Is good NHS management a waste of money?

Last week's report from the OECD paints a picture of an NHS that continues to improve outcomes for patients but still has work to do to match the very best care in the world. The report was published on the same day that NHS chief executives met to hear about the Operating Framework for 2012/13 – in effect, their marching orders for next year.

The Operating Framework set out an ambitious agenda, including a new emphasis on improving dignity and patient experience as well as reducing unplanned admissions from conditions such as asthma and diabetes.

Delivering this agenda while managing the transition to the new system envisaged in Liberating the NHS will test the skills and resilience of managers to the limits. All the more puzzling therefore that the Secretary of State for Health chose the day of the chief executives' conference to write an article for the Daily Telegraph in which he argued that Labour had increased spending on the NHS 'but wasted much of it on managers'. It was hardly surprising that he received a lukewarm reception from an audience that quite reasonably expected to be praised rather than criticised for its efforts in maintaining performance in challenging circumstances.

The revival of manager-bashing reminded me of the report the Fund published this year – The future of management and leadership in the NHS. Drawing on new research and expert contributions, the report argued that there was no evidence that too much is spent on management in the NHS. If anything, the evidence suggests that the NHS is over-administered and under-managed, with the demands of regulators and performance managers requiring the employment of large numbers of staff to ensure compliance with standards and targets.

The commission that produced this report went on to argue that the time has come to value managers rather than to denigrate their contribution. An organisation as large and complex as the NHS, employing more than one million people and spending around £100 billion each year, needs to recruit and retain the very best if it is to successfully navigate the most challenging period in its history. These leaders must include clinicians who move into leadership as well as experienced managers. Great leaders are needed at all levels – from the board to the ward – with the emphasis on leadership teams rather than heroic individuals.

In recognising the importance of leadership and management, the commission acknowledged that management costs should not be exempt from the pursuit of efficiency savings. At a time when £20 billion has to be released from existing budgets to fund new developments and improvements in care, there can be no 'no go' areas. Equally, the NHS cannot rise to the challenges with which it is faced unless its leaders feel supported in the work they do, and are recognised for their contribution.

It is for this reason that The King's Fund will continue to make the case for effective leadership and management. Our new Leadership Review is focusing on the role of leaders in engaging staff, patients and other partners in improving performance and tackling the areas in which the OECD has identified room for improvement. We will be publishing the results of the review at our second annual leadership summit on 23 May 2012.

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#622 RAD

Interesting post - shame that you dont allow the full post to appear in RSS feeds where most people now follow blogs.

#623 Mary E Hoult
community volunteer

Your article states the Kings Fund will continue to make the case for effective leadership & management,engaging Staff,Patients and other partners this is a good start.My experience of the current key leadership at the DOH is that they fail to do just that.I have a communication from one of the most senior leaders telling me "He is not in the habit of speaking patients " so how will the Kings Funds voice be heard ?

#624 Rob Greig
Chief Executive

Interesting blog. A while ago, NDTi evaluated the DfE's Short Breaks for Disabled Children Pathfinder initiative. One clear conclusion was that progress (in terms of policy delivery and new services that families and young people valued) was only being achieved in places that had invested in dedicated short breaks management and planning capacity. Whilst there were many other factors that underpinned progress, (i.e. management capacity on its own did not assure improvement) an absence of such capacity meant good outcomes did not happen.

#625 Steve O'Neill
Hallett O'Neill

Looking forward to your new leadership review. Staff, partner, clinical engagement etc all seem to missing ( in the required amounts) in the current mix of 'Top Leader' initiatives. Improvement is a contact sport and not done from 'on high'.

#626 Michael Bowen

If we assume that 'leadership' in dependent upon not only the leaders as individual (or collectively in leadership teams) but on the setting / context in which they are seeking to lead AND on the followers they are hoping to take with them, then the picture becomes rather more complex than usually gets acknowledged. Changing who is in leadership roles, taking out or adding in leadership roles or training staff in leadership is unlikely to enough. The entire culture (in reality an incredibly complex set of cultures and sub-cultures interleaved with each other) of the NHS has to be addressed. This is vital, but far from straight forward. No amount of investment or externally directed change will have much positive effect without dealing with this and engaging everyone in the change....

#627 Philippa Tucker
Public Affairs Manager
Chartered Management Institute

Chris, a really interesting and important blog.

You hit the nail on the head when you refer to the under-management but over-administration of the NHS. The problem seems to me to be two-fold: no accepted definition of what an NHS "manager" is, (bureaucrat? nurse manager? skilled chief executive?), and a lack of appreciation of managers' skills, unlike clinicians whose skills can be easily appreciated and evaluated - lives saved, babies born, diseases treated. Until the Government, and employers in the NHS, invest in some national metrics for defining and evaluating the contribution that managers make to the success of the NHS, it will be easy for politicians to point to managers as part of the problem, not the solution. Meeting administrative targets and saving money are not celebrated in the same way that improving cancer survival rates, or reducing readmission numbers, is and I am not suggesting that they will ever be. However, if there was a set of recognised national standards to which NHS managers and leaders could benchmark their skills, it might make it easier for managers and leaders, whether from a clinical background or not, to prove their worth and gain the respect and (as you say) recognition that clinical professionals currently do. Thanks for raising this issue, looking forward to working with you on it!

#628 Anonymous1

Spending on NHS management that resulted in good outcomes is not a waste. The challenge is to find a universally acceptable evaluation tool that determines whether a particular leadership management produces the desirable results that meet all stakeholders expectations. Impossible?

Good management requires good leaders. But the health care industry is so diverse, complex, dynamic, variable in outcomes coupled with changing political priorities. This means sustainable good management needs regular review and feedback from key leaders and health care consumers to gauge current expectations to align with current political reforms. This is nothing new to all experienced leaders. .

With at least 8 years shadowing as health minister and yet the leader of all leaders still don't get it right for the NHS - what chances are there for the rest of the NHS mangement leaders?

#629 Bobbie Jacobson

Chris: good blog- but could go further. In addition to clinical management, what about evidence-based manaement for public health specialists that has almost certainly contributed to improving outcomes? It is at risk of being completely lost in the reforms.

#630 John Burgess

After over 40 years at all levels in the NHS I feel that I am reasonably well qualified to comment on the reasons why this venerable institution is highly unlikely to ever be effectively led or managed unless it is freed from the shackles of government interference. Over the past ten years the so called internal market has spawned a veritable army of business planners, bed managers, accountants, statisticians and business managers who agonise for many hundreds of man hours over contracts, funding streams and targets. If anyone wants to know where the extra two or three pecent of GDP has gone I would suggest the following would be a good place to look.
1) The EU working time directive which has resulted in the NHS needing alost double the number of Consultants and Doctors to cover the number of shifts needed to provide a safe service. The alternative is to down skill and employ other clinical specialists who may not have the same skills and who also have to be replaced.
2)The Consultants Contract which has resulted in tying the medical staff down to the extent that they now refuse to cover for absent colleagues because "it is not in their contract". They now demand up tp £600 per session to cover sickness and absence which previously the "firm" covered for free. Extra sessions needed fo fulfil waiting list initiatives also attract these high fees but managers hands are tied because the targets demand the extra sessions. GP's now are not obliged to cover "out of hours" so private companies run the service again attracting high fees and Clinical leaders are now given sessions for management which need to be covered by colleagues(again at extra cost)
3) Agenda for change was so poorley managed that many clinical support staff were handed large pay rises because those allocating the bands did not really understand what the clinical professionals actually did. This often resulted in the assessors being hoodwinked by cleaver professionals who were able to confuse the system.
4) Whenever a target or a contract is set there is a requirement to gather information in order to demonstrate compliance. The costs absorbed by these requirements is often out of all proportion to the benefit achieved. Many hundreds of hours of highly paid staff are wasted in meetings which are often so large that there is no chance of them coming to any meaningful conclusion.
5) And finally! the idea that it is a good use of a highly skilled consultant to ask him/her to become a skilled manager at the same time suggests that one of these will not be done well. To train a Consultant must cost in the millions of pounds. Medicine is moving so fast these days that even a full time specialist finds it hard to keep at the forefront of his/her specialty let alone attend the myriad of meetings now required. Likewise the art and science of management. Do we really want to take a skilled Consultant/GP off the front line to make him/her a mediocre manager. By all means consult and involve senior Clinicians but let them do what they are trained to do and let the managers do likewise. The number of Doctors who can balance being a first class clinical specialist whilst finding the time to be an effective manager and leader are few and far between and those who do often burn themselves out in the trying.

#631 Colin Millar
Cloud Management Systems

Once again it seems apparent there's a chasm between what people think leadership and management is and the reality.

As the article points out, there's already an exceeding burden in relation to measuring and reporting on Government imposed targets rather than giving the managers in the NHS the broad autonomy to achieve the desirable outcomes.

It's time to start developing effective leadership and management skills in the public sector and that means freeing up some of the budget to allow investment in staff which will, in turn, improve organisational outcomes.

#632 John Kapp
Patient Representative

I agree with Andrew Lansley - the NHS is drowning in bureaucracy (alias management) much of which blocks (rather than promotes) good patient care. It is simply too big (like the Soviet Union) and it too is collapsing under its own weight. The solution is to allow it to break it up into many smaller autonomous social enterprises, (mutuals, as is already happening) in which staff feel ownership, so they manages themselves.

#633 Tom
Nurse Consultant

Having spent five years as one of the Clinical Leaders that the DoH continues to promote (as an Assistant Clinical Director) I recently moved back to a role as a clinical researcher. This was largely because the punitive inspection-driven agenda of the CQC, coupled with a Government that takes every opportunity to criticise managers and leaders, has consistently undermined all efforts to put clinical quality at the heart of care. Couple this with a massive top-down reorganisation, and a financial squeeze, and it is no wonder that so many services are running around like headless chickens at present.

#635 Phil McNally

All great comments.
You only need to read 'Good to Great' to see the importance of great leaders and great staff. Value engineering required. Effectiveness can be increased and wastages are there to be seen/found/cut.
Wise of crowds decisions will be more effective than experts and politicians silly ideas (e.g. bispoke IT system for NHS may be waste of £12B says National Audit Office, great idea Tony Blair?)
The ideas on government cost cutting by the extremely tight fisted billionaire Sir Philip Green had great ideas. The idea of centralised buying is mentioned amoungst other good ideas (without cutting staff) by RCN Chief here too:

#636 Sue

John Burgess has this absolutely right - his thoughtful summary of the current situation is spot on - not that many in the DoH would agree!!

#644 Mark Buckle
JOURNEY Consulting

My observation would be that unless NHS leaders are clear about what they are actually leading FOR, then leadership will always be lacking across the organisation. It has always seemed ironic to me (if it weren't so tragic)) that the majority of individuals working in the NHS possess a deep-seated purpose to their work and yet both organisationally and culturally the system seems designed to drive that individual purpose into the ground.

I was hopeful that the NHS Constitution might have the potential to galvanise the people of the NHS around what 'National', 'Health' and 'Service' might usefully mean in the future (especially the latter), but it has been totally swamped by yet another round of arbitrary re-organisation, this time designed around the premise that somehow clinicians will be more effective in managing the NHS than NHS managers themselves. Excuse me, but where is the evidence base to support this new direction of travel?

My belief is that unless we totally reconfigure the idea of 'patient experience' so that it starts to reflect not only what happened to me (treatment) but how it FELT to be treated (care) AND how these experiences are to be judged in the context of Public EXPECTATIONS of the NHS, it will be impossible to shift the NHS leadership model to anywhere purposeful.

Put simply, until NHS leaders are given explicit permission to 'lead for the patient' at an organisational level - supported by a cultural shift that determines that 'this is how we will do business in the NHS,' there is a real prospect of the institution simply continuing to lurch from one political re-organisation to the next. If the energy that currently gets exerted on internal machinations of policy interpretation could be applied to the ‘external’ design of effective, efficient and consistent service design, delivery and ‘experience’, then I can’t help thinking this would be regarded as significant progress amongst the NHS’ political masters.

#661 Dr Ian Williams

As a former campaign leader in respect of a particular hospital and PCT I was often appalled by the inability to convey strategic thinking and duplication of roles among managers at all levels. At the lower levels, the term manager is seemingly given to anyone who can insert a few healthcare assistants or nurses between themselves and the workface. Poor communication, arrogance and bullying typifies such managers as a cover up for their lack of skills. Sadly in the ill informed bureaucracy of privatisation its likely that these types will survive and propagate. I would recommend that any prospective provider taking over from a PCT does'nt just look at the bottom line which can be massaged by short term measures. Don't just quizz the qualified nurses whose dedication generally is unquestionable but rather look at such pointers as staff turnover/satisfaction, outcome measures, patient reponses, management numbers, profiles and functions. Most importantly query management plans and strategies using evidence based criteria. Only then can waste and inefficiency in the new NHS be flushed out.

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