Surgeons vs supermanagers: will NHS money be spent where it's needed most?

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, 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 which tracks the numbers of “very senior managers” for salary reviews. But by September 2020 there were 2,788, meaning 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 Daily 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unnecessary or duplicated elsewhere; the glacial pace of decision-making by regulators and hospital committees; and an outdated referrals system which leads to patients who do not require specialist services being bounced around the system ahead of other patients with greater need.

“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.” He adds that a friend of his “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.”

Bungled change

Since 1980, there have been more than 20 reorganisations of the NHS, which is one of the world’s biggest employers, with 1.2m staff and a £130bn budget (excluding Covid-19 funding) in England.

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 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 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, which costs up to £2bn a year. The array of regulators – from the Care Quality Commission to the General Medical Council – also mean added 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), says “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.

“An intensive care nurse may spend more than 20 minutes an hour just filling in patient data. 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. Treating a patient admitted to A&E may require logging in to six separate systems to access clinical records and order diagnostic tests.

The bureaucracy also stalls new treatments. Singer says the introduction of new procedures or devices can be held up for years because of regulatory hurdles and the need for approval by various hospital committees; it was a “breath of fresh air”, he adds, that this red tape was swept away during the pandemic. 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. 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 NHS bureaucracy dampens innovation and dampens enthusiasm.”

Dr Owain Hughes, a former NHS ear, nose and throat surgeon who founded Cinapsis, a digital tool to streamline the patients referral system. During his 18 years in the NHS, he found GPs often operated “in silos”, referring patients to specialist services sometimes without need, creating longer waits for patients who required treatment.

He says: “The system is dangerously inefficient and communications between GPs and consultants are often hugely time-consuming and expensive... it comes at an astronomical cost to the taxpayer”.

Cinapsis 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 earlier this year. “The reality is very different – it’s the red tape, bureaucracy and box-ticking that I loathe.”

Where now?

Extra money promised by the Government will help the NHS, but requires spending well to really make a difference, experts say. Documents obtained last November revealed that about two thirds of the private hospital capacity block purchased by NHS England at an estimated £400m a month was left unused in the summer of 2020, despite waits climbing for operations.

With the NHS straining at its seams, ministers will be keen to avoid claims they are squandering cash. One project which has already been given the green light is £160m invested in “accelerator sites” across the country which will help fast-track treatments with pop-up clinics. Such projects will be vital in the battle to convince taxpayers they are getting bang for their buck.

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, suggesting 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: “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 the lessons should also be learned from the pandemic - where decisions were made without waiting for instructions from the NHS central management.

A Department of Health and Social Care spokesperson said: “We are determined to empower frontline health and care staff by reducing unnecessary bureaucracy and locking in positive changes seen during the pandemic. Last year we published a comprehensive strategy to streamline processes and save hardworking staff valuable time, from reducing duplicative data requests to rethinking medical staff appraisals, and we are also reviewing how we can make practical changes to support general practice. The [new] Health and Care Bill builds on the NHS’s own proposals for reform to make the health service less bureaucratic, more accountable, and more integrated in the wake of the pandemic.”

Will lessons be learnt? Mervyn Singer is not optimistic. “Since the pandemic has abated, we’ve reverted to type,” he said. “The committees are back, along with prevarication and the form filling.”

Professor Sikora thinks the Government should retrain its eye on a complete NHS overhaul, rather than pouring in unlimited billions “It’s a cumbersome, bureaucratic structure that has gone well by its sell-by date and needs much better management,” he says. “Throwing money at it without reform is not going to achieve anything.”