Wes Streeting’s big speech to NHS Providers in November, expertly sifted by my colleague Rhys McKenzie the latest issue of Healthcare Manager, was part gear-change and part business-as-usual—a combination of tea and terror. I won’t dwell on the manager-bashing or the risks and gaps in his plans for building management capacity and capability. This was all normal, with the usual foreboding that the terror will be white-hot and the tea lukewarm.

But the health secretary deserves credit for what he said about accountability and clarity of responsibility. Here was a combative, sharp politician saying something we haven’t heard before: “I’m prepared to make an unpopular argument with the public about the value of good leaders.” If he follows through, the NHS may get somewhere.

For decades, governments have caged themselves in the fake trade off between the frontline and everybody else. Politicians have failed to talk about what the NHS actually is: a complex system which needs all its different interdependent functions working well. A skilful politician would know how to get this idea across. So Wes Streeting’s “unpopular argument with the public” would be different and politically brave. My hunch is that the cage door is unlocked, if not yet open.

The think tanks and Lord Darzi have shown the value of management and given managers a bit of a morale boost too. More importantly, politicians may be lagging behind the public, who see every day what underinvesting in capital, systems and management means for them, their loved ones and friends. Early themes from the ten year plan consultation suggest the public have a good idea about what’s needed. Among the top priorities for change are communications with the public, the supply chain, shared digital health records, automated systems for patient registration and appointments, and more flexible working patterns. These challenges fall mainly to people in the ‘everybody else’ end of the NHS trench—particularly managers.

Here was a combative, sharp politician saying something we haven’t heard before: “I’m prepared to make an unpopular argument with the public about the value of good leaders.” If Streeting follows through, the NHS may get somewhere.

Streeting may find making this case to NHS staff an even tougher nut to crack. Sadly, many staff groups share the views of the public. Just listen to any phone-in about what’s wrong with the NHS! The ‘frontline vs everybody else’ trade-off has become a deep-seated belief in a two-tier workforce. You see this when the mere idea of redundancies or outsourcing among clinical staff is met with horror, while there’s barely a murmur when it actually happens to clerical workers or facilities management staff. Managers, especially, get ‘othered’ by staff as a whole, often seen as malfunctioning magicians or hard-hearted mill owners. They are neither. Managers are skilled workers in a team of skilled workers. 

Two things will be important if the health secretary is to win over staff. 

First, language. It’s his to choose. Headlines about “failing managers” and “protecting the frontline” undermines the legitimacy of managers and all non-clinical staff. No-one goes on to read the balanced remarks about the hard work and skill of most of managers. The term ‘manager’ also travels wider and deeper than politicians think. Andrew Lansley was shocked to learn that matrons thought he was talking about them when he attacked managers. He thought everyone understood he meant the men in suits at the top of NHS organisations. Leave aside that the ‘men in suits’ were mostly women, he’d only made the job of managers, clinical or non-clinical, harder. Anyone wanting to block change—led by managers—thought the health secretary was on their side. Streeting runs the same risk.

Secondly, managers must be allowed to get on with repairing, or re-creating, the social contract with staff: junior doctors for whom endless payroll errors are the final straw; staff with out-of-date job descriptions stuck in the wrong grade; and people feeling let down, frightened and demoralised by bullying, sexual harassment, violence, racism and inflexible working. These problems have management solutions. Give managers the permission, encouragement and tools to deliver them.

If managers are to get the legitimacy they need, ministers must start talking and planning around a unified workforce’—giving equal value to managers, clinicians and everybody else. Without that, productivity and reform—unloved concepts at the best of times—as well as the ten year plan itself will hurtle over the cliff. //