Wednesday, March 25, 2020

Steve Baker: still decent, still libertarian

When your humble Devil adopted Steve Baker MP as this blog’s mascot in 2010, Steve was somewhat concerned—and asked a number of free market people whether this dubious honour should be politely declined.

Apparently the answers mollified him, as he not only did not ask for his title to be removed, but also bought me dinner a couple of times in the House of Commons—when we discussed, amongst other things, matters libertarian (and Libertarian Party).

Over the course of the last decade, Steve has repaid your humble Devil’s faith in him many times—especially as concerns Brexit, and in the defence of liberty.

Via Guido, here is Steve, close to tears, as he implores the government to sunset the Coronavirus Act after one year rather than two.

The text of his speech is below:
I stand first with my hon. Friend the Member for Isle of Wight (Bob Seely). We cannot neglect his constituents on the Island. I fear that this issue has gone on for far too long, and I want to say sorry to ​him that we did not weigh in behind him sooner. This issue has just got to be dealt with, and I know that my right hon. Friend the Minister knows that.

Secondly, I would like to pay tribute to hon. Member for Bradford West (Naz Shah). She has done an absolutely fantastic job in the last 24 hours. It has been a real privilege to work with her to secure what I think is a fantastic result. At a time like this, matters of the hereafter are close to everybody’s thoughts. They sometimes say that there are no atheists in a foxhole. I certainly would not want to stand by and see my constituents cremated against their wishes, and nor, indeed, would I want to see people buried against their wishes. I really want to congratulate her; she has done a fantastic job, and she has done it in a wonderful cross-party spirit, which has done a lot to reinvigorate my faith in this place and in what we can achieve together when we put our constituents first. Well done to her.

I will pay particular attention to amendments 1 and 6 and Government new clause 19, which relate to the expiry of these powers. When I got into politics, it was with the purpose of enlarging liberty under parliamentary democracy and the rule of law. When I look at this Pandora’s box of enlargement, discretion and extensions of power, I can only say what a dreadful, dreadful thing it is to have had to sit here in silence and nod it through because it is the right thing to do.

My goodness, between this and the Prime Minister’s announcement tonight, what have we ushered in? I am not a good enough historian to put into context the scale of the infringement of our liberties that has been implemented today through the Prime Minister’s announcement and this enormously complicated Bill, which we are enacting with only two hours to think about amendments.

I could speak for the time I have available several times over just on the provisions relating to the retention of DNA, which we addressed in the Protection of Freedoms Act 2012. [Interruption] I see from the expression on the face of the Paymaster General, my right hon. Friend the Member for Portsmouth North (Penny Mordaunt), that she understands the anguish—she probably knows it better than any of us—that we are all going through in passing this Bill.

Let me be the first to say that tonight, through this Bill, we are implementing at least a dystopian society. Some will call it totalitarian, which is not quite fair, but it is at least dystopian. The Bill implements a command society under the imperative of saving hundreds of thousands of lives and millions of jobs, and it is worth doing.

By God, I hope the Prime Minister has a clear conscience tonight and sleeps with a good heart, because he deserves to do so. Libertarian though I may be, this is the right thing to do but, my goodness, we ought not to allow this situation to endure one moment longer than is absolutely necessary to save lives and preserve jobs.

Although I welcome new clause 19 to give us a six-month review, I urge upon my hon. and right hon. Friends and the Prime Minister the sunsetting of this Act, as it will no doubt become, at one year, because there is time to bring forward further primary legislation. If, come the late autumn, it is clear that this epidemic, this pandemic, continues—God help us if that is true, because I fear for the economy and the currency—there ​certainly will be time to bring forward further primary legislation and to properly scrutinise provisions to carry forward this enormous range of powers.

Every time I dip into the Bill, I find some objectionable power. There is not enough time to scrutinise the Bill, but I can glance at it—I am doing it now—and see objectionable powers. There would be time to have several days of scrutiny on a proper piece of legislation easily in time for March or April 2021.

I implore my right hon. Friend, for goodness’ sake, let us not allow this dystopia to endure one moment longer than is strictly necessary.
Once this farce is over with, we must all lobby our MPs in order to strike down this terrible legislation—it must not be allowed to stand for even two years.

In the meantime, it seems that Steve Baker MP must remain this blog’s mascot for the foreseeable future.

Sorry, Steve.

UPDATE: Steve Baker’s comment on this Bill can be found on his blog.

Tuesday, March 24, 2020

The problem with the NHS is not enough management

So, if you read the title of this post alone (and read any media, or talk to any NHS workers), then you are probably going to get annoyed and slag me off—but you are wrong. Let me explain why.

Two incentives

In any ward team in the NHS, there are two separate structures—there are those who work for the Trust itself (who I shall call “corporate”), and who worry about capacity and payments and bed occupancy; and there are the “clinical” staff (doctors, nurses, etc.).

In any NHS Trust, these people are working at almost entirely cross-purposes: the clinical staff are only incentivised as to the best treatment for their patients (and thus are inclined to be conservative) and the corporate staff who need to ensure proper throughput of beds, conservation of costs, etc.

The corporate line of command is largely through Ward Clerks, Matrons, and similar.

As far as the clinical line of command goes, the Consultant is in charge (followed by Registrars, followed by Senior House Officers, followed by F2s, F1s, etc.). It cannot be emphasised enough that their incentives—financial or otherwise—are not in any way aligned with those of the Trust who pays them.

The above is mostly true, except where poor care might lead to prosecutions, or similar, where the Trust is expected to bear all of the costs (not always true—but mostly).

For the reasons outlined above, these two entities are, almost all the time, at loggerheads.

Perverse incentives

For many nurses (and some doctors), the only way to progress over a career is to go into what is called, in the NHS, “management”. What this means is that previously clinical staff are now supposed to be aligned to “corporate” interests. This is perverse for four main reasons:

  1. you remove highly skilled clinical staff from what they do best, i.e. treating patients;
  2. you introduce a “clinical” mindset into “corporate” incentives: this might work, except that you are not screening people for suitability—only career progression;
  3. you have no guarantee that these people are able to manage a team;
  4. in any case, as far as management goes, they can be over-ruled by Consultants. So, they have incentive and responsibility—but without power.

No effective management system can work like this.

What about all the managers?

So, what about all these managers that we hear about in the NHS—aren’t we paying them all to do stuff?

Yes, of course we are. The trouble is that they see themselves as outside of the clinical framework—and often they are required to be.

  1. Strategic Managers—these are the people who worry about how to pay the bills, to lobby the government and NHS-D, NHS-X and more. Their job is to run the “company” and to push it forward. It is not their job to manage wards, or the sick—it is to ensure the viability of the business (and an NHS Trust is a business);
  2. Comms Managers—these people have a number of roles, but the biggest is in reputation management. They also have a huge roles in attracting and retaining staff (we all know that the NHS is short of qualified clinical staff, right?);
  3. IG / HR / IT: widely despised amongst clinical staff, these people nevertheless have a job to do. One can argue that they have been too hide-bound, too conservative—but, with each fresh disaster, this is changing.

So, what is the solution?

It is quite simple: you need managers on the Wards who are actual managers: they are paid to make decisions, and they can triangulate between a “corporate” Ward Clerk and a “clinical” need.

This means—and I cannot stress this enough—that this manager can over-rule a Consultant when necessary.

The role of a Consultant is going to have to change: they can no longer be viewed as “gods” who are utterly indispensable. They must be held responsible not just for the care they ostensibly provide, but also to the Trust for which they work.

Further, these Ward Managers cannot be far-away strategic Trust advisors—they must be on wards, making these decisions, 24/7.

Wait—but they aren't medically qualified

They might be.

But I work as a manager in a small software firm: I don’t know the precise coding implications of doing this or that—but I know how to ask the right questions, so that I understand the consequences of this or that. I can look at timescales, stair-casing impacts, architecture and Board strategy, etc.

In doing so, I am able to weigh up all of the options without specialist knowledge (although a vague knowledge helps in detecting bullshit, obviously). The point being that, given the information from both “clinical” and “corporate” the Ward Manager is able to make a decision—and, yes, be held responsible for that decision—quickly and with a reasonable amount of judgement.

Those who take their management role seriously in private companies (and there are many who do not) are able to divorce themselves from previous associations: in this case, for instance, were a nurse to be promoted it would be because they were a good manager—not that this was the only career advancement open to them.

So, what does this job look like?

These people need to be on the ward all day, every day. That means staffing night shifts too.

These people are directly responsible to the Head of Clinical Management at Board Level.

These people are diplomatic, firm and (I know this sounds trite) good people managers, and also understand the business drivers of the Trust. There are thousands of people that I have met who could do this job well—although they are eclipsed by the tens of thousands who would (and, in some cases, are) do it badly.

How would you test it?

I have come to the conclusion, over a number of years working with NHS organisations, that my dream job would be the CEO of a failing NHS Trust. And I would enact this there (as well as a bunch of other reforms).

Maybe it won’t work—but I think that it will.

What are the risks of this model?

Consultants are going to have their nose severely put out of joint. The BMA will rage about it—but, given that the BMA is almost entirely responsible for everything that is wrong with the UK Health Service, I would be happy to fight them all the way.

I would lobby the government to delist the BMA as a union, and provide solid evidence to show that the organisation is entirely opposed to an efficient health service in the UK. This is not hard to prove.

I would also remove the pointless exams that professions undertake to show that they are “capable”—as with the legal profession, these are trades union exams imposed to keep themselves relevant, and bear no real-world relation to capability or knowledge.


The anticipated outcomes would be:

  1. more clinical staff in clinically relevant positions—this means providing a suitable career advancement path outside of management;
  2. recruitment of managers—misfits and weirdos may apply;
  3. better outcomes for patients—long hospitals stays are deeply unhealthy, and lead to massive complications;
  4. a more secure financial position for the Trust—and thus for the NHS in general;
  5. this means more money to invest in efficiencies such as electronic patient records (EPR)—which will mean an end to sloppy practices and illegible hand-writing.


Finally, I cannot explain to you just how poorly the NHS is run. Money is just thrown away, and there is no prioritisation in any meaningful sense. Comms Teams and clinicians have no contact, and both of them hate the IT Team.

The whole thing is dysfunctional in the extreme: the more one works with the NHS, the less one becomes inclined to see any more money thrown at it.

This essay is a short stab at addressing just one problem: many more need to be solved.

NHS Fail Wail

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