Introduction

Managers are now among the most high-profile actors of all those working within the NHS today. They are often cast as its villains. They do not cure people, as doctors do, or care for patients, as nurses do. Instead they are often accused of cutting services, or as taking up money that could be better spent on care. Managers are overheads in health organisations, blamed by politicians when budgets are overspent (BBC News, 2006a) or wards not clean (BBC News, 2001), and reviled by the media as being responsible when things go wrong in health organisations (BBC News, 1999). They appear as shadowy figures in television dramas about hospitals and healthcare, lurking in the background trying to remind clinicians about finances at times when there are lives to be saved, and cutting services when money begins to run short.

At the same time, however, NHS managers now earn considerable salaries, and are held up (at least within the NHS management community) as exemplars of what it means to balance public values with efficiency and service delivery. They are presented as healthcare leaders who somehow manage to balance the often competing interests of resource efficiency and clinical effectiveness and to organise clinicians without alienating them, and they earn respect from the diverse range of professionals working in health organisations in the process.

Managers therefore appear as rather paradoxical beings – both heroes (Learmonth, 2001) and villains (Greener, 2005d), agents of the state and local preservers of public values against the onslaught of health reform, leaders and pragmatists able to work with the competing interests that health organisations hold within them. Attempting to understand the complexities of the role of managers in today's NHS is made easier by understanding a little history, as well as getting to grips with the changing conceptualisation of management within the NHS.

NHS administration

Accounts of the early years of the NHS are remarkable for often missing out managers completely (Eckstein, 1958; Rintala, 2003). This would be unthinkable today, when chief executives are at least visible in local media and in public meetings of their organisations. It is harder to find those responsible for the ‘administration’ of the NHS before the 1980s.

In the early years of the NHS, those charged with locally organising health services were placed in what would today be regarded as primarily an administrative role.