Case study

Managers and management in the NHS

Researchers examined the relationship between the number of managers in the NHS and clinical performance. Their findings show that, contrary to common perceptions, we need more managers in the NHS to improve patient outcomes.

Who should manage hospitals for you?

The issue

For over 30 years, managers, sometimes with private sector backgrounds, have been recruited to run hospitals and other services in the NHS. Increased use has also been made of the advice provided by external management consultants.

However, cynicism about managers has grown with negative media headlines, such as ‘death by bureaucracy’, ‘greed of NHS fat cats’ or ‘cure the NHS with fewer managers’. But does this mean that the NHS can survive without managers? Are managers an unproductive overhead, as many recent accounts would have us believe?

The research

Addressing these questions has been the focus of research conducted by Professor Ian Kirkpatrick at the University of York and colleagues at the Universities of Bristol and Leeds. Ian’s ongoing research has made innovative use of publicly-available administrative data sources to explore the relationship between management and performance. Often, this information is available over multiple years and relates to the whole population of NHS organizations. Using the data, Ian and his colleagues have developed a better understanding of the nature and impact of management in the NHS.

The outcome

The research showed that, contrary to popular belief, the NHS employs only a small number of managers; approximately 3% of staff are in managerial roles, compared to 9.5 per cent in the economy as a whole. It can hardly be described as ‘over-managed’.

The researchers also found that managers can have positive effects. Across all acute trusts in England, those with a higher proportion of managers saw a statistically significant improvement in performance. Even a small increase in managers, from 2% to 3% of the workforce, led to a marginal improvement of 1% in patient satisfaction scores, a 5% improvement in hospital efficiency and a 15% reduction in infection rates. An earlier study also found that having more doctors involved in management, sitting on the boards of hospitals, had a significant impact on quality ratings and patient satisfaction.

While up to a certain point the impact of managers was positive, this did not apply to the use of management consultants. Analysis of four years of data found that, on average, acute trusts in the NHS spent £1.2 million a year on consultants – roughly equivalent to the cost of 20 more managers, 10 more consultant doctors or 35 senior nurses. This spending had an overall negative impact on the efficiency of hospital trusts, incurring a small annual loss of £10,600.

An important conclusion of this research so far is that the NHS - as a large and complex organisation - needs in-house managers, especially clinicians. It should also be wary of contracting out these roles to external consultants.

Strengthening management is not always a waste of money, and could in fact help to make the NHS work better.

Featured researcher

Ian Kirkpatrick

Professor of Management

Ian Kirkpatrick specialises in the changing management of public services and professional organisations. He has conducted a number of studies focusing on developments in social services and healthcare. Ian has published widely on these topics in leading academic journals and a number of jointly-authored books.

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