Sir Gerry Robinson
Last Updated: 5:42PM GMT 27 Mar 2009
It is almost beyond belief. In just two decades or so, the National Health Service has gone from having virtually no formal management structure, just administrative staff, to this week's announcement that out of a total staff of 1.36 million, 39,900 are managers. Let me put that in context: there are 5,000 more people now employed to tend to organisation than there are consultants – a mere 34,900 – tending to the sick. And if that were not enough to savour, new figures from the Incomes Data Services show that chief executives of NHS foundation trusts now earn an average of £158,000. Across the board at executive level within the NHS, salaries rose by 7.6 per cent in foundation trusts, and 5.7 per cent in non-foundation bodies. It is the starkest of all illustrations of just how far the pendulum has swung from medicinal to managerial.
Not that I am against management, nor high salaries – far from it. I am a passionate believer in management. In my career, as a former chairman of Granada, Allied Domecq, and the Arts Council, I spent much time analysing, writing about and teaching management skills. But in the case of the NHS, what we need are far fewer – albeit far better – managers.
I do not base my opinion on the latest statistics, which the Government is defending as making a "significant contribution to tackling unemployment" – a rather curious reason for hiring more managers in my view – but on the six months I spent advising Brian James, the chief executive of Rotherham Foundation Trust hospital for a BBC documentary in 2006. The aim was to see if proven management techniques could overhaul one hospital's waiting lists, where more than 200 patients were waiting longer than the Government's recommended 18 weeks. I wanted to see if we could come up with a template for hospitals all over the country.
The experience was both salutary and shocking; the hospital staff, including management and consultants, was eager to make it a better, more efficient place. There was enormous goodwill and huge pools of talent. But there was simply no process to pull it all together in a cohesive, sensible way.
When I meet people in the health service now who saw the BBC series, they say the same thing: how typical my experience was of their own hospital – and how the problems I identified persist throughout the NHS today.
I'm afraid this failure of management explains how a hospital such as the Mid-Staffordshire NHS Foundation Trust, which saw 400 needless deaths between 2005 and 2008, continued to function for so long before someone noticed. It explains why the care of seriously sick children at Birmingham Children's Hospital was so gravely compromised as the Healthcare Commission found earlier this month. It also goes some way to explain the appalling treatment received by four disabled people whose deaths were investigated by Health Service Ombudsman and the Local Government Ombudsman whose report was published this week.
Yes, you will get senior people at any hospital – or in any organisation – who lose the plot, who manage things badly. But while Health Secretary Alan Johnson is blaming the recent spate of crises on "understaffing and poor management", it is the lack of any normal system of checks and balances on a much wider scale that leads to failings of this magnitude.
In any "normal" organisation, there would be a "normal" management process. The whole would be broken down into constituent parts: one hospital would report to a head of a group of, say, 10 hospitals, who in turn would report to a regional manager, before reporting to national level. Progress would be measured, mistakes noticed and rectified promptly. That's how huge and successful companies such as Tesco manage.
The chain of command is clear so that it is easy to spot when something is going right or wrong – and to implement change when necessary. Follow-up meetings along the chain are so regular that problems get picked up when they are still manageable, and lessons learnt in one part of the group can be applied simply throughout.
In the NHS, staff may spend hours filling in paperwork and ticking boxes to cover their backs. But who is assessing what they do? Who follows it up afterwards? Some Foundation hospitals don't have to report to anyone who will challenge their procedures – as long as they are filing their regular reports. Trusts may appoint chairmen but I discovered they cannot control, and have little influence over, chief executives. No one ever sits down and asks: "How did it go last month?" No wonder it is chaos.
I understand how this culture of multiple managers develops; I think chief executives get to a point where it is easier to manage other managers than it is to deal with medical and nursing staff, especially consultants, who can be resistant to being told what to do by those with no medical background.
Instead, chief executives surround themselves with a safe set of managers who tell them what they want to hear, and perhaps they look to hire more – for business development or finance or new initiatives. Increasingly, the man or woman at the top of the tree is distanced from the reality of leading doctors, nurses and other staff, and delivering care to patients.
In Rotherham, I tried to persuade Brian James to have fewer managers – and I do think he took my suggestions on board. Certainly, recent figures show Rotherham to have among the lowest waiting lists for inpatients in the country. But that is the exception: the NHS as a whole continues to employ ever greater numbers of managers with no clear evidence that it is being managed better as a result. I want to shake it all up. We need a system in which regional heads must account for a budget, a cure rate, waiting lists etc – certain defined measures – every month. If they don't succeed or improve over time, they will find themselves replaced. Health professionals need managing, they need rules, regulations, vetting; they need someone examining how they are handling their waiting lists. They need praising or criticising where necessary; and they need great leadership to help them change. It might take five or six painful years but I don't think it would take much additional money.
It is galling to think that we, the public, are paying for the current highly risky system – in which some hospitals are brilliant and some dire. With good management, none of them would be dire. That's the truth of it. I'm not a fan of centralisation, but you do need a reporting system that can reveal why hospital A is not a patch on hospital B which is just 15 miles down the road.
The news is not relentlessly grim; the NHS has improved in the past five years – indisputably so. Targets have worked to a degree as they have focused attention on areas that really needed attention. We have also made great advances in the treatment of many diseases, especially cancer. As the Telegraph reported this week, cure rates have improved dramatically with half of all women and a third of all men in England now beating the disease. However, we still rank behind other European nations despite the billions and billions of pounds this Government has given to the NHS since 1997. I would argue that poor management is a factor in this. Until we learn to manage the NHS more effectively, we will never have the health service we pay for – and deserve.
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