Feature

Let the managers manage?

Could the NHS do with less ‘political interference’? Steve Dewar suggests it becomes a devolved agency, but Roger Seifert disagrees

Dear Roger

The NHS is more akin to a family of proliferating octopuses than the traditional organisational pyramid. The notion that it should be run by a secretary of state (often with little managerial or health care experience) is clearly questionable.

The NHS is funded through central taxation, for which national politicians are responsible, so there has to be central direction and accountability. The problem is achieving a balance where national direction is understood, agreed and delivered, but local responsibility protected.

Of course we already have much devolution including numerous semi-autonomous bodies to improve and regulate healthcare (such as the Modernisation Agency and the Commission for Health Improvement). But we need principles of devolved governance to accompany this.

Establishing an NHS agency at arms length from government (accountable to parliament for national objectives) could establish these new rules. In short, it would mean politicians going before parliament to agree targets and standards for the NHS. Beyond that, the NHS would be able to use its own head to do what is right locally.

The value of the agency idea is that it forces a separation between the politician and the detailed running of the service. No longer could they be drawn into NHS detail (an imperative to interfere that is driven by the unbounded accountability placed upon them).

An NHS agency could not only liberate the service, it could also enable government to broaden its horizons towards a concern with social justice and the impact of poverty, environment, food, housing and education on people’s health.

Steve

Dear Steve

The model you present of some ill-defined agency with operational responsibilities to manage the NHS is neither new nor helpful. The idea is riddled with false assumptions about what is wrong with current systems, the purpose of a nationally planned and delivered health service, the role of management, and above all about the nature of democratic accountability in an increasingly undemocratic public sector.

Your proposal is a variant of the rightwing dogma associated with ‘public choice’ theorists, namely that self-seeking and short-term politicians cannot be trusted to allocate resources rationally, nor indeed to set health priorities for the long run. Therefore, while paying lip service to parliamentary democracy, such suggestions seek to replace the elected with the self-confessed clever, unelected ‘expert’ managers with their coterie of heroic advisors and consultants.

In this way, your new big idea hands power to senior managers throughout the service in the false belief that the exercise of management decision-making is neutral, independent, non-political and of course rational. This is both naïve and sentimental.

What is the evidence on what happens when senior managers function outside the controls of governments and/or owners? Widespread corporate corruption, false accounting and reporting, arrogant disregard for users/customers, and worsening labour management practices.

Such a path, on which foundation hospitals are the first step, will replace health care based on shared risks and social solidarity with an increasingly market-driven definition of need based on targets (themselves hardly neutral), greater controls over staff (managers decide, professionals obey), and will end up supping with the devil – drug companies, insurance companies, and banks.

Whatever your reasons for wanting to destroy part of the democratic heritage of public services, please remember that the road to hell is paved with good intentions.

Roger

Dear Roger

You have raised four points. First, my diagnosis. I do believe that politicians in power sometimes put short-term gains before sustainable change (the view also of the Audit Commission¹) – for example, in reducing elective waiting by funding weekend sessions rather than taking time to redesign work to use more specialised nurses.

But you misrepresent my solution. I don’t suggest replacing the elected with the clever. I just suggest the elected stick to their job — agreeing targets for improvement with the service.

Second and third, the purpose of the NHS and the nature of management. I agree the NHS shares risks and builds social solidarity. I don’t recognise or follow the path you take us down — where power outside government equates to corruption, disregard for patients and staff, and an embrace with the devil. What I argue is that we should distinguish between leadership and management. Politicians should lead, setting vision and values. An NHS agency working with trusts would manage, in order to achieve agreed ends.

Fourth, democratic accountability. I admit to wanting to change aspects of our heritage. Let’s agree that the NHS is currently run by a hidden army of civil servants and managers for whom the accountability framework is opaque. I challenge you to find a member of the public who even knows the NHS chief executive’s name, let alone feels any confidence in the way he is held to account.

I suggest clearer roles: government (vision, values and policy), parliament (robust scrutiny) and NHS (delivery and freedom to work with local priorities), alongside accountability structures to match.

Steve

Dear Steve

Your answer is somewhat disingenuous. It assumes a fantastical dualism in which managers manage best when left alone by politicians, whose job is to have chimera-like visions and values. The NHS becomes disembodied, as an organisation in which managers have the ‘freedom to work with local priorities’. Freedom from whom? Staff, patients, political decision-makers? And freedom from what? Bargaining, transparency, and politics?

The two issues remain. Where is the analysis of what is actually wrong with the current health system? Your over-narrow concern with the NHS belies the associated nature of ill-health and health care: remember that most health care is still delivered by women in the home!

And secondly, your refusal to see management as anything other than the rational application of best practice (frequently taken from Harvard Business School’s revealed truths of faith-based managerialism).

The structural change you propose mistakes the nature of the problem, does nothing to improve the bargaining position of staff and patients, and puts more power in the hands of senior management teams who are unable and unwilling to see their own feet of clay.

Roger

Dear Roger

Disingenuous? No. Rather, I genuinely think managers might manage better if their relationship with politicians was clearer. At its simplest, this might mean the freedom that came with a dozen rather than 62 national targets. At it’s most sophisticated, it might be what Christopher Hood (professor of government, All Souls, Oxford) calls a new public sector bargain with higher level of mutual respect.²

I also want more, not less, bargaining, transparency and politics (both national and local), which should involve fewer ‘orders of the day’ and less game-playing (think of the energy wasted on achieving A&E targets for the week of measurement). For me, the key is accountability: pulling the current ‘behind the scenes’ relationship between government and service out into the open using parliament to facilitate debate on expectations and performance.

I should sum up. On the downside, I feel that you have given me views that I don’t have. I don’t take the view of management that you ascribe to me. As for positives, first I agree with the need to focus on health not health care — hence the need for a secretary of state for health (not healthcare). And second, despite our different views I suspect we agree on the value of politics (in the widest sense), even if we disagree on how politicians might avoid the type of disembodiment that you fear, in an increasingly diverse health system.

Steve

Dear Steve

Two issues remain that underpin our short debate. What is the overall direction of policy and who is guiding this? And what combination of decision-makers is most likely to allow a future NHS to broaden out into the world of housing, welfare, the environment and diet as opposed to the creation of some metaphysical salami (sliced so thin as to be easily digested by the circling sharks)?

The voices that government ministers hear come mainly from the private (US) for-profit health sector, senior health managers and civil servants, and an assorted set of the enemies of the (welfare) state such as the Daily Mail, market minded academics, and the conveniently highly paid consultants.

The voices they should listen to, in terms of a viable welfare future, are those groups opposed to privatisation, marketisation and payments for service use — a perhaps imperfect combination of local and national political interests, pressure groups, and (urgently) representatives of the staff, through bargaining and not partnership models. Neither blueprint nor magic wand, just old fashioned government by the people.

Roger