The wrong time for a radical reduction in NHS management?

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New details of the design of the NHS Commissioning Board raise serious questions about whether the NHS will have sufficient managerial capacity during the turbulent period ahead. In papers released yesterday, the Board describes the potential loss of talent as one of the 'key risks' associated with the transition process.

The Board will have 3,500 employees in all – a reduction of many thousands compared to the numbers of people currently performing similar functions in primary care trusts, strategic health authorities and the Department of Health. The budget available by 2014/15 will be approximately half of what is currently spent on the functions it will take over.

Although the Board's proposed organisational structure resembles, at first glance, the current SHA and PCT cluster arrangements, the reduction in the numbers of people working at the regional and local levels is striking. The 4 regional sectors and 50 local teams will each employ around 50 people – making them much smaller than SHAs and PCTs, and altogether very different entities. This is particularly the case at the regional level, which is set to almost vanish.

Comparing headcounts is not entirely straightforward, as the new teams are not intended to perform exactly the same functions as the organisations that precede them. However, with the majority of staff in local offices focusing on commissioning primary care and other directly commissioned services, there will only be around 10 people in each locality to oversee the development and assurance of clinical commissioning groups – a task that will be critical if the reforms are to succeed.

There is a particular concern that many of the most experienced managers will leave the system, as the number of senior posts in the local and regional levels of the Board will be limited. Some of these people will find jobs in the emerging commissioning support organisations and clinical commissioning groups, but there is a risk that many talented individuals will look for more certain and more stable work outside of the NHS.

Last year, our independent commission into the future of leadership and management in the NHS showed how important good management really is. It found no evidence to support the notion that the NHS is currently over-managed – if anything, it may be under-managed. While the current financial environment makes it essential that the NHS gets maximum value for money from resources invested in management and leadership, arbitrary spending reduction targets are unhelpful.

There are clear risks associated with replacing the existing managerial structures with new and untested ones at a time when the NHS needs to focus on maintaining financial control and identifying productivity improvements to the value of £20 billion. The danger is that NHS organisations will be left with little capacity to make progress on the issues that matter most – such as quality of care and financial performance. This is particularly true during the transition period, while leaders focus instead on the challenge of implementing the reforms.

SHAs in particular have played a critical role in efforts to reconfigure services and improve productivity, and there is a real concern that the dramatically reduced capacity for strategic thinking and planning at the regional level will create a barrier to further improvement (see, for example our recent report on the future of health care in London).

The next 12-18 months will be the most hazardous phase of the government's reform process. The NHS faces major structural upheaval with reduced capacity for management and leadership, at a time when resources are under extreme pressure. If the government dismantles the current managerial apparatus before the new structures are sufficiently developed, it risks losing talent from the NHS at the very time when it is needed most.


Teresa Harding

Member of the public with a social policy degree.,
Comment date
27 January 2012
Why did you not comment on all this nonsense as soon as the Govt made the proposals? It is rather too late now that expertise is being drained away from PCTs. Why did you not say that many of the top managers at the PCTs were medical professionals? Instead you sat idly by and allowed the Govt. to peddle the lie that people at the front line were the right people to make decisions about commissioning, rather than 'bureaucrats'. As for patient involvement in these decisions, this is a joke. If my GP practice is any example and, I do not remember being consulted by it on anything, then patients are the last people who will have a say in what is being planned. What you have colluded in is the privatisation of the NHS and the real beneficiaries will be private companies which will generate huge profits at the taxpayers expense. Many Britsih companies are far from innovative and their only source of growth in income comes from taxpayers. I suggest you read Will Hutton on this subject.

Chris Naylor

Comment date
27 January 2012
Hello Teresa, thanks for your response. My comments in the blog are very much based on things we’ve said over the last 18 months. I’d really encourage you to have a look at the Leadership Commission report (linked to above) if you’re interested in our thoughts on this. We’ve responded to the proposed changes elsewhere too, for example, in our initial response to the white paper back in July 2010 we argued that the changes went 'too far, too fast'. We've made similar points on other occasions since then. Good quality leadership and management in the NHS are critically important, and we’ll continue to try to put that case across.


Comment date
02 February 2012
I think some key points are raised in this post, by removing these job roles during such a critical change period I think many will agree with you is unnecessarily risky.

I think in the government's/ DoH's mitigation we are in a transition period and I in my limited experience we are already seeing some of the sectors / commissioning support organisations taking on the managerial functions. However, if this peroid is long enough or structured enough is another question. Furthermore, the question you, and the Kings Fund have previously raised over whether the change is going to be successful if a lot of the workforce has left is something that hasn't been fully answered.

Mary Hawking

Comment date
04 February 2012
With the reduction/abolition of PCTs, what happens to what one might call the "housekeeping" functions they perform?
e.g. basics - registration of patients; payments to practices once approved - by whom?; management of funding streams e.g. premises reimbursements (and for practices in PCT-owned premises direct contracts); performers lists for not only GPs but also dentists and pharmacists; revalidation; Registration Authority activities and RBAC; *and responsibility for providing GPs with GP IT systems and support after 31.3.13 when GPSoC ends*?

I agree: providing good well organised and cost-effective services in the NHS (or any other organisation) requires a good organisational structure - and the personell to administer it.

Why is this government so indifferent to the structures needed for day-to-day running of the NHS?

Simon Knowles

NHS Improvement
Comment date
07 February 2012
And it's not just the legitimate housekeeping functions that are a problem. The centre continues to demand vast chunks of data (information, NOT intelligence please note) which distract from genuine management and leadership activity.

It's good to see that Jim Easton has been appointed as National Director: Improvement and Transformation, but one might legitimately ask who is going to be left with the energy, imagination and time to Improve and Transform? Apart from Jim of course.

Anthony Trigwell

PPG member
Comment date
19 July 2012
Chris's comments are most interesting given the stated objectives of the latest round of NHS reforms seems to be improving outcomes by transforming the management of vital life saving services...Doing what is necessary to maximise value and customer experience is vital for the the long-term well-being of any business. Whether we like it or not the NHS is a business and over the years this sometimes appears to have been forgotten. Whilst nobody wants to loose good people; change is necessary and the main question now is whether the latest NHS reform is the right way to go or whether some other daft and unproven ideas will be dreamed up by other talented people?

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