Purpose

– This article aims to examine middle managers in health care and how their role has changed in times of fiscal constraints. It seeks to focus particularly on how cost savings influence the position of middle managers in the organisation between governance and advocacy pressure.

Design/methodology/approach

– A total of 25 Swedish middle managers from public health care organisations during fiscal constraints were interviewed about what contributes to their positioning in the organisation.

Findings

– The loyalty of middle managers is tested in the "in between" role. Excessive loyalty, in any direction, can distance a middle manager from their expected position. In times of a weakening economy, middle managers are expected to be a tool that is used by the management to communicate savings, personnel reductions, redundancies and closures. This contributes to middle managers sliding out of their role in between.

Practical implications

– Middle managers' skills are within care itself. In times of cost savings, demands are placed on their ability to handle advanced management tasks. They need to gain a clearer insight into management control, understanding conflict management and leadership.

Originality/value

– The article explains not only why middle managers slide up (take on governance roles) and down (take on advocacy roles) in the organisation, which has been described previously. It also explains why middle managers slide out (abdicate responsibility) of the role between governance and advocacy during times of fiscal limitations.