By John Power,  Sean Phillips, Stuart Carroll

The scale and volume of challenges facing the new ministerial team at the Department of Health and Social Care (DHSC) necessitates a significant turnaround operation to enhance NHS productivity and performance. Indeed, the Secretary of State for Health and Social Care used his first public statement to reflect that “the policy of this department is that the NHS is broken”. Amid operational pressures (including long waits for care), poor patient satisfaction (at its lowest levels since the early 1980s), high-profile cases of abuse and anaemic productivity growth since the pandemic, the way that the NHS is managed and led is back firmly in the spotlight. The work of managers – particularly non-clinical, operational managers – working across the NHS is often invisible to the public, but touches almost every aspect of health and care delivery from the implementation of electronic patient records and upgrading the hospital estate to planning rotas for doctors and nurses. Yet the present debate concerning health and care management is often driven by a weak or anecdotal evidential basis. In a recent interview, the Health Secretary reflected he was “unconvinced by the majority of research…which suggests the NHS is under-managed”. A recent study concludes that “there is little existing evidence to support either this narrative or counterclaims.” As the 2015 Smith Review noted, management capacity and capability is “under examined” in healthcare planning. Politicians (of all stripes) alongside commentators in the media have in recent years blamed poor performance on “NHS managers”, whilst holding more positive opinions about “front line” staff. A recent analysis from the Policy Unit at King’s College London reveals half of the public believe there are “too many managers in the NHS”.. Some healthcare professionals also reflect this view, perceiving non-clinical managers to be a challenge to professional autonomy and authority. In the public policy debate, too much emphasis is placed on discussion about the volume of managers working in the NHS: the narrative that either simply expanding the headline numbers of ‘managers’ or in scaling back a ‘bloated bureaucracy’ will deliver the necessary service improvement and efficiency gains. A greater focus on management capability is needed, as is a deeper understanding of the permissions and incentives which enable or inhibit improved performance and productivity. We also need to re are employed between NHS England (NHSE) and DHSC. In addition to this, the recently-published Independent Review of NHS Performance, authored by Lord Darzi, finds that “regulatory type organisations now employ some 7,000 staff, or 35 per provider trust, having doubled in size over the past 20 years”. The “right balance of management resources in different parts of the structure” is needed, he concludes. Such an assessment must not fix its attention solely upon the management of hospitals (as important as this is) but must also consider the requirements of the healthcare system as a whole – particularly primary and community healthcare services whose management and leadership requirements are less frequently discussed in policy debates, but where expectations for the transformation of services are great and there are unique challenges and circumstances to be addressed given these are far more devolved and dispersed care settings. Moreover, we should not solely investigate roles, but must also consider the architecture and “organisational culture” which influences activity within the NHS as well as the NHS’s interaction with Government departments and arms-length bodies. The focus and purpose of this report, therefore, is two-fold: 1. Firstly, to present a more detailed portrait of the state of NHS management today to inform the discussion around about future reform. How is management distributed across the country and across organisations? Would a greater volume of managers overall deliver improved performance? Are there particular skillsets we are lacking? 2. Secondly, to set out the case for change and to make a series of recommendations for reform.  

London: Policy Exchange, 2024. 62p.