Joe Home is a clinical fellow at the Health Foundation, currently seconded via the National Medical Directors Fellow Programme. As a junior doctor, he worked clinically at Manchester University NHS Foundation Trust while holding a number of trade union roles, before taking a leadership role in the trust where he led junior doctor workforce engagement and transformation.
Joe recently worked on our long read Strengthening NHS management and leadership, identifying priorities for reform for Sir Gordon Messenger’s current review of leadership in health and social care in England.
The long read drew on insights provided by leaders and managers across the NHS about how the health service could better value and support them. We spoke to Joe about the key themes and ask how this compares to his own experience as a clinician and a leader.
What are the main challenges facing NHS managers?
Managers are often an unseen and under-appreciated segment of the health care workforce, and yet good management is key to running high quality and efficient services.
Our interviews highlighted a number of common challenges for people in leadership and management roles. People talked about heavy workload and long hours, a high upward reporting burden, and a myriad of often conflicting priorities and stakeholders to respond to. The pressure is particularly intense at the moment as the NHS attempts to recover and rebuild after what has been an immensely challenging few years. Although there has been significant focus on tackling the elective care backlog, staff recovery has not received as much attention so far, despite the workforce being the people expected to deliver those services.
How do you think managers are perceived, both inside the NHS and beyond?
Most managers in the NHS have a vast array of responsibilities, which can be hard to define in simple terms. As a result, there’s often little understanding among clinical teams of what managers actually do. That makes them an easy target to blame for inefficiencies, and the ‘too many managers’ narrative isn’t helpful.
You can see how it develops. As a junior doctor you have little exposure to non-clinical staff. Any contact you do have tends to be in more negative circumstances: a patient safety issue or a problem with your rota. If you get what feels like an unsupportive response, it contributes over time to a sense of ‘them and us’. When I moved into a management role, many clinical colleagues described it as ‘a move to the dark side’, which made an already difficult transition even harder.
If the people working in the health service don’t understand or value NHS managers, then the public have no chance. When people clapped for the NHS during the pandemic, the work of doctors and nurses was often highlighted, however there was little mention of those working behind the scenes to help keep things going.
How have you found making the transition from clinician to manager?
At the start of the pandemic I took on a new leadership role, managing staff redeployment across the trust. Among other duties I found myself working with our medical workforce team to redesign rotas and workforce models. I realised how pressured and understaffed the team was. Rather than trying to give junior doctors a hard time, managers worked round the clock to support clinical services.
This exposure was a real learning point for me. I came to understand there are whole teams of people working day and night to make the hospital run as it does. And because clinical staff don’t always get to see that, they can underestimate what that managerial workforce do, or that they too are under pressure and don’t always have the resources or support they need.
Personally, the move to management hasn’t always felt easy. There’s this fallacy that doctors are natural leaders with highly transferable skills. But it’s not so simple. Clinicians are often great at dealing with issues in the short term (treating the patients in front of us). But as clinicians we’re not taught to project manage, deal with complex budgets or manage diverse teams. And we certainly have no training in long-term strategy.
What kind of training and support does a new manager receive – and where could it be strengthened?
There is some great training out there. The NHS Graduate Management Training Scheme is fantastic, but most managers in the NHS don’t come via that route. And while some trusts have understood the value of creating a standardised development offer for their managers and leaders, that’s certainly not the case everywhere. Many of the people we spoke to described having to figure out for themselves how to manage when they started in their roles, and source their own training.
This is very different from the clinical world. Take a surgeon, who once fully qualified, will have completed 20+ years of training and be signed off by relevant authorities to be able to do that job safely and autonomously. Even after this point, you’ll be constantly measured on your performance. If you step out of that role into a management job, as say a clinical director, the training and support available to you will be negligible in comparison, but you will still be expected to perform and be held accountable. This suggests that management must be easy, and undervalues the skills and knowledge needed to do such an important job. And that’s really interesting because a low performing manager at that level will have an impact not just on a few patients, but on how the whole service runs.
Even early-career managers often carry a lot of responsibility. A friend manages a regional cancer service. He’s only a few years into the job but he’s accountable for the care of thousands of patients. If things go wrong, it’s his career on the line. Whereas if you look at me, 5 years into my clinical work and the buck doesn’t stop with me. Of course, I have responsibility to my patients, but I can always defer to a senior consultant if I’m not sure.
As a manager in the health service, you also don’t have an established professional body or royal college to back you. A strong message from our interviews was that people would like to see that change, with more recognition of NHS management as a profession in its own right. They want an organisation to represent them, one capable of standing up for their interests at national level.
Having less structured support in place for non-clinical roles also impacts on how willing people are to embark on service improvement. Because sometimes even if your service is underperforming it’s less risky for a manager to maintain the status quo rather than introduce a big change that may or may not work. There’s also a lot of firefighting going on, having to focus on staffing for the next day, rather than having any time to think about what services should look like in 5 years' time.
What do you think the priorities for improvement are in relation to NHS management?
In our long read we highlighted several important areas for the Leadership Review to consider in terms of improving NHS management. This includes tackling the variation in management practice and improving access to training and development so that managers have the skills and knowledge they need – from collaborative leadership to performance management and quality improvement. Ensuring management workloads are feasible and that management time is spent where it can add most value is also key.
Overall, it would be good to see more emphasis on understanding and valuing the role of managers and leaders in the health service. That involves increasing the support available to them and finding ways to challenge the negative stereotypes that persist.
This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.