7 July 2023

Management decline: it’s time politicians told the truth about NHS ‘penpushers’


My first exposure to arguments about how the National Health Service is run was when I was around 10 years old.

It was the late 1980s, and the BBC had unveiled a new drama series, based in an A&E department, called Casualty. One of the main characters in those early days was Dr Ewart Plimmer, A&E’s clinical lead, and a running theme was the battle between the noble, hard-pressed doctors and nurses on one side and the bean-counting, heartless managers on the other. It was not subtle, but it made its point.

I remember this because my father had gone from clinical psychologist to chief executive of the psychiatric hospital where he worked. Although at 10 I didn’t absorb the nuance of the argument, there was a lot of muttering and occasional shouts about the clichéd, inaccurate depiction of how the NHS actually functioned.

Thirty-five years later, and having spent a period of time as a clerk on the House of Commons Health Committee, I see some very familiar arguments still in currency. The persistent, knee-jerk opinion is that there are ‘too many managers’ and that more money should be diverted to front-line clinical services. It’s not true, and it never has been. In 1983, Roy Griffiths, then deputy chairman of J. Sainsbury, had been commissioned to review NHS management, before which it had been virtually non-existent. He recognised that professional leadership was vital.

Let’s be clear about one thing: the NHS is huge. NHS England employs 1.275 million people and has the fifth largest workforce in the world. According to the NHS Confederation, managers account for about 2% of NHS staff; the average figure in the workforce at large is around 9.5%. Yes, the number of managers has risen, but only in line with a massive expansion in NHS spending. If anything, the NHS is under-managed.

Labour’s health policies for the next election are fronted by Wes Streeting, one of Sir Keir Starmer’s more fluent and persuasive performers. The party has a lot to say about workforce planning, not a sexy subject but a vital one, but it is all about clinical jobs: physicians, nurses, district nurses, health visitors, mental health staff. On management, there are just the old tropes: a pledge ‘to identify unnecessary bureaucracy and reduce it’, to shake up clinical trials to ‘reduce the administrative burden for everyone’.

In December 2021, Streeting was more explicit. He criticised the Government for spending money on managers and management consultants. ‘That means less investment in the front line, where some barely earn enough to get by,’ he added. Nigel Nelson, the veteran political editor of The Daily Mirror, dismissed these staff as ‘health service penpushers’.

It is depressing to see that the rhetoric has barely moved on in 30 years. If anything, the Labour Party seems to have regressed from the days of Tony Blair, when the government was at least in the foothills of serious NHS reform. Streeting is at least saying some encouraging things, pledging that he ‘would not look over NHS England’s shoulder’ as secretary of state and talking about ‘a new model of care’. He has indicated a willingness to use private sector capacity to reduce waiting lists and has used Blairish words like ‘choice’, ‘change’ and ‘modernisation’.

I am not one of those who fetishises ‘consensus’ or ‘bipartisanship’, and I think ideology and a clash of ideas are hallmarks of a healthy political system. But healthcare in the UK absorbs around a tenth of our GDP, more than anything else except welfare, and it would make sense to try to find some elements which could be taken off the table.

The main parties are very close together on better use of technology, especially employing the NHS App as a kind of patient gateway to clinical services, and on making GP appointments easier to book, avoiding the 8am bottleneck. Maybe these issues could be set aside and developed quickly and by agreement.

I have enormous admiration for Alan Milburn, who was Blair’s health secretary from 1999 to 2003. In his tenure, he grasped the opportunities of private sector capacity, devolved power to hospitals and emphasised patient choice. He understood – and still does – that the NHS needs to be reinvented. He now believes prevention and chronic disease management in the community are the key to that reinvention. If I were prime minister of either colour, my ideal outcome would be an ennobled Milburn back in charge at the Department of Health.

Streeting has shown glimpses of a future minister willing to admit unpalatable truths, though I remain sceptical about his resolve to implement them in the meat grinder of Whitehall. The NHS must change, and change radically, and that cannot be achieved wholly by consensus between two fundamentally different world views. But the change that is needed will have to be overseen by a first-class, world-beating management, and it would benefit us all of we could find common ground in retiring the misconceptions – no, lies – about managers and accept that they are part of the solution, not adding to the problem.

Click here to subscribe to our daily briefing – the best pieces from CapX and across the web.

CapX depends on the generosity of its readers. If you value what we do, please consider making a donation.

Eliot Wilson is co-founder of Pivot Point Group

Columns are the author's own opinion and do not necessarily reflect the views of CapX.