Shared leadership: the way forward for NHS

Although managers are often criticised, it is a fact that, without management nothing will happen. One area where criticism is frequently levelled is towards those who add to the growing “burden of regulation” whether that burden is carried by private sector business or public services. A review carried out in 2009 showed that NHS organisations were subject to some 35 different regulators, auditors, inspectorates and accreditation agencies that can demand information from the various parts of the system.1 Those who criticise the level of bureaucracy within the NHS should recognise that it is necessary to provide greater transparency, comparable performance data to inform choice, to drive accountability and improve quality, and this does come at a cost. A recent report, commissioned by The King’s Fund looks at the need for strong leadership and management in the NHS.2 The report begins by offering a history of NHS leadership, looking at key reports through the years that have focussed on management and leadership issues. The most notable include the Cogwheel report of 1967 which called for more involvement of clinicians in management – a move which was dissipated by the 1974 reorganisation of the NHS and the arrival of the ill-fated ‘consensus management through multi-disciplinary teams which gave everyone a veto on any decision. In 1983 the Griffith’s report resulted in the introduction of general managers who, during the creation of the internal market in the 1990s restyled themselves as chief executives. More recently, the last Labour Government sought move involvement of GPs and primary care staff in the commissioning of care through its 1999 Health Act. Lord Darzi’s Next Stage Review final report in 20083 placed emphasis on clinical leadership and the current Health and Social Care Bill may yet result in the biggest shift of power and accountability in the history of the NHS.

Managers in the NHS

The report concluded that it is an almost impossible task to measure the level of administration and management in the NHS. There is a plethora of statistics about managers, management and administration, but very little information that can be properly analysed about who they are, what they do, and what their impact is. Figures from the NHS Information Centre, for example, indicate that over the decade to 2009 total NHS staff numbers in England rose by 333,650 to 1.43 million, a 30% increase. Within that, professionally qualified staff rose by almost 34%. Workers from support to clinically qualified staff, which confusingly includes bank, agency and nursery nurses as well as clerical, administrative and some maintenance staff – rose by just over 27%. Infrastructure staff, which includes some managers along with finance, IT, personnel and estates, and services such as cleaning, catering and laundry (but not when those services are outsourced) rose by just under 38%. The number of managers and senior managers, as defined in the survey, rose by 84%. However, the report commissioners believe that these figures are misleading. In reality, it says, the absolute increase in senior managers and manager numbers over the decade was just over 20,000 while the increase in professionally qualified staff was just under 184,000. The percentage of managers in England has risen from just over 2% of total NHS staff in 1999, measured by headcount, to just over 3% in 2009, and has since dropped back slightly. On a full-time equivalent basis, the number of managers rose from 2.7% to 3.6% of NHS employment. Evidence submitted for the report by David Buchanan, professor of organizational behaviour at Cranfield School of Management, analysing the NHS workforce data collected together by the Commission, concludes that rather than the much publicised growth in management numbers, the NHS may actually be an under-managed service. Using data from seven representative NHS trusts, he points out that a clinical directorate consisting of a consultant, general manager and senior nurse may well be managing a £40 m a year business in a hospital with a £350 m turnover. NHS chief executive, Sir David Nicholson also provided some recent figures. He told the Commons Health Select Committee that the administrative and management costs for strategic health authorities, primary care trusts’ (PCTs) commissioner arms, the health department and the various regulators and arms-length bodies are now calculated to be £5.1 bn – a figure that will reduce to £3.4 bn as administration costs are cut by one-third over the spending review period from 2011 to 2015. This £5.1 bn equates to just under 5% of the health budget. To that, however, would have to be added management and administration costs in hospitals, general practice and parts of the community service.