The role of managers in NHS good governance

30 June 2021

What are different levels of management responsible for in the NHS – and how can we tell if they are practising good governance?

We all know what NHS managers do, right?

In provider trusts they enable the delivery of services by making sure clinicians have what they need to care for patients.

This includes securing the right buildings, facilities, equipment, information and support staff to get the job done as safely and efficiently as possible. It also means building and implementing accountability and reporting systems and processes so that clinical activities can be planned, monitored and reported on.

Managers also have a critical role to play in continuous improvement by working with clinicians to identify what improvements need to be made and developing and implementing improvement plans.

Management structures can take on an almost infinite number of shapes depending on the size and type of trust and the services it provides. In all cases, management decisions support and implement the board’s goals and values.

Managers make operational decisions and handle all of the work that makes the operation tick. Management interconnects with every department in the operation.

Middle management and executives

Senior management look to middle and front-line managers to interview, hire, train and retain new employees. The task of hiring employees also includes delegating tasks according to the trust’s needs and identifying employees whom they can trust to get the job done. Retaining quality employees involves evaluating data and employee performance to encourage excellence in work standards.

Executives are the liaison between the board and middle and front-line managers. One of their duties is to communicate the board’s expectations to employees in all levels of the trust and across all its services. To accomplish this, managers may break down the board’s expectations into short- and long-term operational goals to see implementation through to completion.

While the board sets strategy, managers are responsible for enabling delivery and holding employees accountable for their actions.

Range of skills

Managers need a variety of skills that are distinctly different from those of non-executive board directors. First, they need good motivational skills, so they can inspire staff and create a working environment in which everyone thrives.

Along the same lines, it’s good for managers to have strong coaching skills. Most employees will require some level of training and they need continued encouragement to improve their performance.

While the board may set an overall budget, department managers often have to produce their own budgets and communicate their budgetary needs to senior managers. Senior managers communicate the lower managerial budgetary needs to the board so that budgetary matters get reconciled throughout the trust.

Managers have to be able to please or, on occasion, appease people on many different levels and from many different facets of the organisation. As a result, managerial positions are often high-pressure/high-stakes jobs that require a cool head and sound decision-making and taking under pressure.

Managers who have good collaborative skills can often take some of the pressure off themselves by using problem-solving strategies to move past challenges.

Financial and regulatory challenges and technological advances have a trickle-down impact on operations. Effective managers are good at adapting their management structures and processes in short order as required. During times of rapid change, good managers are also highly effective at communicating those changes.

Managers with strong skills take the initiative to get projects started and oversee them until they’re completed. They’re also willing and able to intervene if something is going awry, taking action to set things right. Managers have a critical role in identifying and managing risk in line with their trust’s risk management strategy and policy and, critically, in alignment with the board’s risk appetite.

So, it is clear that managers have a vital and often unrecognised role in the quality and corporate governance agenda of every trust. They make the organisation tick; they are often the glue that holds it together.

If clinicians and managers work together in a spirit of joint endeavour aligned with NHS values, patients and taxpayers get a better deal and the trust will probably be practising ‘good governance’.


  • Management and governance are different but good governance relies on good management.
  • Managers have a critical role to play in providing assurance.
  • Well-governed trusts are those where managers and clinicians work together to deliver the goals of the organisation and the NHS.

If you have any questions or comments about this briefing, please call us on 07732 681120 or email

Prepared by GGI Development and Research LLP for the Good Governance Institute.

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