Contributors: Sylvia Davidson, Paul Evans

Key points

  • Ony 3% of staff in NHS hospitals are employed in management roles
  • a lot of staff hold management responsibilities whilst also working on the front-line in patient care
  • employing full time managers will enable clinicians to focus on patient care. 
  • Top NHS executives paid far less than industry equivalents
  • Too few managers leads to expensive use of management consultants

Politicians and the media regularly accuse the NHS of spending money on managers rather than front-line patient care. Over many years such accusations have resulted in many people thinking that the NHS is top heavy with thousands of overpaid managers.  

Lansley’s reforms of 2012 targeted management and led to a big reduction in managers. When General Gordon Messenger was appointed in 2021 to lead a review into management in the NHS, the media hoped this would lead to a cut in the number of fat-cat NHS managers and bureaucrats so more money is spent directly on patient care.  

And again, in late 2022, when Steve Barclay appointed Patricia Hewitt to review NHS organisation, it was reported gleefully that this would ‘slash the number of bureaucrats’ and reduce ‘pen-pushers’. 


In reality, the NHS has far fewer managers than other industries. Many of the figures for the number of managers that have been suggested, such as that managers makeup almost half of the NHS workforce, have been due to (wilful) misinterpretation in the media of the figures provided by the NHS.  

Workforce data shows that the percentage of NHS employees that are doctors or nurses, is around half, but this does not mean that the rest of the NHS is composed of managers, the other half of the NHS workforce includes cleaners, porters, canteen staff, healthcare assistants, scientists, data analysts, IT staff, administration staff, and managers.  

Approximately 3% of staff in NHS hospitals are employed in management roles and this is a much lower level than in the economy overall in England, where 11% of staff are employed in management roles 

Furthermore, this group of NHS managers are not a group-apart from other NHS employees, a lot of staff hold management responsibilities whilst also working on the front-line in patient care. And people whose job title is ‘manager’ or ‘director’ may still get involved in hands-on front-line work. 

As to employing managers being a diversion of funds away from front-line care, the reverse is more likely to be the case, as so many clinical staff carry out managerial tasks, it stands to reason that employing full time managers will enable clinicians to focus on patient care. 

Big salaries?

The other accusation thrown at NHS managers is that they are ‘fat-cats’ on high salaries. However in comparison to equivalent positions in private sector industries, they are paid a lot less. While the majority of NHS trust chief executives are paid under £200,000 and some chief executives of large foundation trusts can be paid around £250,000 per annum, in contrast, chief executives running FT 100 companies of a similar scale are paid far more: for example, the chief executives of several water companies were each paid in the region of £1.5 million to almost £4 million in 2021.  

There is evidence to suggest that instead of having ‘too many managers’ the NHS actually has too few managers. In recent years the NHS has spent vast sums of money buying in management from management consultancies, due in part to a lack of in-house staff. 

From 2016-19 the government’s spending on management consultants in the NHS trebled to £22.65 million, and in more recent years, spending has increased still further. In February 2023, openDemocracy revealed that NHS England quadrupled its budget for outsourced consultancy work to £83 million in 2022. 

However, it is unclear if the employment of management consultancy firms is a positive for the NHS. In 2018, the London School of Economics found management consultancies offered poor value and brought inefficiencies to the NHS. 

It is difficult to assess what is the optimum number of managers, but by comparison with other industries, it is possible to conclude that the NHS does not have too many managers – using the figures that the NHS provides.

The idea that it does, is often perpetuated by some politicians and parts of the media, based on the assumption that huge savings can be made by reducing the number of managers. This underplays the fact that the management of resources and staff is a role fundamental to the effectiveness of the NHS.

It is right to get good value from public money, but the focus on management numbers has become an easy criticism, not an argument backed by solid research. It is often an attempt to knock the NHS for wastefulness coming from those who perhaps would rather distract from the consistent underfunding of the service.



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