WHAT the NHS really needs is more managers.
No, I made that up. But I doubt that many TCW readers will have spent time perusing the report, ‘Leadership for a Collaborative and Inclusive Future’ commissioned and commended enthusiastically to Parliament recently by Health Secretary Sajid Javid. The title alone is enough to cause a ripple of ennui in the masses. However I am a bit of a nerd with regard to such documents, and someone has to read them. Then I noticed the headline in the Daily Telegraph, ‘Senior NHS managers to be paid more to move to the seaside’, and that clinched it.
The report’s authors are Sir Gordon Messenger, a military man of considerable distinction, and Dame Linda Pollard, the chair of Leeds Teaching Hospital Trust, who has large experience in chairing a variety of organisations including Coutts Bank. From their CVs both seem to have extensive experience in leadership and organisational management.
Working on the assumption that being an expert gives one the right to be wrong with authority, I was immediately suspicious that this was going to be the usual sort of report churned out by the powers-that-be, i.e. full of platitudes and unrealistic aspirations. I was somewhat surprised: it is a very strange report.
To give some context. Their brief was ‘to examine the state of leadership and management in the health and social care sector’. Or, to put it more succinctly, why management in the NHS and the care sector is often so dire.
The methodology involved forming ‘an inclusive and diverse team’ (alarm bells ringing already) all ‘bringing their own lived experience’ (oh dear) who then embarked on a ‘listen and learn’ exercise engaging with over ‘1,000 stakeholders’ from all parts of the health and social care sector.
No information is given on how the team or the stakeholders were selected, or any discussion on confirmation bias which to me would seem an obvious risk in such an approach. There is no empirical evidence to support their conclusions and a complete lack of references. All of which makes this a very unsatisfactory document on which to base any meaningful action. It is little more than a distillation of a range of individual opinions. But lived experience seems to trump all these days.
Sir Gordon’s initial two main observations are (I paraphrase) that first-rate leadership can make a difference, and that the development of such leadership skills is frequently absent in the NHS: no surprises there. But taking a sort of ‘an army marches on its stomach’ approach he states that, ‘a well-led, motivated, valued, collaborative, inclusive, resilient workforce is ‘the’ key to better patient and health care outcomes’ (his italics).
I am reminded of the story of an A&E sister who was a nursing officer in the Territorial Army and spent six months in Afghanistan. On return to work in the UK she was tearing her hair out after a couple of days. The reason, she stated, was that in the Army people did what they were told. So perhaps the military approach has some value.
The report makes a modest seven recommendations focusing around better training and appraisal for NHS managers with a more structured career. Nothing too controversial there: the current system is very ad hoc and needs to be improved. It recommends ‘a single set of unified, core leadership and management standards for managers’, but oddly fails to define what these standards might be.
However the strangest recommendation (the second in the list) is headed ‘Positive equality, diversity and inclusion (EDI) action’, and continues: ‘Embed inclusive leadership practice as the responsibility of all leaders’.
This statement alone makes me question the whole usefulness of the report. I wonder how many of more than 1,000 healthcare stakeholders emphasised the importance of EDI training? In my opinion most groan at the prospect unless, of course, the ‘stakeholders’ largely consisted of diversity managers (see confirmation bias earlier). I am not saying that EDI is of no importance but I struggle to understand why it seems so central to managing the NHS, and the supporting text does not, in my view, add any justification other than it is good to be nice to people. It is notable that when presenting to parliament Sajid Javid emphasised that this did not mean more EDI managers, just better ones. Hmm!
Sadly the reality is that woke has consumed Whitehall and no initiative is now acceptable unless it contains the relevant buzzwords. I am only surprised that the report did not mention personal pronouns.
The final recommendation, presumably, is the one which prompted the Telegraph headline about top managers moving to the seaside: ‘Improve the package of support and incentives in place to enable the best leaders and managers to take on some of the most difficult roles’.
This is easier to understand. When considering some of the disasters in the NHS, such as at Morecambe Bay, you have to ask who would want to go in and clear up the mess. I noted a point in the recent Ockenden report into the maternity services in Shrewsbury and Telford which was missed by the media, namely that between 2010 and 2022 the trust had eight CEOs. This is highly indicative of a trust in deep trouble. The most likely reason is that, following appointment, each new CEO turned the stones over and discovered a range of nasties which largely defied resolution without wholesale restructuring, and this could be a very career-limiting project.
Here I need to ‘fess up’, (dry throat, sweaty palms, get it over quickly). At one point in my career I was a clinical manager, although not a very senior one. This was in addition to the day job of being a consultant radiologist. Consequently I have been able to observe and experience NHS management first-hand, at least in the acute sector. The role of the clinical manager theoretically is to set the clinical goals for the department in line with the Trust requirements and national objectives. In reality it was about cost-cutting (sorry, cost improvement programmes, or CIPs) and trying to deliver a service with ever-increasing demand, unrealistic targets and limited resources both human and financial.
Hospital management structure is very hierarchical and ‘relies heavily on siloed (sic) personal and organisational accountability’, to quote the report. This means that each group jealously guards its own bit of the cake with relatively little collaborative working. An obvious example is the inability of hospitals to discharge frail elderly folk into social care (the exception being a pandemic panic where the government mandated thousands of such discharges with tragic consequences).
Ultimately this report fails because it makes no reference to the elephant in the room which is that the NHS and social care are completely broken, probably beyond the ability of even the best managers to repair. They have been shaky for some time, but the last two years of Covid-related madness have dealt the final blow with uncontrollable waiting lists, missed targets, impossible waits in A&E, staff shortages in all areas, inability to see a doctor and care homes struggling for staff. Tweaking the management structure brings to mind deckchairs and the Titanic.
There remains the question, was I any good as a manager? Distance lends wisdom, we are told, so on balance I hope I was a better doctor!