As the UK government sets its sights on building an NHS fit for the future, one critical but often overlooked question remains: Does the NHS have the management capacity it needs?
A common narrative suggests that the health service is burdened by excessive bureaucracy and too many managers. However research challenges this perception, revealing that the NHS may, in fact, be under-managed and not fit for purpose.
The submission from the University of York to the Independent Investigation of NHS in England (Lord Darzi) highlights significant concerns about the decline in management capacity across NHS Trusts and system-level partnerships. Backed by data and ongoing research, the findings point to a worrying trend: a shrinking managerial workforce struggling to keep pace with growing service demands.
Contrary to popular belief, research evidence indicates that the NHS is not over-managed. While administrative functions account for around 26% of the workforce, the proportion of managers is strikingly low. Estimates suggest that ‘pure play’ managers make up less than 2% of the workforce, with even lower numbers in primary care, although we acknowledge that there are a number of staff from clinical backgrounds whose roles include management responsibilities (Kirkpatrick and Malby, 2022a[1]). In comparison, across the broader UK workforce, managers, directors, and senior officials comprise approximately 9.5% of employees (Kirkpatrick et al, 2017[2]).
The Institute for Government (2024[3]) has gone as far as to conclude that the NHS is ‘dangerously under-managed.’ The problem is not just about numbers—it is also about capacity, efficiency, and the ability to lead and support clinical services effectively.
Analysis of NHS workforce data from 2010 to 2024 (see Table-1) indicates that the number of managers has not kept pace with rising staff numbers and clinical activity levels. Between 2010 and 2019, the total NHS workforce grew modestly, while the number of managers remained stagnant or even declined. Even in more recent years, despite increased demands on services, the annual growth rate of NHS managers has lagged behind that of clinical staff and patient activity.
For example, the average annual change in the total NHS workforce from 2010 to 2024 was 0.15%, whereas the average[4] annual increase in senior managers was only 0.07% (see Table-2). Over the same period, NHS activity—including emergency attendances, outpatient appointments, and GP referrals—grew at a much faster rate. The evidence suggests that NHS managers are being stretched ever thinner, with increasing spans of control and rising workloads.
The Consequences of Under-Management
Under-management in the NHS is not just an operational challenge; it has serious consequences for patient care, staff wellbeing, and system efficiency. Key risks include:
Workforce strain: Increasing workloads and burnout among NHS managers, contributing to high turnover rates and loss of institutional knowledge.
Frontline burden: A growing administrative burden falling on clinical professionals, diverting time away from patient care.
Reliance on consultants: Expensive and often inefficient external consultancy services being used to fill management gaps.
Missed opportunities for improvement: Without sufficient managerial leadership, the NHS struggles to implement innovations, drive productivity improvements, and successfully integrate care services.
What Needs to Change?
To address these challenges, policymakers must take decisive action:
Recognise the importance of management: NHS managers should be seen as essential contributors to healthcare delivery, not as unnecessary overheads.
Strengthen leadership development: Investment in management training, particularly for clinical leaders, is crucial to building future leadership capacity and capability.
Increase managerial capacity: A clear workforce strategy should include targeted efforts to recruit and retain skilled managers at all levels.
Challenge negative narratives: Media and political discourse must move away from ‘manager bashing’ and recognise the value that effective leadership brings to healthcare.
Improve working conditions: Reducing excessive regulatory burdens and enabling managers to focus on leadership, rather than bureaucratic firefighting, will enhance efficiency.
Enhance managerial focus: Increasing analytical capacity and ensuring targets and incentives are relevant and meaningful will support managers to focus attention on issues that matter.
Conclusion
The NHS’s ability to deliver high-quality patient care depends on having the right leadership and management structures in place. The current trend of declining managerial capacity, coupled with the pervasive negative narratives around NHS managers, poses a real threat to the sustainability and effectiveness of the health service. Addressing this issue must be a priority for policymakers, healthcare leaders, and academics alike.
For queries about the full submission please contact:
Professor Ian Kirkpatrick
ian.kirkpatrick@york.ac.uk
+44 (0) 1904 326444
Data sources:
Emergency Admissions and A&E Attendances monthly data is obtained from NHS England: https://www.england.nhs.uk/statistics/statistical-work-areas/ae-waiting-times-and-activity/. Monthly data is available from August 2010/11 to March 2023/24.
Admitted Patient Care and Outpatient monthly data is obtained from NHS England: https://digital.nhs.uk/data-and-information/publications/statistical/provisional-monthly-hospital-episode-statistics-for-admitted-patient-care-outpatient-and-accident-and-emergency-data. Monthly data is available from April 2010/11 till March 2022/23.
GP referrals for first consultant-led outpatient appointments is obtained from NHS England: https://www.england.nhs.uk/statistics/statistical-work-areas/outpatient-referrals/mrr-data/. Monthly data is available from March 2010/11 to March 2023/24.
[1] Kirkpatrick, I. and Malby, B. (2022a) – https://www.nhsconfed.org/long-reads/nhs-overmanaged
[2] Kirkpatrick, I., Veronesi, G. and Altanlar, A. (2017) ‘Corporatisation and the emergence of (under managered) managed organizations: the case of English public hospitals’, Organization Studies, 38, 12, 1687-1708.
[3] Institute for Government (2024) – https://www.instituteforgovernment.org.uk/publication/fixing-public-services-labour-government/nhs#footnoteref129_mk3ixxa
[4] Compound average annual growth rate is calculated to smooth the effect of volatility of periodic values and therefore to make change rates of different values more comparable. Formula used to calculate CAGR is: CAGR=((EV/BV)^(1⁄n)-1) ×100%. EV=Ending Value, BV=Beginning Value, n=number of months.
