Why management matters so much for the success of the NHS 10 Year Health Plan

This long read is a joint publication from The King’s Fund and the University of Birmingham’s Health Services Management Centre.

Introduction 

This long read examines the current state of NHS management and how it needs to be strengthened and professionalised if it is to realise the ambitions of the 10 Year Health Plan for England. We highlight the need for both the political and policy centre, and leaders of local NHS bodies, to create the conditions for a more devolved, trustful and healthy NHS organisational culture. 

The 10 Year Health Plan sets multiple ambitions for improving health and care. Three shifts are at the heart of the plan: from hospital to community, from analogue to digital, and from sickness to prevention. The plan places great store on the potential of technologies to transform the NHS and promises action to improve the quality of care. It also emphasises the need to increase productivity and stabilise finances.  

The plan states that these ambitions will be achieved through financial incentives, greater transparency, and a new operating model intended to shift power from the centre to people and frontline staff. The plan reiterates the importance of personalised care and patient choice, and the role of NHS staff in leading change. It promises to ‘slash bureaucracy’, cut national targets, and give greater autonomy to well-performing NHS organisations. 

The new operating model recognises the need to strengthen NHS management. Proposed actions include building on the Messenger and Pollard review, setting higher standards for managers based on a new system of regulation, and establishing a College of Executive and Clinical Leadership to train and develop senior managers of the future.  

Cultural change will not succeed unless it engages staff at all levels and addresses real pressures in the workplace. The plan makes all the right noises about valuing staff and supporting them to care for patients, but the legacy of the Covid-19 pandemic and recent industrial disputes have created an extremely challenging environment. The annual NHS Staff Survey reveals highly variable staff experience. It is essential that local employers elevate the people agenda, including placing greater value on HR management as a core contributor to staff experience and organisational effectiveness. 

In 2024, over 41% of NHS staff reported feeling unwell due to work-related stress; burnout remains prevalent, and a high number of Black, Asian and ethnic minority staff still experience harassment, bullying or abuse. Reports such as Too Hot to Handle? lay bare the reality of the effects of racism on staff and patients in the NHS, which are often minimised, denied or deflected.  

Local managers play a key role in working with staff to motivate teams and boost the discretionary effort that is essential to implementing the 10 Year Health Plan.  

The current position of NHS leadership and management 

The media and political mantra that there are too many managers in the NHS is a fundamental misunderstanding. In his rapid investigation into the state of the NHS in 2024, Lord Darzi highlighted that the NHS spends less on management than equivalent international health systems, noted that it had lost too many skilled managers due to the Lansley reforms of 2012, and argued that its problem is ‘not too many managers but too few with the right skills and capabilities’. Research shows that even marginal increases in the number of managers can lead to statistically significant improvements in the performance of NHS acute trusts, as measured by patient experience, reduced infection rates and overall efficiency. 

Darzi pointed to the increased number of staff in national bodies and regulators between 2015 and 2024, which created a significant burden on local managers and further encouraged a culture of looking upwards to the centre rather than out to patients and communities. This results in an overly centralised system that may distort priorities and disempower staff delivering care. 

A distinctive feature of health care management and leadership is that much of it is undertaken by clinicians: hospital wards and community health teams are usually led by nurses; hospital, community and mental health service divisions will have a clinical director who is typically a senior doctor or allied health professional; and primary care organisations such as GP federations are led by experienced GPs. Clinicians are frequently unprepared for taking up these roles, and research reveals that often little or no training and support is available to them.  

There are worrying signs of the effects of the pressures on clinical managers and leaders, and on NHS managers generally. It is increasingly difficult to recruit to clinical director, executive and non-executive director roles, with these positions often considered too difficult, particularly in a context where these roles are frequently disparaged by the media and politicians as ‘fat cats’ or ‘bureaucrats’.  

NHS management is central to ensuring that health services are run safely, efficiently and in ways that assure patients of a positive experience. After investigations into scandals in patient care, public and other inquiries continue to point the finger at failures of NHS management and boards. Although this accountability is right and proper, there is rarely much discussion – and even less action – about investing in, training and professionalising NHS management to help avoid such failures of clinical and organisational governance.  

The 10 Year Health Plan and the associated upcoming workforce plan present an opportunity for the NHS to break out of this cycle of under-investment in and denigration of managers, and build the capabilities needed to deliver its ambitions.  

What needs to be done to strengthen and develop NHS management? 

Strategic management and leadership 

Politicians rely on NHS managers and boards to deliver their priorities for the NHS. These include achieving financial stability, reducing waiting times and lists, enhancing patient safety, harnessing the potential of artificial intelligence (AI) and digital technology, and improving patient access to care and support.  

NHS boards are responsible for setting direction for their organisation, even as they navigate multiple central directives and balance the needs of local services, patients and communities. For executive teams, making the space for this strategic work is an exacting task. They report feeling overwhelmed by ‘keeping the show on the road’, trying to meet an avalanche of central targets, and avoiding being castigated by their political bosses.  

A core challenge for local NHS leaders is how to ensure effective clinical and corporate governance. The board must assure the quality, safety and effectiveness of care given to patients while being steward of public funds (operating according to the Nolan principles of public life) and ensuring a healthy, just and supportive organisational culture.  

Management and leadership are learnt through a mix of education, experience and ongoing development. For too long, the NHS has survived on a culture of leaders learning on the job and ‘muddling through’. Necessary strategic management skills include those listed in the box below.  

Peer networks can provide important support, insight and advice for what are often lonely, tough and pressured roles. These networks may be self-organising, provided centrally by the NHS, or offered by a membership body such as the NHS Confederation. Similarly, buddying and mentoring can help senior NHS managers and leaders grow in their roles, avoid significant pitfalls, and remain focused on the central challenges of clinical and corporate governance.  

Operational management 

Delivery of the 10 Year Health Plan relies on there being enough skilled and experienced operational managers, particularly in middle management roles. These managers work in close partnership with clinical teams and are essential to the design and delivery of service improvements and change – for example, how outpatient clinics, patient communications, and staff working practices will operate, implementing new ways of using technology and AI, and supporting the shift of care to community settings.  

Too often, operational managers are undervalued or overlooked, despite their vital role in navigating complexity, driving improvement and supporting frontline teams. Networks such as Proud2bOps (developed by the NHS operational management community as a form of peer support) have highlighted the need to recognise operational management as a profession that deserves investment, development, and a strong collective voice.  

Professor Richard Bohmer argued that high-performing organisations are those in which managers work in close partnership with clinical leaders to define processes and standards, build supportive systems, use data rigorously to monitor and improve performance, and foster a culture of continuous learning and reflection.  

The evolving world of work also demands new skill sets, as digital technologies continue to reshape the way health and care systems function. Essential operational management skills required by NHS leaders include those set out in the box below. 

Although some local NHS organisations invest significantly in training and developing managers and clinical leaders in these essential operational and people management skills, others do not. Local organisations have a duty to prioritise such staff and their development, and national leaders must value and celebrate this critically important part of the NHS workforce. 

The need to professionalise and support NHS management 

The Department of Health and Social Care (DHSC) recently consulted on proposals to introduce NHS manager regulation, including a voluntary register of NHS managers and a system for disbarring those who commit major breaches of core standards. Regulation will be underpinned by a new NHS management and leadership framework encompassing a code of practice, standards and competencies, and a national development curriculum.  

 A code of conduct and management standards are necessary but not sufficient. Also needed are actions to support and professionalise NHS management and leadership. These include an independent professional college for NHS managers, like a medical royal college, that can uphold core standards of education and practice, provide networking and support, and advocate for NHS management as a profession.  

In 2024, the government announced plans to establish a college of executive and clinical leadership, with a commitment for ‘this resource to be available to every type of leader’ in the NHS. NHS England has indicated that the launch could be in April 2026 subject to a DHSC-led process to establish it. Such a college must not be part of the DHSC or a central NHS body; instead, it should be independent, enduring, and valued as upholding and supporting the profession. There is useful experience from Canada and Australasia from which to learn.  

As proposed by the Messenger and Pollard review, and the Rose report before that, there is a need for accredited, funded and mandated training of NHS managers, including chairs and non-executive directors. As with doctors, lawyers, accountants and other professionals, there should be a formal requirement for continuing professional development. This needs to be expected of, funded and provided for everyone who takes up a leadership role within the NHS.  

Current proposals for NHS manager regulation are primarily focused on those working in NHS providers and local commissioners, including NHS trusts, primary care and integrated care boards. They have less to say about managers and leaders in the regional and national agencies that regulate and manage local NHS performance. The regulation and professionalisation of NHS leadership must apply equally to those in these central and regional roles.

The role of the centre 

A distinctive aspect of the NHS is its highly centralised nature, which is remarkable by international comparisons. Despite successive attempts to enable greater local decision-making and autonomy, politicians seem unable to let go and support managers to lead effectively.  

It is of note that during the urgency of the Covid-19 response, when many central requirements such as Care Quality Commission inspections and mandatory appraisals were suspended, local trust leaders and staff felt enabled to plan and organise the pandemic response in a flexible manner that suited the rapidly changing circumstances. For example, trusts organised ‘mutual aid’ for intensive care beds and other services, so that organisations could maximise use of capacity and staff and ensure that needs were met. There are lessons from this ‘wartime’ experience for usual ‘peacetime’ organisational practice.  

To deliver the ambitions of the 10 Year Health Plan, national leaders must create the conditions whereby each local trust and primary care organisation can run and improve its services in line with national priorities while being sensitive to local needs. National leaders must stop things that get in the way, cut the number of ‘must do’s’, reduce the burden of regulation, and model behaviours that are both accountable and supportive. The NHS needs a cultural shift, from compliance and oversight to one rooted in commitment, shared purpose, and professional accountability, and where effective performance management is not about control or enforcement but about enabling improvement, supporting development, and fostering a culture where people feel valued and trusted to lead.  

The NHS’s new operating model emphasises the importance of local system leadership, working with patients and communities, and staying in touch with frontline staff and services. Reorganisation of integrated care boards (ICBs), the protracted abolition of NHS England, and establishment of new regional teams is causing inevitable distraction and delay. Clarity and alignment of strategic oversight functions is urgently needed. 

As well as these changes, there is a need for a change in the leadership style of the ‘centre’, away from command-and-control management of performance targets towards a more mature accountability rooted in greater trust and negotiated local outcome measures.  

Only through clear national support within a new system of independent manager regulation will local leaders feel empowered to challenge inappropriate central pressures or bullying behaviours, particularly when raising concerns about patient safety and the quality of care. In his interviews with CEOs in the NHS, Nicholas Timmins found that ‘bullying is systemic; it comes from all directions externally, not the least of which are the politics of health, the media, regulation and financial constraints’. 

Only by embedding talent management and career planning supported by robust national frameworks, investment in leadership and management development, and meaningful local accountability can the NHS hope to develop the leaders it needs – at all levels – for the future.  

The role of local leaders  

The NHS is a complex adaptive system that cannot be run effectively through hierarchy alone. Attempts to micromanage the NHS from the centre have often failed because service improvement must be enabled, owned and delivered by the local staff, and cannot be imposed. This was made clear in Professor Don Berwick’s review of NHS patient safety culture following the Mid Staffordshire NHS Foundation Trust scandal. 

Within NHS organisations, strategic leaders face the same reality, in that they cannot directly control what happens daily within clinical teams. Improvement depends on trusting and supporting those teams to perform at their best, helping to create the right conditions, and equipping them with the skills, tools and space to innovate, in partnership with patients and local communities.  

Evaluation by Warwick Business School of the NHS and Virginia Mason Institute partnership found that trusts with stronger internal social connections achieved significantly better outcomes, despite receiving the same resources and support as others. The key difference lay in the quality of relationships between those leading local improvements.  

At the heart of this are thousands of NHS operational team leaders and managers, often working in shared leadership models. This is where the greatest potential lies. Supporting the workforce to perform at their best is central to transforming services and the ambitions of the 10 Year Health Plan, but will only be realised if the HR management profession, and associated training and development, are also championed and properly resourced at a local as well as national level.  

The future of the NHS will be shaped mainly by the everyday choices and commitments of its leaders and managers. Local management – those who lead, support and connect teams on the ground – are the ones who hold the greatest influence over whether improvement takes root and care improves. To fulfil this role, these senior managers must be trusted, invested in and properly supported by the policy and political centre. The responsibility for enabling the core shifts set out in the 10 Year Health Plan rests primarily with the NHS leadership and management community itself.  

Conclusion  

The 10 Year Health Plan is rightly ambitious in wanting to make much-needed changes to what care is delivered, where and how. Change on the scale of what is envisaged depends on the 1.3 million staff who work in the NHS, and in turn the calibre and capacity of the managers who lead their teams, departments and organisations.  

Countless reviews of NHS management and leadership have identified what needs to be done. The NHS must invest in training, both locally and nationally, developing and supporting its managers and clinical leaders with the same focus as high-performing organisations in other sectors.  

Ensuring excellent operational management is critical, including inclusive and supportive line management of people within teams. Strategic management skills for all board members are similarly crucial to ensuring excellent clinical and corporate governance of the overarching organisation. 

There is a need for a concise and formal code of conduct and standards for managers, embedded in a proportionate system of manager regulation, along with a commitment to require and fund continuing professional development and a new and independent college of NHS management and leadership. This must be accessible to all NHS staff with managerial responsibilities, and applicable to the national leadership cadre to ensure consistency, excellence and equity across the system. 

For its part, the centre must create the wider conditions for NHS management to be valued, supported and effective. Those in central and regional roles must model the management and leadership behaviours they advocate for local organisations, ensuring appropriate balance of trust and accountability.  

In his rapid investigation of the state of the NHS last year, Lord Darzi highlighted that management capability in the NHS is behind where it was in 2011, which has left the system ill-equipped to deliver and to transform. The time is now ripe for sustained action to support and further develop the leadership and management needed to make the 10 Year Health Plan a reality for staff, patients and communities.