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.


Lord Blagger said...

Here's the real problem. In the NHS the three legs of a health service are combined. Suppliers, regulator and insurer combined.

Post code lotteries come about because insurer and supplier are in cahoots, where the insurer refuses to pay for needed treatments, and supplier goes along with it. It needs to be treat first pay later. The current system screws patients

Or take the general slaughter in the NHS. 12,000 a year killed from avoidable errors. That's the regulator in cahoots with suppliers, doctors etc. It's the insurer in cahoots because paying damages to those killed and maimed hits it. Victims have to pay the costs.

What needs to happen is that the three legs need to be split.

Then you have the treat now pay later costs. Pensions. All off the books. 30-40% extra costs coming, with 30-40% cuts in services.

So what system is needed to replace the NHS? Look at Europe, and Bismark systems. All the legs are split. End result far higher levels of care and at lower costs.

Beveridge systems are crap.

If we look at the spending on the NHS. It has increased 100% in real terms.
Outputs have increased by 5%

Nessimmersion said...

Lord blagger has it. The primary error is attemting to have a national service.
No other country has copied the British model, for a very good reason, it's a screamingly incompetent way to set up a health service.
First get local accountability in place and allow people a choice, its what the danish, dutch,french, ozzies etc etc do, ultimately if people don't like whats on offer they can choose something else. They are the ones paying for it.
Trying to run anything as a Stalinist monolith will always end in the mire, no matter how good the management.

Devil's Kitchen said...

I agree with all of the above.

However, in using the term “NHS”, I am assuming that this national religion is not easily reformable along the lines that we all know it should be. So, accepting this as a given, we need to understand how to make the “NHS” work better than it currently does. Which, honestly, would not be difficult.


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