FEATURE
Let’s do more
with less
David A Buchanan and Steve Macaulay discuss
developing middle managers for the front line of change
“M
anagers are the jam
in the sandwich. They
don’t like the negative
stereotype. Even
on Holby City the
manager is the bad guy, the lowest of the low. The
NHS itself is not doing anything to curb ill feeling
towards management.” (Operations manager)
Middle managers often have a poor reputation.
Nowhere is this truer than in the health service:
UK healthcare managers attract a lot of criticism,
and have been described as unnecessary ‘grey
suits’ and costly ‘pen pushers’ by government
ministers. However, the findings from our recent
study involving 1,200 middle managers in the
NHS paint a radically different picture. Who are
these middle managers, what contributions do
they make, what gets in their way and what key
capabilities do they need?
The reality is that middle managers are on the
front line of driving change. This is not widely
recognised, however, and they are poorly supported
in this role. This article describes the key role
that middle managers play, and how L&D can
spearhead supporting investment that could
generate significant returns,
for little cost.
The NHS is one of the largest employing
organisations on the planet but figures show
that only around 3 per cent of its 1.3m staff in
England and Wales are ‘managers and senior
managers’. However, this calculation excludes
middle managers, and does not count those whose
‘hybrid’ roles combine clinical and managerial
responsibilities – ward sisters, matrons, laboratory
supervisors, clinical directors and so on. Around
30 per cent of the staff of a typical acute hospital
have managerial roles, when those other managers
and hybrids are taken into account.
It is often said that ‘clinical staff are not engaged
in healthcare management’. That is not true. In
that typical hospital, the hybrids outnumber the
pure managers by four to one. National policy has
created a massive change agenda for hospitals,
which are required ‘to do more with less’, to
reduce their costs, while improving the quality and
safety of care, at a time when demand for acute
services is rising along with patient expectations
of quality of care. The capacity for driving
these changes thus sits mainly with
a hybrid group, many of
In search of
middle managers
“ You’ll hear people say
‘management’ in inverted
commas. And I’ll say ‘but you all
manage’. I think that there’s always
been quite a hierarchy in the NHS and
we need to break that down. I want everyone to
take accountability and responsibility.”
(Modern matron)
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FEATURE
whom have little or no management training, work
only part time as managers and do not even see
themselves as managers.
National policy involves reducing the numbers
of (pure) managers in the health service. This
will only place a greater management burden on
hybrids who are already stretched to cover both
clinical and managerial responsibilities.
How do middle managers contribute?
“Managers make a huge contribution to patient
care, developing services, measuring quality. I go
to all the clinical meetings and I act as a lynchpin.
If I’m not there, the discussion and outcomes can
become fragmented.” (General manager)
Despite the many challenges, middle managers
make major contributions in the following areas:
• maintaining day-to-day operations, keeping the
show on the road
• firefighting and troubleshooting, performance
management, solving ‘wicked problems’
• championing innovation and change, spotting
and designing service improvements
• performance improvement, leveraging targets,
dashboards, benchmarking
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• developing infrastructure, IT, equipment,
physical facilities
• managing serious incidents, implementing
remedial actions
• developing others, staff development, teamwork
• managing external partnerships and
relationships, across the wider community
• patient experience focus, ensuring business
decisions consider the patient’s voice.
Middle managers are thus on the front line
of operational management and change
implementation, contributing to improving the
quality of the service as well as organisational
effectiveness. If the distinction between
management and leadership is that managers
ensure smooth running while leaders drive change,
middle managers are clearly both, and they are
primarily leaders. This profile is a long way from
the stereotype of the expensive change-resistant
bureaucrat. But most of the managers to whom we
spoke felt that they were simply under so much
pressure that they didn’t have time to develop
those contributions as fully as they would have
wished. So what can be done?
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24/06/2013 12:37:29
properties
in practice
top team communications
clear, consistent, two-way, listening
business intelligence
IT systems that provide appropriate and timely information, easily
zero non-value-adding
streamlined governance, simplified audit and compliance systems
autonomy to innovate
fixing problems on own initiative without sign-off delays
organisation structures
no silos, information sharing, cross-service collaboration
organisational norms
patients not targets, engagement, management valued, risk taking
performance management
hold managers to account, provide support for
performance problems
inter-professional work
mutual respect between clinical and managerial staff
support services
rapid, appropriate advice, action, and problem solving
personal development
leadership and management training and development
teamwork
collaboration, information sharing, consider wider impact
of decisions
resources
staffing, investing to save, granting decision rights within budget
Making an even bigger contribution
“Implementing anything new takes massive
amounts of energy, and you are ground down, with
doors closed in your face repeatedly. It’s hamsters on
the wheel.” (Modern matron)
It comes as no surprise that, in the current
economic climate, the single main challenge for
hospital managers is the pressure to cut costs. But
this is not the only factor affecting their output.
Most are faced with increasing workloads, and
note the lack of ‘head space’ and the need for
‘broad shoulders and thick skin’. Then there is
the daily pressure to meet exacting performance
targets and to deal with burdensome regulation.
IT systems in many hospitals are dated, are
difficult to operate and maintain, and provide
inadequate information, which is often late.
While there is no shortage of ideas for
service improvement, there is often no money
to implement changes. Constant staff shortages,
recruitment problems and increased job insecurity
are other headaches.
Many middle management roles have become
‘extreme jobs’: long hours, fast pace, high intensity
and pressure, uncertainty, rapidly changing
priorities. We found many middle managers who
enjoy the pace, excitement and challenge but
multi-tasking across complex roles can lead to
fatigue, burnout and mistakes that, for hybrids,
may have adverse consequences for quality of care
and patient safety.
Practical steps to create
an enabling environment
We asked managers what practical steps their
organisations could take to give them the
headroom, to allow them to make even bigger
contributions to clinical and organisational
outcomes. The table above summarises their
suggestions describing what it takes to create an
‘enabling environment’ in which managers could
make even stronger contributions.
“I’ve been inspected recently by six different
agencies. And they all want information, reports,
and action plans. Nobody ever asks me how many
lives we’ve saved, or how many people got better
as a result of the treatment they received. I spend
a lot of my time writing policies.” (Emergency
department lead nurse)
The actions necessary to building and
maintaining such an enabling environment are
relatively simple, and they are also cost-neutral.
Middle managers need more space, more time,
more autonomy. Simplifying organisation
structures, streamlining governance, reducing
bureaucracy, giving people more freedom, more
discretion, the ability to innovate, to take risks, to
introduce changes – you can do all of this for free.
The L&D agenda:
key management capabilities
“We don’t have any managerial training and lots of
work is left to us. I expect that in the future we will
be left to make more decisions.” (Ward sister)
Many middle
management roles have
become ‘extreme jobs’
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FEATURE
Managers need to strengthen their capabilities.
The national austerity that is reducing public
expenditure seems likely to continue for several
more years. The health service will continue to
be affected, despite rising public expectations and
increasing demand.
So, what capabilities do middle managers need
in this high-pressure, rapid-change context?
A modern matron answered that question
defensively, saying: “Look, I think I have the
capabilities to do my job. I’m just not allowed to
use them.”
That is a telling remark, which would be shared
widely across the middle managers involved in
this study. However, many hybrid managers do not
have a management background. They may have
been on a short course for a couple of days, but
few have any substantial management training.
Our study suggested that a small number of key
capabilities carry a premium in the
current context:
• political skill All managers have to be able to
negotiate the internal politics of a ‘professional
bureaucracy’, in which different interest groups
share power but do not always share the same
perspectives and goals, thus making political
skills essential
• resilience ‘Mental toughness’ is needed to
deal with painfully slow bureaucracy and
change, setbacks to established plans, and
recurring challenges concerning failures to
meet performance targets; in terms of building
resilience in challenging settings, healthcare
could learn from military experience
• inter-professional collaboration Some of the
most powerful changes we saw implemented
during our study were based on close clinicalmanagerial partnerships, which are increasingly
critical but can be difficult to establish because
they require mutual trust and respect, and
abandoning traditional stereotypes
• performance management Managers openly
admit that the service does not handle poor
performers well; a common sentiment is ‘we’re
too nice to each other’. Poorly performing staff
are often moved on to another area, and this
dimension of human resource management has
to change
• financial skills It is difficult to reduce spending
and increase efficiency when you don’t have
accurate and timely information about your
cost drivers, where revenue is being generated
and which services are loss-making. The NHS
funding model is increasingly complex, and a
wider understanding of how it works would
be invaluable
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• addressing wicked problems ‘Tame’ problems
are clearly defined and you know when you have
solved them but most management problems
are ‘wicked’, with different stakeholders having
competing views on the nature of the problem
and how to solve it. There are no ‘right or
wrong’ solutions, only better or worse ones.
What does this mean for L&D?
L&D can do much to close the gaps in skills and
knowledge. Here are two examples.
Political skill: During the research, we were
asked to run (separate) development programmes
in organisational politics for senior nurses,
operations managers, and foundation trust
governors at one hospital. These sessions included
a diagnostic, ‘how political is your organisation’,
identified common and rare political tactics,
assessed the individual and corporate costs and
benefits of ‘playing politics’, explored with real
cases how the constructive use of organisational
politics can enhance reputation and performance,
and ended with a self-assessment of participants’
political styles.
Wicked (ill-defined) problems: We were also
asked by another hospital to run workshops on
wicked problem solving for their ‘100 leaders’
cohort. In addition to exploring the differences
between tame, wicked and ‘super wicked’ problems,
these workshops introduced participants to the
tools of end-state mapping (what do we want to
achieve?), mess mapping (visually representing
the problem) and multi-level future mapping
(necessary actions). These tools are less important
than the productive dialogue that they encourage,
typically (as in this case) involving stakeholders
with wildly differing views of the problem and
how to solve it. The ‘wicked problem’ that they
chose as the basis for this discussion was why are
we not managing poor performance effectively?
Could this apply to
your organisation?
“We want to turn this into a great organisation,
a great place to work. We need to engage people or
lose talent, especially in general management roles.
Retaining talent in management roles is going to
be a problem. They could just walk away to other
sectors.” (Director of human resources)
The health service could usefully capitalise
on managers’ motivation and commitment by
promoting a positive image of their contributions
to patient care, and by empowering them to solve
problems and to drive innovation and changes
on their own initiative. We need to move beyond
the traditional negative stereotypes of middle
The reality is that
middle managers are
on the front line of
driving change
management, and to recognise and develop their
key strategic roles in designing and implementing
change and innovation.
This conclusion is consistent with research in
other sectors, where middle managers are seen not
just as passively implementing senior management
directives but as acting as intermediaries between
frontline and top team, helping to shape and drive
service developments and future
strategic directions.
There is a tendency to see the NHS as isolated
and uniquely apart from other organisations. We
would simply pose these questions:
• do these conclusions and recommendations
apply to your organisation, whatever the sector?
• do you have a middle management group that
makes unrecognised, unrewarded and underdeveloped contributions to your business?
• are they central to shaping the mission-critical
changes that you know are going to
be necessary?
It is time to take a fresh look at these ‘leaders in
the middle’ and the context in which they operate,
and to consider the business impact of increasing
the levels of recognition and support that they
receive. Remember, increasing recognition and
support may not cost you anything but could
unleash fresh ideas and the energy and space to
implement them.
The research on which this article is based
was funded by the National Institute for Health
Research Service Delivery and Organisation
programme (award number SDO/08/1808/238
How do they manage? A study of the realities
of middle and front line management work in
healthcare).
This article is based on independent research
commissioned by the National Institute for
Health Research. The views expressed in it are
those of the authors, and not necessarily those
of the NHS, the National Institute for Health
Research or the Department of Health.
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David
Buchanan
is professor of
organisational
behaviour
at Cranfield
School of
Management
and co-author
of Power,
Politics and
Organisational Change.
He can be
contacted
at david.
buchanan@
cranfield.ac.uk
Steve
Macaulay
is a learning
development
executive
at Cranfield
School of
Management.
He can be
contacted at
s.macaulay@
cranfield.ac.uk
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