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The government asks the public what they want from the NHS, and the answers are a predictable mix of anger and reasonableness. 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 down the heat in the rooms, pay for missed appointments, tell staff to lose weight.
If someone mentions management, it is usually to denigrate. “Fire all those useless managers and pay doctors more!” But what if the NHS is actually a classic management problem?
If we step back we will see that the NHS is a complex organization that is failing both staff and patients. Is productivity is falling while consuming increasing amounts of the government budget. In any other situation, you would send the change specialists.
I am not claiming that the NHS is Apple after Steve Jobs, or British Steel in 1974. It has no shareholders to reward, no simple bottom line. Nor would I propose privatization. But I do note that managing a huge, complex organization is a highly developed skill, rarely appreciated by politicians, commentators or the majority of management consultants whose parasitic relationship with the NHS symbolizes the problem. A vicious cycle has developed in which governments prevent good leaders from doing many of the things they want to do.
Successful management cultures are decisive. Strong leadership, clear organizational boundaries, a detailed understanding of customers, and a deep understanding of costs are crucial. The NHS is missing from each.
The first thing you might notice, if you parachuted in, is that the NHS is a terrible employer. I can’t think of another organization of this size where staff have little control over their schedules and suffer bullying and discrimination despite spending hours in tolerance workshops. Where IT systems are malfunctioning and the ceiling, in some places, is literally collapsing. Where hard-working, capable people are underpaid and poor performers almost never leave, no matter how many days they are “on sick leave.” Rigid pay bands mean that the experience and dedication of the mid-level nurse, who has worked for 20 years, is not adequately rewarded.
Making the NHS a more positive workplace could go a long way to turning things around. productivity drop. At the moment, surgeons are sitting on their hands because the operating rooms and patients are not prepared. People who used to work overtime can no longer afford it. But it is difficult to improve morale when there is little pay linked to performance and when attempts to eliminate poor performers end up in labor courts.
No one is really in charge, because the system is maddeningly centralized and decentralized. The leadership is divided between politicians (who meddle because they are responsible for the vast budget) and the chief executives of NHS England, Trusts and other fiefdoms, including a sprawling quangocracy whose autonomy is restricted by the centre. The Treasury insists on annual budgets, which makes long-term planning impossible. Hospitals with poor results are bailed out by taking money from the best ones, without giving any incentive to improve.
It’s all there, in reports from brilliant leaders that are gathering dust. General Sir Gordon Messenger, who commanded 40 Commando in the Iraq War, has described “institutional insufficiency” in the way NHS leaders are trained, developed and valued. Sir Ron Kerr, who led Guy’s and St Thomas’s Trust, has argued for empowering NHS leaders to lead by reducing bureaucracy and managing talent. Lord Stuart Rose, who ran Marks and Spencer, found more titles in the NHS than he had seen in any multinational company. Common themes include complexity, balkanisation, a chasm between managers and doctors and the torrent of demands from Whitehall.
You can go back further, to Irish-born businessman Gerry Robinson, who made a program about the six months he spent trying to reduce waiting lists at Rotherham General Hospital. I met Robinson once. He told me that the NHS would never improve until it realized that managing complex organizations is serious business.
The obvious conclusion is that the government should stop meddling, raise salaries and search the world for executives with excellent track records who can make the NHS a great employer and drive improvements. That’s much easier to write, of course, than to achieve. Any attempt to remove politics from the system has backfired: especially in 2012, when the Conservatives ended up creating NHS England and the Department of Health as two centers of power.
Sir Keir Starmer wants us to “reimagine” the NHS. Perhaps what we need to imagine is a classic management change.