From administration to system management
In the earliest days of the NHS, the task for managers was administration rather than leadership. Organisations were smaller and less complex, with nurses, doctors and administrative staff organised into separate hierarchies.
Increasing complexity has shaped the development of the management task: the NHS system has grown exponentially, with complex structures developing to underpin it. While there was once a simple accountability hierarchy from front-line services to the Secretary of State, there is now a complex system of public and private providers, with a plethora of regulators who impact on what managers need to do. The advent of the internal market in particular, together with a growing recognition of national and international competition law, means the task is one of complex system management rather than simple administration.
Management in the NHS has also reflected wider developments in management, with the increasing specialisation of management tasks. Disciplines including human resources; procurement; IT and estates management have evolved, and with that the need for specialist managers in addition to managers with general administrative skills. Clinical specialties and sub-specialties have also developed, again requiring leaders who have specific expertise in addition to generic skills.
The nature of the NHS requires leaders and managers at multiple levels; leadership of small units and multi-disciplinary teams; of departments and hospitals and of networks and systems. This focus on distributed leadership is re-emphasised by the National Leadership Council, whose vision is that 'world-class leadership talent and leadership development will exist at every level in the health system to ensure high quality care for all.'
Balance of clinical and managerial power
The NHS relies on consensus, particularly consensus between managers and clinicians. Despite the advent of general management and the move away from a formal consensus management structure from the 1980s onwards, NHS managers require skills in persuasion, negotiation and influence to achieve their goals perhaps more than managers in other sectors. The tension between the desire for a clear chain of command and the professional autonomy of clinicians has been an ongoing feature.
As the government's response to the 1983 Griffiths report states: 'we do not undervalue the importance of consensus in a multi-professional organisation like the NHS. But we share the Report's view that consensus, as a management style, will not alone secure effective and timely management action, nor does it necessarily initiate the kind of dynamic approach needed in the health service to ensure the best quality of care and value for money for patients.'
Clinical leadership was emphasised in the 1983 Griffiths report, which recommended that clinicians should be more closely engaged in the management process and participate in decisions about priorities in the use of resources. The focus on clinical leadership was highlighted with the publication of Lord Ara Darzi's NHS Next Stage Review in 2008, where the explicit involvement of hundreds of clinicians in the process focused attention on the need for more clinical leadership and engagement with management decisions.
This has been further developed in 2010 by the coalition government through the White Paper, Liberating the NHS: Equity and Excellence. Though there has been less investment in clinical leadership in primary care than in secondary care, this will clearly change as a result of the White Paper proposals.
Public scrutiny and accountability
NHS managers operate within a complex political environment. Prior to the 2010 election polling showed that health care was the second most important issue affecting voting intentions, with more than a quarter of people saying it would be one of the key factors in deciding how they voted. The NHS is subject to constant public scrutiny, both locally and nationally, to which managers are required to respond. Managers are required to operate within a system which has inherent tensions: reconfiguration of services or funding of certain treatments are examples of areas where political imperatives can conflict with pragmatic strategic management.
The political nature of the NHS can also result in a short-term approach to management, with managers less able to focus on longer-term strategy as they focus on delivering political imperatives. Frequent reorganisations also require managers to alter their focus and can again detract from longer-term strategy. While clinical leaders often remain in the same organisation or area for a number of years, non-clinical managers change jobs much more rapidly and relationships have to be re-forged.
'Bureaucracy is bad'
'Management' is often an unpopular concept with politicians, and across the political spectrum they have stated their desire to reduce bureaucracy and 'management' in the NHS. The NHS Confederation, among many others have expressed concern that managers, particularly in primary care trusts and strategic health authorities, have received significant criticism from politicians without acknowledgement that they are often central to maintaining performance and delivering change.