The NHS has a leadership problem. Good services need good leaders, but the service never seems to have enough quality to go round. Hospital performance isn often driven by factors out of their control, and at times the top jobs are impossible due to meddling Politicians who want to micro-manage without taking responsibility.
Despite this it’s hard to feel sorry for NHS managers. Too many of them justify their high salaries by their position in a hierarchy rather than by what they achieve for patients.
This is the latest announcement from Sajid Javid
We’ve been through this before under John Major.
Major spent a fortune increasing NHS bureaucracy, and recruited a whole load of senior managers with no healthcare experience.
Some came from industry but loads of them came from the armed forces – the cold war was winding down and we ended up with a bunch of former cold warriors.
Predictably they were a complete disaster.
I worked with one of them, a former submarine commander, who had been pushed out of the navy for accidentally sinking an Irish trawler. He gave a speech to a group of hospital doctors with the memorable line:
“we have been through choppy seas, but I am confident I can steer us towards the lighthouse”
Some surgeon at the back put his hand up and said:
“Away. Always steer away from the lighthouse. That’s the whole point of them”
The whole room sniggered as one
Another one I knew was ex-bomb disposal. It was at a time when the purchaser/provider split had become a chasm, and he was incredibly antagonistic to the other side. He tried to persuade him to calm down and be a bit more win’win
“There is no win/win in bomb disposal”
Was the reply.
If you think that I am being too quick to dismiss bringing in leaders from the military or the private sector I will admit that there are certainly some key skills common to both. There, however, some huge things that you need to be able to grasp to run an NHS organisation effectively:
1. The management process and the clinical processes aren’t the same thing. Clinical processes very from department to department, and are completely different to the management processes. You can have the best, most efficient management processes in the world, but if they aren’t aligned wth the clinical processes it means nothing – you are managing the map not the territory.
2. staff are loyal to their patients, their clinical team and (mostly) to the concept of the NHS – not to the Trust or Trust management. They don’t really care less about which NHS organisation employs them or what it says on their lanyard. Most of them will have been through multiple re-organisations and will have been employed by multiple different Trusts. They will be around long after the CEO or the FD have moved on, and if they don’t like you most of them will be happy to wait until you fuck off.
3. clinical autonomy is massively important. No matter how much you want to be in charge you have to cede some power and decision making to clinicians otherwise quality suffers and outcomes get worse. The only way to be in charge successfully is to allow frontline doctors and nurses to hav the power to intervene to change patient care. Having the power means giving it away.
3. efficiency is not what it seems – lots of private sector definitions of efficiency don’t really work with healthcare. Reducing costs for your organisation often simply moves the spend somewhere else. Increasing the number of patients you ram through a department makes it look more efficient to an accountant, but looks like worse clinical care to staff and patients, and leads to worse outcomes and higher staff vacancies
4. The NHS is built to withstand the most difficult scenarios – if war breaks out A&E will still function, staff will still come to work. That makes it incredibly resistant to change – but that is a strength not a weakness – that is why it coped so well over the last 18months
These approaches aren’t apparent to people who learned to manage in command and control structures. The NHS needs leadership, it doesn’t need micro-managing and clinicians don’t need to be controlled.
1. You spend years and millions on a massive change programme and absolutely everything is exactly the same afterwards
2. You change one box on an obscure form and the entire Trust starts behaving completely differently
These are lessons that private sector people struggle to grasp, and which makes them poor recruits. There is a role for commercial people on the board, but as Non-Executive Directors. After all… if the private sector were so much better why did the NHS out perform the private sector during Covid?
I am afraid with the NHS the same crap policies come round again and again. Any moment now Javid will ask a celebrity chef to review hospital catering. We saw what bringing in top private sector people achieved with Dido Harding.
This announcement from Javid has little or nothing to do with improving NHS management and everything to do with centralising power with the Secretary of State and making sure existing senior leaders toe the line and don’t speak out if there are shortages of Doctors Nurses and Money.
Meanwhile the real threat – staff shortages and falling morale get worse