We have all read headlines that the NHS is overly controlled and bloated at the top by managers, who if they were just stripped away would see much better value for the public and make doctors and nurses’ lives easier.  It is true that as a manager working in a non-clinical capacity, the public, the media, and politicians rarely want to see or hear from you – the opinion of a “grey suit” carries less credibility or influence than a practitioner from the coalface of the service. Managers are frequently and unapologetically portrayed and perceived as the over-paid, restricting bureaucrats who are determined – at best – to prevent innovation and clinical freedom by strangling them with gateways, approvals, and incessant meetings, and at worst are only truly out for their own personal power.

We know that these representations aren’t true, however. In January 2022 the NHS Confederation and independent academics from the University of York and London South Bank University reported that managers make up c.2% of the workforce compared to 9.5% of the UK workforce[1], similar figures from Nuffield Trust showed this was 4% and 10% respectively in 2015[2]; the number of managers having been cut back in recent years, despite the COVID-19 pandemic. As Stephen Black has argued, even medical charities employ more managers than the NHS.

With such an enduringly and unerringly negative reputation, what can be done to support managers better in the NHS? Why is it so hard to shift attitudes towards managers, particularly those who have not been clinically trained, or not holding clinical management roles? Is it because we all have little understanding of what managers do and therefore contribute? We believe it is time to raise the profile of managers[3].

The lived experience of most healthcare managers is nothing like these lazy misrepresentations (although occasionally volumes of meetings can be a bit much) – their work feels urgent, important, and necessary – indeed essential. Their work in the operational delivery of services so patients can access their appointments, or hospital beds reliably, of managing and supporting staff wellbeing and development, of securing finance, of quality improvement, of enabling improved productivity so more treatments can be undertaken and of securing sustainable investment for local people, is never done. There is always more to do, always greater demands from regulators, too few hours in the day and more often than not, little if any leeway in what must be done and when. Managers carry a huge sense of duty and feel heavy responsibility for their roles and outcomes, with usually few local peers for support, given the tiny proportion that managers make of the NHS workforce.  Our managers often feel that they are on their own.

Colleagues from all professional backgrounds demand and recognise good management, valuing it and appreciating the struggle when it is lacking. Managers enable talented clinicians to succeed, they create the conditions for effective teamwork, excellent service, and compassionate care to thrive. Often this is seamless, invisible to the unfamiliar, and therefore sadly taken for granted by those less connected or informed.

Too often does the media or local gossip resort to “manager-bashing” – the tolerance for any errors or misjudgements so limited, the assumption that senior leaders must be out for their own ends so lazily cited and consistently propagated. Why should it be so hard to believe that management staff might have the same values and drive as clinicians do? That they have chosen public service and the health care profession because they want to make a difference to our lives, our world, and our society.  Managers need to be allowed to take their role as central to the multi-disciplinary team – just as no two doctors are the same, no two managers are the same, and stereotypes belittle us all. This is why it is so important to all our success for clinical leaders to be visible and audible in their support for managers.

In this series of blogs with BMJ Leader we challenge all clinical leaders, from any profession, to inform themselves about NHS management – what do you really know about them – the managers you work with? And we challenge you to commit to championing NHS managers and upholding a parity of esteem; what stops you from advocating for your manager peers in access to development and opportunity, research, and innovation? What role do you have to play in influencing the image of the profession positively?

Join us in the next few months as we raise a Call to Action, inviting our clinical colleagues to celebrate managers, as members of the same team.

Upcoming session: Proud2bOps and the FMLM have joined together to support a collaborative conversation between Medical and Operational Managers. Sharing insights into each other’s role and why we should champion each other and work better together. Thursday 24th November, 12:30-13:45.  If you are an NHS Operational Manager or a Medical leader in a provider organisation and would like to join this session please register here: sfh-tr.proud2bops@nhs.net


  1. NHS Confederation (2022), Is the NHS overmanaged?
  2. https://www.nuffieldtrust.org.uk/chart/are-there-too-many-managers-in-the-nhs
  3. Strengthening NHS management and leadership – The Health Foundation