Scarcely is there a more unloved bunch than the humble NHS manager. The public narrative surrounding the NHS very much regards these unwanted pen pushers as starving those who do the real work of funds and resources that ultimately result in the various states of chaos that the NHS is usually thought to be in.
A recent study from LSE suggests there may be an element of truth to the accusation, as hospitals that hired more managers, or indeed spent more on management, didn’t seem to perform any better (or worse) than hospitals that spent less on management. The authors argue, however, that this is less due to the managers per se and more due to the restrictions placed on them by the service.
For instance, they highlight that whereas 11% of the overall workforce are managers, this falls to just 3% in the NHS. The claim that the NHS is not so much over-managed as under-managed was reiterated in work conducted by the King’s Fund in 2017. Not only are there fewer managers in the NHS than in other health systems around the world, but the managers that are there are typically underpaid relative to managers in other sectors.
Managerial constraints
The LSE team goes on to highlight that whereas managers in private companies are typically answerable to owners or shareholders, in the NHS there are often numerous objectives, many of which might conflict with one another. Equally, in each hospital, clinicians have considerable power and influence over key decisions.
The political nature of the NHS also means that the government plays a major role in regulating the service. This can pull managers in numerous directions, many of which distract them from focusing purely on improving performance. There is also a general discouragement of risk-taking with maintaining the status quo the norm.
Of course, this should not imply that managers don’t matter in the NHS, and the authors are themselves keen to point that out. Indeed, this was very much the finding of another study from the University of Bristol. The study found that managers in healthcare seem to correspond with higher clinical performance.
The researchers gathered data from 160 different hospital trusts in England over a period from 2007 to 2012. This period was selected as the data contained within it was consistent, both in terms of the performance of those trusts and HR numbers. The ultimate aim was to try and understand whether the number of managers in each trust had any impact on the overall efficiency of the hospital, the experience of the patients, and general clinical quality.
Measuring effectiveness
To measure efficiency, the researchers compared the ability of each trust to increase their clinical outputs relative to their various inputs. So, for instance, the patient experience would be gauged by examining data from the NHS Adult Inpatient Survey, whilst clinical quality would be gauged via hospital infection rates.
Via regression analysis, the team was then able to attempt to draw a connection between the number of managers in a trust and the outcomes achieved by that trust.
When the data was analyzed, it revealed that a relatively small increase in the number of managers correlated with a 1% increase in patient satisfaction, a 5% increase in hospital efficiency, and a 15% reduction in infection rates. These are gains that the authors’ estimate would cost approximately £500 million to achieve.
Now, there are obvious questions about correlation and causation, but the researchers believe that whilst it’s impossible to ascertain causation with certainty, it is nonetheless highly likely that a link exists between the number of managers and clinical effectiveness.
What the two studies suggest is that management does matter to the successful functioning of hospitals, but also that their scope is limited by the unique political and operational constraints placed on them to manage in the way that managers in other sectors would regard as the norm. Before people criticize NHS managers, therefore, they would perhaps be well served to remember those constraints.
