course, been a longstanding preoccupation. The NHS is a complex, hybrid creature that has undergone multiple periods of organisational change.

The insertion of 'general management' was the core of the Griffiths Report of 1983 and since then, 'top down' reforms have been near-continual. Managers were afforded significant roles in the 'internal market', or 'purchaser-provider split' reforms of the early 1990s, while more recently, policy has focused on the role of 'systems leadership'.

The contribution that managers can make to the performance of the NHS has also been recognised. Following his review of NHS leadership, general Sir Gordon Messenger highlighted the 'very real difference that first-rate leadership can make in health and social care, with many outstanding examples contributing directly to better service'. Similarly, Lord Darzi praises NHS managers for 'keeping the show on the road', despite mounting pressures.

Nevertheless, while the omens seem good for future investment in NHS management, it is less clear how this should be done. The very nature of management and leadership in the NHS is complex and unclear.

What exactly is management and leadership in this context and who are the managers? Where does management and leadership happen, and how exactly does it add value to NHS service delivery and organisation? The question of how managers should be trained, educated and supported is also important, especially given the recommendations of Lord Darzi and his team.

In our own research, funded by the Health Foundation, we are seeking to address these questions. As a starting point, we will draw on what is already known about NHS managers, but will go beyond existing work by seeking to understand what kind of management capacity the NHS actually needs.

Our study, spanning over 2 years, will also focus on the crucial issue of what makes for effective management capability.

Assessing capacity raises obvious questions about whether there are sufficient managers in post. Current research highlights the falling number of managers relative to clinical staff and how management capacity in the NHS is low both by international standards and compared to the private sector.

But while this concern is fully acknowledged, we still know little about the true size of the 'management function' in NHS organisations. Earlier research suggests that management and leadership roles are widely 'distributed', often performed by busy clinicians (or hybrids) on a part-time basis with only minimal leadership training and education.

The phenomenon of 'the accidental manager' is also a longstanding issue in the wider UK economy.

Understanding capability raises additional concerns about what managers contribute to performance and the skills and processes required. Existing research suggests that high-performing health care organisations are those that invest in management.

But why is this the case? While managers provide essential coordination, 'keeping the show on the road', it is likely that they can achieve so much more. Under the right conditions, managers may also play a key brokering role in supporting the dissemination of innovations and their implementation to practice.

Finally, we will explore the conditions that support (or not) effective management capability. One element is likely to be on training and competency frameworks for managers.

That many NHS managers have moved into managerial roles with only minimal management and leadership training and education is well known. Much will depend on the support for managers to enact their roles, on the learning cultures of NHS organisations, and access to reliable and accurate information.

There are also many other complicating factors. At more operational levels, heavy workloads and frequent interpersonal conflicts often overwhelm junior and mid-level managers. Their work is varied and fast-paced and while it can be rewarding, it is often stressful and demanding. Indeed, at senior levels there is often a high turnover in leadership roles.

A further challenge are the numerous occupational 'tribes' in the NHS whose interests and preferences do not always align. Management roles are often unwanted by clinicians; so, translating new ideas into practice can be an uphill battle.

Hence, while Lord Darzi's conclusion that 'managerial capacity and capability have been degraded' in the NHS feels like a step in the right direction, more needs to be done to understand what capacity is needed and how to improve capability. Only then will NHS managers be truly recognised as part of the solution than the problem.

Written by Leo McCann, Ian Kirkpatrick and Kirsten Armit and first published on the HSJ website.

Funded by the Health Foundation, researchers from the School for Business and Society (University of York) will assess current management capacity and capability within NHS trusts and system-partnerships in England.