The NHS needs managers as well as leaders

Nigel Edwards argues that the 'unglamorous work' often undertaken by middle managers should not be forgotten, and supporting them a key priority.


Published: 24/03/2016

Leadership, the art of inspiring people and bringing them together around long-term aims, has received a lot of attention in the NHS. It is a cliché to read in a report that it was an important part of a change programme. We have also been told that we need to move from “management” – the more prosaic task of overseeing and improving services and the way they work – towards leadership, rather in the way thirty years ago celebrated management thinker Peter Drucker argued that a shift was required from administration to management.

I do think leadership is important: but my concern is that the obsession with it has obscured the importance of effective administration and management. It doesn’t matter how great a leader you are if you do not have the ability to execute your ideas, especially if you are trying to change a system which is not stable or performing reliably. We also know from research that the quality of one’s immediate line manager is an important determinant of staff wellbeing and morale.

While there are competing views of leadership there is some basic agreement about what its core components are. Management, on the other hand, has a much less clear definition. Management tasks and roles may well be carried out by non-managerial staff, and some people who are doing managerial jobs may not even see themselves as managers. The term “middle manager” covers a very wide range of responsibilities and budgets, varying wildly in scope. What they do and how they spend their time at work is similarly diverse. That hardly narrows it down.

So too are the pathways to management. Many people find their way from clinical roles, others work their way up from clerical or admin jobs, and some come in through more formal routes. This makes talking about them as a group difficult and may partly explain why they have received less attention than the more glamorous area of leadership.

I think we need to do more to recognise their importance. I suspect that there is a lot more to be done to support and develop them, with several areas requiring more thought and attention.

The first is that there is not enough recognition that the technical knowledge of the area one is responsible for managing is important. Interestingly, while the people who lead hospital groups tend to be experts in running groups of organisations, they take very great care to ensure that the hospital managers are real operational experts. The idea that management is a generic skill and does not require deep knowledge both of the area being managed and the processes, people issues and other technical aspects of the management role is a myth. I suspect it is a result of over-emphasising the importance of “leadership”, which stresses personal competences and behaviours and tends to down play technical knowledge.

From this it follows that training and development for management roles is vital and while many of the skills and elements of the role need to be acquired on the job this needs to be done with appropriate supervision, time for reflection and peer support. Many people find themselves in management roles without this room to learn.

The design of jobs and how they fit into the structure is a third area where more thought may be required. Previous research has shown that there is a high risk of job roles being poorly defined, overlapping with others and not having clear objectives. Combined with poor appraisal, this is not a good recipe for an effective organisation.

There should also be more recognition of the importance of keeping things running smoothly – rather than simply responding as they go wrong. One of the findings of work I have been involved in for many years on the emergency care system is that its performance depends on rigorous attention to detail to ensure the continuous flawless operation of a large number of different interlocking systems. Firefighting and crisis management are exciting, and NHS managers are very good at it, but the unglamorous job of making things work is where the real action needs to be.

The final area I would highlight is also very visible in emergency care. It is what I call the ‘epidemic of assurance’. Checking; ensuring that if things go wrong blame can be allocated (preferably elsewhere); diverting people from the actual job to complete forms, join conference calls and engage in other non-value adding work: these features of NHS life seem to be taken for granted. Yet viewed from the outside they appear strange, dysfunctional and irrational.

I think more attention to supporting middle managers – whoever they are – must be a key priority. Creating more peer support and conversation within and between organisations could do some of this, but some will require investment in development and support. Without this leaders can lead but it will be difficult to follow them effectively.

A version of this blog first appeared in Managers in Partnership.

Suggested citation

Edwards N (2016) ‘The NHS needs managers as well as leaders’. Nuffield Trust comment, 24 March 2016.