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This project addressed three questions. First, how are middle management roles in acute care settings changing, and what are the implications of these developments? Second, how are changes managed following serious incidents, when recommendations from investigations are not always acted on? Third, how are clinical and organisational outcomes influenced by management practice, and what properties should an ‘enabling environment’ possess to support those contributions?Data were gathered from around 1200 managers in six trusts through interviews, focus groups, management briefings, a survey with 600 responses, and serious incident case studies. For this project, ‘middle management’ meant any role below board level that included managerial responsibilities. Evidence provided by trust workforce information offices revealed that the management function is widely distributed, with > 30% of hospital staff holding either full-time management posts or ‘hybrid’ roles combining managerial with clinical or medical responsibilities. Hybrids outnumber full-time managers by four to one, but most have only limited management training, and some do not consider themselves to be managers. Management capabilities now at a premium include political skills, resilience, developing interprofessional collaboration, addressing ‘wicked problems’, performance management and financial skills.Case study evidence reveals multiple barriers to the implementation of change following serious incidents. These barriers relate to the complex causes of most incidents, the difficulties in establishing and agreeing appropriate action plans and the subsequent problems of implementing ‘defensive’ change agendas. The conclusions from these case studies suggest that the management of serious incidents could potentially be strengthened by adding a change management perspective to the current organisational learning focus, by complementing root cause and timeline analysis methods with ‘mess mapping’ processes and by exploring opportunities to introduce systemic changes and high-reliability methods in addition to fixing the root causes of individual incidents.Interview, focus group and survey evidence shows that middle managers are deeply committed but face increasing workloads with reduced resources, creating ‘extreme jobs’ with long hours, high intensity and fast pace. Such roles can be rewarding but carry implications for work–life balance and stress. Other pressures on middle management included rising patient and public expectations, financial challenges, burdensome regulation (external and internal), staffing problems, incompatible and dated information systems, resource and professional barriers to implementing change and problematic relationships with external agencies. Despite these pressures, management contributions included maintaining day-to-day performance, ‘firefighting’, ensuring a patient experience focus in decision-making, translating ideas into working initiatives, identifying and ‘selling’ new ideas, facilitating change, troubleshooting, leveraging targets to improve performance, process and pathway redesign, developing infrastructure (information technology, equipment, estate), developing others and managing external partnerships. Actions required to maintain an enabling environment to support those contributions would involve individual, divisional and organisational steps, most of which would be cost neutral.Recommendations for future research concern the assessment of management capacity, the advantages and drawbacks of service-line organisation structures, the incidence and implications of extreme managerial jobs, evaluating alternative serious incident investigation methods, and the applicability of high-reliability organisation perspectives in acute care settings. Funding The National Institute for Health Research Health Services and Delivery Research programme.

How do they manage? A qualitative study of the realities of middle and front-line management work in health care