Inside the NHS: Why middle managers are refusing top jobs

04 July 2016 -


The National Health Service is facing a shortage of candidates for its executive positions at hospitals across the UK, as potentially-suitable managers opt to remain in middle management, a new report has revealed

Jermaine Haughton

Skilled and experienced leadership is needed more than ever at the top of the National Health Service, as chief executives are faced with financial, clinical and political challenges to maintain their hospitals to the highest standards of patient care.

However, departing NHS CEOs are warning that the organisation is currently struggling to tempt enough talented, experienced and qualified senior and junior managers into executive positions.

The Health Service Journal reported that 14% of chief executive roles in NHS trusts are either vacant or will soon be unfilled, while other research states that, over the past 18 months, the mean tenure of an NHS provider chief executive is just three years.

The issue has been exacerbated by a number of the longest-serving chief executives, including Sir Robert Naylor, Karen Dowman, Angela Pedder, Steve Shrubb and Sir Jonathan Michael, announcing their retirement intentions last year.

Interviewed by the King’s Fund think tank and the hospital's lobby group NHS Providers, 12 former health bosses concluded that the shortage of good candidates available to lead NHS organisations is explained by a number of factors, including good pay and working conditions for middle managers, and intense pressure from regulators and the media.

The King’s Fund estimates that managers, including hospital and health service managers, are around 4.8% of the NHS workforce, taking up £8billion of the institution’s £100billion budget.

A significant proportion of hospital staff do, however, work in dual roles as clinicians and managers.

As well as conducting day-to-day tasks such as managing pay, resources and performance, middle-ranking managers are typically responsible for implementing new policy initiatives for front line staff, such as waiting times targets.

But as an individual moves higher up the ladder into senior and executive management, they are able to play a greater decision-making role in the planning on the policies within their Trust, including how to improve access, fully-equip doctors and nurses and move to a 24/7 service. Furthermore, NHS executive positions are generally tied to a six-figure salary, with reports that a NHS CEO can earn up to £340,000.

Why, then, are middle managers seemingly unwilling to take the top jobs at the NHS?

Regulation, regulation, regulation

The enhanced role of regulation in the affairs of hospitals in the UK over the past decade is identified as a major complaint for current chief executives, and is a factor which puts middle managers off from applying for the top job.

Following the Mid-Staffordshire and Francis inquiries, which exposed systematic failures that resulted in patient deaths, there has been a increased government focus on regulation, with greater prominence of public body Monitor, the creation of the Trust Development Authority (the two now merged) and of a statutorily independent NHS England.

While NHS chief executives say they welcome regulation and the respective bodies, some told the King’s Fund that their freedoms have been repeatedly chipped away through ‘extreme micro-management’ as money has got tighter.

Sir Robert Naylor of University College London Hospitals NHS Foundation Trust said that those freedoms have “pretty much entirely disappeared. I think there’s still some benefit in being a foundation trust as compared to being a more directly managed unit. But it’s been very, very severely eroded”.

Another criticism is the information demands placed on chief executives by regulators, which cost time, energy and money.

Karen Dowman said: “When you have a number of different commissioners all wanting the same information in slightly different ways and then the various national tiers – CQC, Monitor, the TDA [Trust Development Authority], NHS England – the regulation and the information demands have got overbearing. A disgraceful waste of money.

“We are in constrained times financially, and I am sure we could lose 20 posts if it wasn’t for this endless different tweaks of information for different things.”

Mark Newbold, formerly CEO of the Heart of England NHS Foundation Trust, explained that the failure of the different regulators to co-ordinate their efforts, information and systems led to each body requiring different actions to the same problems happening within the hospitals.

He said: “It felt like you were tied to a tree, and each time they just went around with the rope another time, so you were getting more and more tied down. It was all terribly counterproductive and fruitless, not helping patients at all.”

Media Scrutiny

As the administrative face of their hospital's, chief executives often face the brunt of antagonism regarding the state of bureaucracy in the NHS.

During an General Election debate last year, Prime Minister David Cameron boasted about the thousands of “bureaucrats” he had laid off, promising to rid the service of more.

Like in the private sector, NHS chief executives face the heat of poor performance and adulation of tremendous feats, but for hospital bosses, underperformance often leads to death or life-changing problems rather than diving profits.

In the wake of the Harold Shipman and Mid-Staffordshire Hospital scandals, NHS chief executives have found themselves named and shamed by national newspapers, broadcast outlets and, now, social media.

Southern Health NHS Foundation Trust chief executive Katrina Percy, for example, is clinging onto her job after widespread calls for her resignation after the release of a damning report revealing “serious concerns” over the organisation, which experienced hundreds of unexpected deaths of patients with learning difficulties and disabilities.

Such public scrutiny is reportedly deterring many middle managers from putting themselves forward for chief executive roles.

NHS chief executives also receive a lot of media derision for their salaries.

Headlines such as ‘Greed of the NHS fat cats: How bosses got £35MILLION in pay rises last year, enjoying champagne parties, exotic holidays and shopping trips to Harrods as hospitals battled to make ends meet’ enter NHS chiefs into the same executive pay debates and pressures as seen in the private sector, at a time when junior doctors are striking over pay cuts and the organisation’s financial deficits continue to spiral.

Bosses say that lower-level managers dodge the “fat cat” headlines, as even Jeremy Hunt, the health secretary, has questioned why dozens of NHS executives earn more than the prime minister.

Earlier this year, the Colchester Hospital University NHS Foundation Trust made the headlines as it became one of 15 NHS organisations to have requested approval to pay its recently-appointed chief executive Frank Sims £185,000 per year, more than David Cameron’s £142,500 annual salary.

Impact on NHS performance

Ultimately, the lack of middle managers willing to become NHS bosses will hinder patient care, according to the report, as “there simply isn't enough talent to go round.”

Instead, NHS boards are having to rely on interim bosses, with some long-serving CEOs, like Sir Robert Naylor, having to delay their retirement plans until a suitable replacement is found.

A stagnation in the C-Suite leads to a lack of direction and confidence on the wards, with trusts in special measures suffering particularly badly with a loss of leadership that risks creating strategic instability, wasting financial resources, reducing staff morale and affecting quality of care.

Antibiotic resistant viruses, soaring financial costs and caring for a growing older population are all among the challenges chief executives will need to brace their hospitals for.

Simon Stevens, the CEO of NHS England, has set out the target of running the NHS in 2020 with a mere £8billion increase to its budget, if it can implement 2-3% annual efficiency gains.

However, a Financial Times report found that productivity is currently growing at less than half this rate, threatening a far larger funding gap. Therefore, long-term chief executives with an array of skills are essential of the NHS is to meet its goals.

Karen Taylor, Director, UK Centre for Health Solutions, said: “Attempts at denigrating NHS managers is bad for patients and reduces the supply of talented staff needed to run an effective NHS while undermining patient and public confidence in healthcare.

“The political and media clamour for greater transparency, better comparable performance data to inform choice, drive accountability and improve quality - all come at a cost - and the cost is investment in good quality, effective management.

“A conundrum that needs to be resolved as soon as possible.”

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