The value of middle managers in large organisations, not least in the NHS, has been questioned for decades. When times get tough, the knives inevitably come out for what the Conservative MP John Redwood, secretary of state for Wales in the mid-1990s, called “the men in grey suits”.
Indeed, the 2013 Francis report into failings at Mid-Staffordshire hospital attributed examples of poor elderly care to a breakdown between managerial systems and clinical practice, with insufficient learning from incidents and errors and where lessons had been learned, they had not been shared across the organisation. In essence managers were to blame.
Yet a significant proportion of middle managers are hybrids, with clinical backgrounds, located at different levels of an organisation – for example clinical director, senior nurse manager, diagnostic unit manager or ward manager. They aim to improve quality of care for older people in hospitals – this may be why they took up a managerial role in the first place.
On the one hand, our study, funded by NIHR Health services and delivery research programme, shows these hybrid managers can translate management initiatives to improve the care of older people into practical applications in a clinical setting. They can inform those management initiatives because they understand the realities of frontline delivery of care. On the other hand, our study also reveals that the voice of hybrid middle managers is ignored in hospital settings in terms of their suggestions for change, upwards, downwards, and laterally within the organisation, so that care of older people improves.
One ward manager, a middle manager with a nursing background, who participated in our study, said: “I have seen instances where doctors have been on the ward and patients have fallen and they’ve paid no attention, which is alarming. They perceive, ‘it’s a patient safety issue that lies within the domain of nursing and nothing to do with me’.”
For doctors in middle managerial roles, it is challenging to make their voice heard among medical colleagues in a hospital. Geriatricians that take the managerial lead in the delivery of clinical care to older people claim their voice too is ignored, in large part because of medical tribalism that pervades hospitals.
One geriatrician said: “There are still a lot of specialist doctors working within a hospital that don’t see elderly care as part of their business, even though loads of our patients in every area are elderly.
“For some specialists in areas other than the elderly care department, they don’t seek out knowledge about the prevention of falls.”
Our study highlights how such challenges might be mediated. First, we identified social capital – an individual’s understanding, trust and reciprocity with others – as a key factor in helping hybrid middle managers break down professional boundaries, get their voice heard and exert a level of strategic influence upon care of older people.
Second, while our study shows hierarchies are widespread in healthcare, it also highlights examples of hybrid middle managers’ voice being heard to inform quality improvement in the care of older people, where teams have developed a collective identity that extends across professional divides.
The challenge derived from our study is a managerial one, but it is one that requires greater support for, rather than criticism of, middle managers, so their voices inform change. It is unfortunate that the current political climate is one that seeks to scapegoat middle manager ranks.
