Ten years ago, NHS super-managers with six-figure salaries, expense accounts and hefty pensions were a rare breed in the country’s hospital boardrooms and local commissioning groups.
Not any more. While nurses have seen their pay fall in real terms over the past decade during an era of austerity, the ranks of these richly rewarded health bosses have swelled dramatically.
In September 2010, there were 985 hospital directors and healthcare managers in England earning more than £110,000, according to NHS Digital, the health information centre that tracks the numbers of “very senior managers” for salary reviews. But by September 2020 there were 2,788. It means their numbers have almost tripled in a decade.
The top tier of NHS bosses who get pay and pension benefits worth up to £450,000 a year is about to get even bigger. The Telegraph revealed earlier this month that the NHS is hiring 42 new executives on salaries of up to £270,000 for new integrated care system boards for health and social care. Tory MPs said they were “appalled” by the decision.
Critics say the NHS - which faces a record waiting list in England of 5.6 million patients - is already well stocked with highly-paid managers. Much more important than hiring even more, they say, is to cut the stifling levels of bureaucracy that hamper doctors, nurses and other frontline staff who treat patients.
Doctors who spoke to The Telegraph this week made repeated complaints about bureaucracy: they criticised the constant demands to report data which may be unnecessary or duplicated elsewhere; the glacial pace of decision-making by regulators and hospital committees; and an outdated referrals system which leads to patients who do not require specialist services being bounced around the system in front of other patients with greater need.
“There are some very good managers in the NHS, but the solution of managers to new problems is always to hire more managers,” says J Meirion Thomas, a former cancer consultant at the Royal Marsden Hospital in London, who has investigated healthcare reforms over the last four decades.
“They often have very little clinical knowledge and can be more worried about hitting targets than treating the patients in most need.
“A friend of mine left the NHS after he found that patients on the operating list, which had been drawn up on clinical need, were being replaced with those on the waiting list to meet the hospital’s targets.
“The NHS is now grotesquely over-managed. I’ve never heard of a bad manager being sacked.”
Since 1980, there have been more than 20 reorganisations of the NHS, which is one of the world’s biggest employers. The NHS in England now employs 1.2m people and has a £130bn budget (excluding Covid-19 funding).
The coalition government reforms under the Health and Social Care Act 2012 created a fragmented system - and were later admitted by senior Tories to be one of their worst mistakes. The act introduced by Andrew Lansley, the then Health Secretary, was later described by one insider as “unintelligible gobbledegook”.
The number of managers, which had been falling, began to rise again. By 2015, Lord Rose, former head of M&S, said in a review of the NHS that it was “drowning in bureaucracy”.
One of the biggest demands on frontline staff is the constant requirement to record every aspect of medical care on excessively detailed forms, from how many times a seriously ill patient might be turned over during the night to their daily nutritional intake.
Other staff are required to collect reams of hospital performance data. It has been estimated by the NHS Confederation it costs up to £2bn a year to gather data for reporting purposes.
The array of regulators that oversee the NHS - from the Care Quality Commission to professional regulators such as the General Medical Council - also mean regular reviews, appraisals and form filling.
Mervyn Singer, a critical care consultant at University College Hospital and professor of intensive care medicine at University College London (UCL), said: “The idea was that using computers would save time, but technology has created a new monster that takes the doctor and nurses away from the patient because they are sitting at a monitor writing stuff.
“An intensive care nurse may spend more than 20 minutes an hour just filling in patient data. Much of it in my mind is unnecessary. In the old days, you had paper notes, but you had far less form filling.” A Health Education England report in 2019 warned that up to 70 per cent of a junior doctor’s working time can be spent on administrative tasks.
The bureaucracy also stalls new treatments. Singer said the introduction of new procedures or devices could be held up for years because of regulatory hurdles and the need for approval by various hospital committees. He said it was a “breath of fresh air” that this red tape was swept away during the pandemic.
Reform of ‘outdated legislation’
A new breathing device for Covid-19 patients which he and his colleagues worked on in partnership with the Mercedes Formula 1 team took just 100 hours from the initial concept meeting to approval for use on patients in March last year.
The Continuous Positive Airway Pressure (CPAP) devices are now being used around the world. Singer estimates that pre-pandemic it would have taken two years for the devices to be approved for patient use. Lord Frost, the Brexit minister, told peers last week there would be reform of “outdated EU legislation” around medical devices and clinical trials.
Professor Karol Sikora, a leading oncologist and the medical director of Rutherford Cancer Centres, which provides cancer treatment and diagnostic imaging services to the NHS, said: “There are a lot of talented people who can really innovate, but the NHS bureaucracy dampens innovation and dampens enthusiasm. Too often, they end up walking away.”
Dr Owain Hughes, a former NHS ear, nose and throat surgeon who founded Cinapsis, a digital tool to streamline the patient referrals system, said the NHS still relied on archaic procedures.
He found during his 18 years in the NHS that GPs often operated “in silos” without access to specialist advice and were referring patients to specialist services that in some cases did not need to be seen, also creating longer waits for patients who required treatment.
He said: “The system is dangerously inefficient and communications between GPs and consultants are often hugely time-consuming and expensive, with letters or emails or calls through switchboards. It comes at an astronomical cost to the taxpayer.”
Cinapsis, a clinical communications platform, which allows a GP to consult a specialist while they are seeing a patient and ensure those who need specialist and urgent treatment get it. It significantly reduces unnecessary referrals, but is currently only used by a small number of trusts.
GPs also complain that bureaucracy has proliferated in recent years. Practices face multiple targets under the Quality and Outcomes Framework, a pay for performance scheme under which GPs must provide information or meet more than 70 indicators, from maintaining a register of the number of patients with heart disease to participating in “network peer review” meetings.
“Whenever I talk to non-medical people about my job, they always imagine the worst part about it is blood, gore, suppurating wounds, dead bodies and rectal examinations,” Dr David Turner, a Hertfordshire GP, wrote in the medical magazine Pulse earlier this year. “The reality is very different - it’s the red tape, bureaucracy and box-ticking that I loathe.”
Andrea Simpson, a practice manager at Silverdale Medical Practice in Salford, Greater Manchester, said: “It’s tough in general practice because you’ve got all this bureaucracy, and all these targets”.
While targets may have their uses, she says “one of the most important things is that patients can actually see their GP. The wait for non-urgent appointments can be two to three weeks.”
NHS England recommended GP practices implement a “total triage” model during the pandemic and discouraged appointments in person.
Sajid Javid, the Health Secretary, said this week GPs should now be offering face-to-face appointments after criticism that patients face their own long delays and bureaucratic hurdles in just trying to get access to their local practice.
The mother of a young woman who died after being diagnosed with stage 4 cancer told MPs last week how her daughter had to contact her GP more than 20 times before securing a face-to-face appointment.
Andrea Brady believes her daughter Jessica, 27, a York University graduate from Stevenage, Hertfordshire, would have been diagnosed at an earlier stage if she had seen a doctor sooner.
The Royal College of General Practitioners has defended online consultations and has said they do not represent substandard care. But whether appointments are online or in person, bureaucracy is still a problem.
Dr Chaand Nagpaul, the chair of the Council of the British Medical Association, said this week that pointless red tape needs to be scrapped so GPs can focus on their patients. “Unnecessary bureaucracy and targets need to end full stop,” he said.
Extra money promised by the Government will help the NHS, but is not the whole answer, say independent experts.
Professor Stephen Smith, former Dean of Medicine at Imperial College, has called for a national review on how to fund the NHS in the 21st century. He has suggested it could be a Royal Commission or a judge-led inquiry.
Professor Sir Chris Ham, former chief executive of the health think tank The King’s Fund and co-chair of the NHS Assembly, which advises on NHS delivery, said: “You can’t run a National Health Service without national standards and policies, but we’ve gone overboard.
“People who are running services locally spend too much time feeding the beast of the NHS with information and it takes away time from things that are much more important.”
He also said there needed to be more proportionate and light-touch regulation.
Lessons should also be learned from the pandemic - where decisions were made at speed and clinical teams found solutions without waiting for instructions from the NHS central management.
Before he stood down as health secretary, Matt Hancock proposed a series of measures to “bust the bureaucracy” in the NHS.
His report, published in November last year, said the NHS did have “relatively high levels of efficiency”, but it could be improved.
He outlined plans to ensure staff were not inputting duplicate data for patients’ records, to reduce the form-filling for GP practices and to ensure regulation was proportionate.
Will those proposals happen? Mervyn Singer, a hospital consultant, said he is not optimistic of any lasting changes from the epidemic.“Since the pandemic has abated, we’ve reverted to type,” he said. “The committees are back, along with prevarication and the form filling.”