Ignore middle managers at your peril. They may be central to development and implementation of policy, explains Dr Kathryn Oliver

Middle managers are more important than people often think – and that is very true when it comes to influencing and implementing public health policy.

In fact, middle managers without a professional training in public health may be the most influential people in public health policy – holding a more significant role than directors of public health, academics, business leaders, or politicians.

That middle managers in the health service and local government hold the key public health policy roles will come as a surprise to many experts in the field.  To date, research into the best ways to influence public health policy has tended to focus on the skills and attitudes of researchers and policy makers.

Research has too often overlooked the role of those who are heavily involved in policy development and implementation – the middle managers. Yet it is middle managers who have successfully brought issues such as a minimum unit price for alcohol to the forefront of the policy agenda.

The impetus for minimum unit alcohol pricing can be seen as having been created by local NHS managers and council officers in Greater Manchester who provoked Westminster into a response by declaring that Manchester was unilaterally considering the policy.

And it was the Greater Manchester region’s managers – not health bosses – who were responsible for transforming stroke services from having the worst survival rates in England to amongst the best.

Directors of public health and academics do, nonetheless, hold important roles in making and developing public health policy, but it is important to recognise what these roles are.  Our research shows that public health professionals and academics are only indirectly connected to policy – via managers.

We conducted a study of 152 policy leaders across local government and the NHS in Greater Manchester, asking academics, public health professionals and policymakers to nominate the people they thought were most influential on public health policy in the region.

Only a small minority of the ten or so local directors of public health were named as having any influence at all.  We found that the majority of academics were only connected to other academics, while most public health directors were only connected to their own teams and to fellow professionals.  It was the middle managers who had the strongest connections across sectors.

It may be difficult to accept the conclusion that middle managers hold the key policy position, as it appears to challenge the role of professional experts, including directors of public health and academics.  But the conclusion actually suggests we should pay serious attention to how the middle managers operate.

We think that one reason this attention has not been given previously may be that the skills which are so essential to good management seem prosaic.  These include persuading people, running meetings, bringing people together and being able to seem friendly and credible to multiple audiences.

These skills and roles are not often taught, they are not part of professional training or regulation and as a result they are usually not measured.  They are not ‘headline grabbing’ – yet nevertheless they seem to be essential in getting things done.

We developed a framework to categorise the activities of these managers. This framework shows how they were active through the whole policy process – from conceiving ideas, to developing detailed proposals, finding evidence and champions, and masterminding debates. The influential managers were able to wield this influence because they were seen as credible, friendly and reliable by people across the NHS and local government.

This places the managers in a very powerful position – able to control how information is passed between different groups.  They become the ‘go-to’ people from research and policy alike. They act as gatekeepers for important meetings and for groups of executives. They provide policy content and context and manage selected experts and executives to act as ‘champions’ on policies.

The reality is that if you have a good idea, you must first convince the middle managers. NHS and local government executives and council leaders trusted the managers to ensure that only feasible policy options are brought in front of them.

These findings are very important in terms of planning and implementing NHS reforms  – and provide an implicit challenge to some of the reforms currently taking place.  Health Secretary Jeremy Hunt and his predecessor Andrew Lansley criticised the ‘pen-pushing culture’ in the NHS, promising to reduce bureaucracy. This research suggests that approach may need to be re-evaluated.

Our experience was that managers are always looking for evidence and for engagement from universities. The usual barriers were always there – shortage of time, apparent irrelevance and difficulty in accessing journal articles. However, from our observations, we suggest that universities and academics could do more to engage with the managers. I went to a lot of public meetings in which local health policy was developed and discussed. Often, I was the only academic there.

A good first step for any research project aiming to have local impact would be to identify the prominent managers – getting to  know them, letting them know about your time frames and likely outputs. Collaborative institutions such as the CLARHCs may help, but only where there is a willingness to enter into the debate with an intention to learn on all sides.

Academics that want to influence the managers should be realistic, be truthful – and go to the meetings.