Introduction

Despite repeated reorganisations, the NHS continues to be under severe pressure as it faces profound challenges in terms of growing patient demand, shrinking resources and a rise in external competition. More than ever, it depends upon the effort, knowledge and expertise of its workers. Managing the healthcare workforce was a central focus for Coalition government reforms and it continues to present several challenges; not least that demand for workers often exceeds supply and workforce is often the single most expensive budget item. Thus, it attracts (political, media and public) attention during times of recession and budget constraints (Hyde and McBride, 2011).

The NHS is regularly described by the size of its workforce – often erroneously as the third largest in the world (after the Chinese army and the Indian railways). In fact, it is the fifth largest employer after the US Department of Defense (3.2m), the Chinese military (2.3m), the US supermarket chain, Walmart (2.1m) and McDonald's (1.9m) (Alexander, 2012). In 2015, the NHS workforce amounted to 1.3 million (Health Education England, nd). Together with a further 1.6 million working in social care, the health and social care workforce accounts for 1 in 10 jobs in the UK (Imison, 2015, 20).

The NHS wage bill is £45 billion (DDRB, 2016, 7), accounting for about 40% of the total NHS budget (Kings Fund, 2010) and the majority of health expenditure across all health systems. For NHS providers in England, this amounts to ‘about two thirds’ of their total expenditure (Lafond, 2015, 11). Moreover, the NHS is marked by the diversity of employment, with over 300 occupations and over 1,000 employing organisations (Health Education England, nd). Although managerial decision-making can go some way towards mitigating shortages and containing costs (through training and development, for example), workforce planning and establishing new ways of working are sophisticated procedures that require strategic and operational coordination if they are to improve organisational performance (Hyde and McBride, 2011). Therefore, managers matter (King's Fund, 2011).

Over the past 30 years or so, a series of health reforms have affected the NHS workforce. As a result of these and combined with the more recent austerity policies, there has been a growing impact upon pay, skill mix, morale and motivation of all staff. While not discounting the effect of reforms upon all staff (especially clinical staff), we focus, in this chapter, upon NHS managers.