Is poor leadership really the cause of the skyrocketing NHS waiting lists? Given the upcoming review of NHS leadership launched by the newbie Health and Social Care secretary, Sajid Javid, it appears that the government thinks so. There were tough words from Javid in his party conference speech about the need to reform the NHS, trailed more vividly in the Times. And this is hardly surprising—as we head into a tough spending review, Tories will want to know they are getting value for money for the £30bn health and social care levy, especially when the national insurance rise to fund it has proven so controversial. Javid has tasked a retired military chief—Gordon Messenger—to review leadership and management in England’s largest organisation “by early 2022.” Is this merely conference politics on Javid’s part, or will anything serious come of it?
Javid has an unenviable in-tray. NHS waiting lists over five million, a wider hidden backlog of care, and social care “to fix… once and for all,” to name just a few challenges. All this with staff shortages of around 100,000 in the NHS and at least that in social care—and, of course, the need still to manage the rest of the pandemic. Of these priorities, he will know that long waiting lists are the Achilles’ heel for governments, and public patience with them will, before long, wear thin. On the other hand, the NHS is currently enjoying significant public support post-pandemic. The commitment and motivation of staff to “do what it takes” is clear, and a number of very rapid innovations—from the vaccine rollout to widespread reconfiguration of services—have made an impressive display of resilience and adaptability.
The size and complexity of the NHS must be bewildering for most politicians, who are often unused to managing any organisation, let alone being accountable for the most complex in the country. It is not surprising that appeal is made for trusted outsiders to give a view. In commissioning a review into the management structure of the health service Javid is taking a well-worn path—before the current Messenger Review came others, not least the Kerr Review (2018), the Rose Review (2015), the Dyke-Hampton Review (2009) and the Griffiths Review (1983). With the exception of Kerr, the reviews were led by business leaders, and one military man (Hampton). Their usefulness crucially depended on the extent to which they grasped the main issues, given the different context the NHS works in to, say, Marks & Spencer (Rose) or Sainsburys (Griffiths). Across all the reviews, two findings stood out: the need to support and train managers better; and the need to clarify lines of accountability.
The latter “sort-out-who’s-in-charge” message may chime with the party faithful. It also chimes with Javid’s early thoughts, at least as reported in the media before the conference in Manchester. “Hospital managers who fail to clear mounting NHS backlogs will be sacked under government plans for reform,” screeched the Times front page. And “…the health secretary is said to be preparing new powers to seize control of poorly performing hospitals with the insistence that ministers cannot just ‘throw cash’ at the NHS.” Javid was reported as being “frustrated that ministers lack the means by which to hold failing leadership to account, with hospitals enjoying considerable local autonomy.” The unmistakable logic is that fear of the sack is the key ingredient spurring managers to improve, and that failure to achieve goals is down to local leaders. Fresh into the NHS from business, it might well seem so.
Those with longer experience of managing health services know otherwise. In a recent wide-ranging interview, Alan Langlands—successful chief of the NHS in England 1994-2000— firmly dismissed the use of terror in management as counterproductive. Yes “performance management” was needed to deliver a small number of priorities, but always accompanied by support and training. As US health chief Don Berwick noted in another NHS review after the scandal of Mid Staffs, terror demotivates, blame produces perverse results, and in a service as highly stretched as the NHS both can trigger a haemorrhage of experienced staff. On the other side of the coin, a common feature in NHS trusts rated “outstanding” by the Care Quality Commission is having a well-recognised system of management, with a supportive learning culture which fosters trust, openness and allows more freedom in decision-making on the front line.
For sure, in a service with over one million staff in England, some leaders and leadership teams will be weak. But long known in the NHS is the endemically lower performance of NHS trusts in specific places—for example in some coastal areas and outer London. Here there are real structural reasons contributing to low talent, staff shortages and significant churn, as noted in the Kerr Review. Unlike businesses, the NHS first and foremost has social over economic objectives, and so cannot simply close down and move to more favourable locations. And clearly national government has a role to play—in particular, addressing chronic underinvestment and staff shortages (also besetting general practice).
Remedies will need to be more sophisticated than simply threatening to sack more people, or bringing in a fresh local team obviously “in charge.” Let’s hope that’s the starting point for the new review.
