The value of middle managers in large organisations has been questioned for decades. When times get tough, the knives inevitably come out for the ‘men in grey suits’. There are few places where this cynicism towards the strategic importance of middle managers has been more evident in recent years than in the NHS. New research, however, suggests that the NHS may have underestimated the importance of a particular breed of managers – those with a clinical or professional background, referred to here as ‘hybrid’ middle managers.
Identifying the ‘hybrid’ middle manager
A hybrid middle manager is anyone whose professional background enables them to act as a ‘two-way mirror’  – capable not just of assimilating top-down management knowledge, but also of translating and transmitting ideas belonging to clinical practice back up into their organisation. Hybrid middle managers may have various professional backgrounds and may be located at different levels of an organisation – from ward manager to clinical director. Their strategic value does not come by virtue of their role, but rather the level of influence they are able to exert downwards to their teams and upwards, for example, to the wider clinical governance agenda. A ward manager, for example, may have deputy ward managers and team leaders below them, to whom they can broker knowledge cascaded through internal management channels. At the same time, they may offer a credible voice at departmental or divisional management meetings, a role which they can use to share practical knowledge and experience gained from day-to-day clinical practice. This type of hybrid middle manager has been calculated to represent around a third of all staffing in a traditional hospital, compared to just three per cent of ‘pure’ general managers.
The strategic importance of the hybrid middle manager
Studies into private sector corporations commonly highlight the importance of middle managers as ‘knowledge engineers’ – capable of combining visionary concepts emanating from the top of an organisation with practical knowledge from the shop floor. The same has been found to be true in the healthcare setting, where hybrid middle managers are uniquely placed to translate strategic management initiatives into practical applications in a clinical setting. However, the influence of these hybrids in the NHS is more complex and important than the mere ability to bridge the knowledge gap between the top and bottom layers of an organization.
Knowledge brokering in service improvement
Studies into organisational behaviour indicate that hybrid middle managers have an almost unrivalled ability to broker knowledge within and between healthcare organisations. These managers operate at the frontline of service delivery and enjoy a credibility and legitimacy within their clinical communities that is not afforded to more generalist managers. They do not just understand the importance of accumulating knowledge, but also what it can be used for. The nature of clinical practice, where knowledge is constantly used alongside individual judgements, means hybrid middle managers are well equipped to act as brokers, connecting the subjective knowledge used in day-to-day clinical decision making with the more specific managerial information used in strategic service planning. In effect, they are able to apply their professional ‘mindlines’ to more explicit organisational ‘guidelines’. This knowledge-brokering role has been identified as a key component in service improvement. In relation to the clinical governance agenda, their fusing of patient safety knowledge from clinical governance systems and the frontline of clinical practice is crucial to ensuring high-quality care for older patients in hospitals. 
Contingencies framing the influence of hybrid middle managers
It important to acknowledge that not all hybrid middle managers are equally important knowledge brokers. The levels of influence they are able to – and, in some cases, are prepared to – exert are dependent on a number of personal and professional circumstances. 
The hierarchical nature of healthcare means some professionals have more perceived legitimacy than others. Nurses, for example, have legitimacy with their peers, but this can dissipate when trying to broker knowledge with and between doctors.
Hierarchies also exist within professions, with certain clinical specialities perceived as enjoying a higher status than others, which can have an adverse impact on their ability to influence.
Concerned at being seen as a manager first and a clinician second, hybrids have been found to use a number of different tactics to try and maintain a level of professional credibility. Some argue that a managerial position allows them to deliver better care. Others position themselves as a ‘representative’ of their profession or take up administrative positions within their professional bodies, which they use as a type of shield to perceived management encroachment. 
The extent to which hybrid middle managers engage with the potential of their role is governed in many cases by their overall perception of general management. Often this view is formulated early in an individual’s career, but the effects, in terms of being reluctant to embrace a knowledge-brokering role, can be long-lasting.
Social capital – an individual’s understanding, trust and reciprocity with others  – has been identified as a key factor in helping lower-level hybrid middle managers to break down professional boundaries, to broker their unique knowledge and thereby exert strategic influence. Hierarchies are widespread in healthcare, but in organisations where teams had developed a collective identity, there was evidence of effective knowledge brokering that crossed status and inter-disciplinary divides.
— Graeme Currie, Deputy Director CLAHRC WM, Implementation & Organisation Studies Lead
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