Intended for healthcare professionals


England’s 10 000 “missing managers” are holding back the NHS, says think tank

BMJ 2023; 381 doi: (Published 08 June 2023) Cite this as: BMJ 2023;381:p1313
  1. Matthew Limb
  1. London

England needs vastly more managers in hospital and community settings to free up doctors and other professionals to improve services and solve the healthcare workforce crisis, say analysts.

The progressive think tank the Institute for Public Policy Research (IPPR) said that the number of managers in NHS hospital and community settings had fallen between 2010 and 2019 from 35 200 to 34 900 while most other staff groups had expanded over the period. According to its projections, that is 10 000 fewer managers than if growth had been at a “sustainable level” and matched compound growth rates for other staff.

“We suggest this decade has seen the emergence of 10 000 missing managers,” IPPR said, describing the NHS as “one of the most undermanaged health systems in the world” in an analysis that makes 10 recommendations for workforce reform.1

“More managers are crucial to freeing up the time of doctors, nurses, and other professionals to do the caring,” said Chris Thomas, head of IPPR’s commission on health and prosperity.

IPPR’s report said that extra managers could help deliver service and technological innovations and relieve a workforce crisis marked by soaring pressures, staff sickness, and low pay. “If nothing is done soon, demand will continue to outstrip capacity and England will only get sicker, and as a result poorer,” Thomas said.

The analysis is based on findings from a “workforce assembly” gathered by IPPR whose members include doctors, other health professionals, carers, and social workers. It said that the deep crisis in England’s health and care sector is because of a “growing and sustained mismatch between worker demand and worker supply.”

Between 2010 and 2019, the number of staff in hospital and community settings rose around 1% a year. At the same time there were increases in outpatient appointments of 4%, diagnostic activity of 5%, and admissions at major emergency departments of 3%.

Productivity gains haven’t filled the gap, meaning “more pressure and work for each staff member,” IPPR said.

IPPR compared the rate of growth of the numbers of managers in hospital and community healthcare settings from 2010 to 2019 to the rate of growth of all clinical professionals and doctors, and “estimates of the workforce growth needed to deliver sustainability in the next decade.” It said that any businesses comparable in size to the health and care sector would struggle to maintain productivity and effectiveness with the same “management deficit.”

Ian Kirkpatrick, chair in public management at the University of York, welcomed the “brilliant and timely report,” saying that the findings were consistent with his department’s research highlighting that the NHS is “undermanaged and that this situation has worsened over the past decade.”

He told The BMJ, “The overall picture is one of increasingly lean administration in the NHS, with rising work intensification (and spans of control) for managers and possible unintended consequences for the work and wellbeing of clinicians, who are forced to pick up additional administrative tasks.”

Kirkpatrick added, “I suspect that this is a key factor behind clinical burnout, absenteeism, and turnover. It also means that the NHS has reduced capacity to invest time in crucial innovation and improvement activity—although this link still needs to be proven empirically.” He said the evidence showed that growing management capacity can have tangible benefits for patients as well as the wider workforce.

Thomas said IPPR’s workforce assembly members had highlighted the need for “enabling” managers in different settings who “understood how the health and care system fit together.”

He told The BMJ, “We haven’t recommended an immediate 10 000 increase all at once. It’s hard to know what the balance is in terms of optimised management. There is a role for integrated care systems in outlining what kind of undermanagement they have.”

IPPR said that managers could implement new technology and innovation agreements that would translate into better working conditions, as well as better patient outcomes and cost efficiency.

It said reform should start with a “circuit breaker” to end the current “vicious cycle” in the health and care workforce, including pay restoration, reform of pay review processes, a substantial increase in social care pay, and a funded retention programme.

It also recommended increased support for women returning to work after maternity leave to help tackle the gender pay gap.


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