A version of this article first appeared on the Nuffield Trust website. It's part of a series called 'Fact or fiction?', where experts from the Nuffield Trust give their take on the data and evidence behind some of the current perceptions of what is happening with the NHS. The Nuffield Trust is an independent evidence-based research organisation.
It's election season, and NHS managers and 'bureaucracy' are once again in the firing line. The Coalition boast of putting "more money on to the front line and less into management"; Labour and its supportive press accuse them of the opposite.
On this issue at least, Westminster is in tune with the public mood. The Tory polling guru Lord Ashcroft found that the public see "too much being spent on management and bureaucracy" as the single biggest problem facing the NHS — more important than hospital closures, waiting times, or rationing.
Are they right?
What we know
1. No, half the NHS workforce are not managers
Political figures have sometimes implied that managers make up eye-wateringly large proportions of the NHS workforce. UKIP's Louise Bours claimed that "clinical staff are outnumbered by so-called 'bureaucrats', using up huge amounts of money that would be better spent on front-line services". Her speech suggested that she was talking about managers.
But the group she is talking about includes all staff who aren't doctors or nurses. That means it includes not only cleaners, porters, and canteen staff, but hundreds of thousands of healthcare assistants who are actually providing care to patients. These people are not diverting money from the front line: they are the front line.
The number of people who are employed specifically as managers is much lower. As counted up by the Health and Social Care Information Centre, it is only around 51,000 people out of 1.17 million. This includes doctors and nurses who do full-time management roles. At a total 4% of the workforce, it compares to 10% in the UK economy as a whole.
Far from eating up large chunks of the budget, there is circumstantial evidence that the health service doesn't have enough senior professional management capacity for such a complex system. Despite the financial pressure it is under, the NHS spends vast amounts buying in extra management capacity from consultancies. Recent surveys suggest it also has great difficulty recruiting people to senior roles as these become ever more pressurised.
However, these jobs aren't the whole story of management or 'bureaucracy' in the NHS. A study of middle-level and front-line managers in hospitals found more than 30% of all staff held some kind of management responsibility. How do we explain this?
2. NHS managers aren't who people think they are
The public discourse about NHS managers tends to imply they are a discrete suit-wearing group, set apart from doctors, nurses and patients. But there isn't such a neat line between 'managers' and 'non-managers'. Lots of people do a little bit of management — even though they might have a full time professional role. Meanwhile, people whose job title is 'manager' or 'director' may still get involved in hands on front line work.
Looking at doctors in the NHS, many hospital consultants will also have managerial responsibilities as the lead for improving or overseeing a certain area. And Clinical Directors, key leaders who jointly run hospital specialty areas, still spend time practicing medicine or surgery. Although only the small minority who are full time managers get counted in official statistics, people with clinical qualifications and responsibilities make up the great majority of NHS staff with management responsibilities.
So NHS management is not a group of people, it is a set of tasks, and one that is largely done by doctors, nurses and other clinicians. From this perspective, employing full time managers could help to free up clinically qualified people to provide patient care.
3. There are savings to be made
There's no doubt that we should be trying to improve the efficiency of management, administration and clerical work. In fact there are signs that we already have: since 2010, there has been an 18% reduction in managers. And as NHS trusts and other bodies have drawn up plans to make ambitious savings over the next five years, they have already assumed further savings on management and administration.
Big, difficult reductions in these areas are already priced into the health service's future. So watch out for politicians claiming they'll save new money by cutting back on management and administration. Are they just describing what will already happen? Or are they raising these targets further still? And if so how exactly will they help speed up progress?
4. People might want more bureaucracy than they think
Managers are there to monitor, oversee, and control the NHS. And much as voters and politicians worry about the time and money spent on these tasks, they vote for and enact policies that require them.
The internal market in the English NHS, introduced under John Major and intensified by Labour and the Coalition, is supposed to drive hospitals and other care providers to improve by competing for patients and contracts. It creates a layer of planners and funders to make this possible.
It's difficult to say whether these administrators and contracting officers should be counted as 'managers': they don't directly manage clinical staff and services like a ward or practice manager does. But although much of the planning they do would be necessary under any system, the public would probably have no hesitation in calling them bureaucrats. Administration by these groups, NHS England and Clinical Commissioning Groups, cost over £2 billion last year.
A recent study also suggested that English hospitals seem to spend more on administration than those in other countries not subject to an internal market. It links this to the need for hospitals to compete for funding and to carefully set aside income to invest with. It may be that the market is working, telling hospitals they need more management and monitoring to run smoothly and deliver quality.
The authors of the study are more sceptical about whether the extra spending adds value. But either way, according to Lord Ashcroft's polling, the public seem keen on targets and performance management as a way to raise performance, even if their effectiveness is variable. They too require administrators and managers to record figures, report them up the chain of command, monitor them, and crack down on those not meeting standards.
Fact or Fiction?
The idea that the NHS employs an unjustifiably huge number of full-time managers is just wrong.
The savings from reducing their ranks would be small, and likely self-defeating if we went too fast. NHS trusts need people to analyse and make decisions. If they don't have those people, they will hire some in as management consultants.
At the same time, it is certainly true that management and administration should be looked at critically, and there are opportunities to make savings in areas such as finance, other back office functions and clerical work caused by a reliance on paper records. There is also undoubtedly scope to improve administration. We must remember, though, that some of it is linked to those perennial political favourites, targets and competition.