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The government is asking the public what it wants from the NHS, and the answers are a predictable mixture of angry and sensible. We all have an opinion about the healthcare system, just as we do about Tesco, or the BBC. Many of the ideas are familiar: turn the heating down on wards, pay for missed appointments, tell staff to lose weight.
If anyone mentions management, it’s usually to denigrate. “Sack all those useless managers and pay the doctors more!” But what if the NHS is actually a classic management problem?
Stand back, and you see that the NHS is a complex organisation which is failing both staff and patients. Its productivity is falling while it eats up increasing amounts of the government budget. In any other situation you’d send in the turnaround specialists.
I’m not claiming the NHS is Apple after Steve Jobs, or British Steel in 1974. It doesn’t have shareholders to reward, nor a simple bottom line. Nor would I propose privatisation. But I do note that managing a huge and complex organisation is a highly developed skill, one which is rarely appreciated by politicians, or commentators, or most of the management consultants whose parasitic relationship with the NHS symbolises the problem. A vicious cycle has developed in which governments stop good leaders from doing many of the things they want to do.
Successful management cultures are decisive. Strong leadership, clear organisational boundaries, a detailed understanding of customers, and a deep understanding of costs are crucial. The NHS is lacking on each one.
The first thing you might notice, if you were parachuted in, is that the NHS is a terrible employer. I can’t think of another organisation of this size where staff have little control over their schedules, and suffer bullying and discrimination despite spending hours in workshops on tolerance. Where the IT systems malfunction and the roof — in some places — is literally caving in. Where hardworking capable people are underpaid, and poor performers almost never leave, however many days they are “off sick”. Rigid pay bands mean that the experience and dedication of the middle-ranking nurse, who’s worked for 20 years, is not properly rewarded.
Making the NHS a more positive place to work could go a long way to reversing the fall in productivity. At the moment surgeons are twiddling their thumbs because operating theatres and patients haven’t been prepped. People who used to work overtime just can’t face it any more. But it’s hard to improve morale when there is little performance-related pay, and when attempts to remove underperformers end up in employment tribunals.
No one is really in charge, because the system is maddeningly both centralised and decentralised. Leadership is split between politicians — who meddle because they are accountable for the vast budget — and CEOs of NHS England, Trusts and other fiefdoms including a sprawling quangocracy whose autonomy is curtailed by the centre. The Treasury insists on annual budgets, making it impossible to plan long term. Badly performing hospitals are bailed out by taking money from the best, giving no incentive to improve.
It’s all there, in reports by brilliant leaders which are gathering dust. General Sir Gordon Messenger, who commanded 40 Commando in the Iraq War, has described the “institutional inadequacy” in the way that NHS leaders are trained, developed and valued. Sir Ron Kerr, who ran Guy’s and St Thomas’s trust, has argued in favour of empowering NHS leaders to lead by slashing bureaucracy and managing talent. Lord Stuart Rose, who ran Marks and Spencer, found more titles in the NHS than he’d seen in any multinational company. Common themes include complexity, Balkanisation, a gulf between managers and clinicians, and the torrent of demands from Whitehall.
You can go further back, to the Irish-born businessman Gerry Robinson, who made a programme about the six months he spent trying to bring down waiting lists at Rotherham General hospital. I once met Robinson. He told me the NHS would never improve until it realised that managing complex organisations is a serious business.
The obvious conclusion is that the government should stop meddling, raise pay and scour the world for executives with excellent track records who could make the NHS a great employer and drive improvements. That’s far easier to write, of course, than to achieve. Every attempt to take politics out of the system has backfired: notably in 2012, when the Conservatives ended up creating NHS England and the Department of Health as two power centres.
Sir Keir Starmer wants us to “reimagine” the NHS. Perhaps what we need to imagine is a classic management turnaround.
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