Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
No my name is not Cassandra
- Annabelle Mark (30 November 2001)
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If managers don't take on change then the government will
- Paul McDonald (30 November 2001)
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Managerialism, the culture, is the albatross around the NHS' neck.
- Steven Ford (1 December 2001)
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NHS Mismanagement
- Paul Reid (5 December 2001)
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the centre is at fault
- Gordon Pledger (6 December 2001)
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apres deluge, moi
- Adrian Midgley (6 December 2001)
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Making it change by leaving it alone
- Charles Normand (6 December 2001)
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In fact its worse
- Peter Barling (6 December 2001)
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Re: No my name is not Cassandra
- Ahmad Risk (11 December 2001)
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Response to The Redisorganisation of the NHS
- Professor Sian Griffiths, 4 St Andrews Place, London, NW1 4LB (11 January 2002)
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Annabelle Mark, Professor of Healthcare Organisation Middlesex University Business School
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Dare one thus predict that the next crisis will be because, disillisioned managers leave the NHS, GPs are found not to have sufficient managerial never mind leadership skills to undertake the agenda now placed in their lap, so the delivery of the government agenda is not achieved, and the public suffer.This is but one scenario and I hope I am wrong, but surely one of the lessons of Bristol is that without sufficient managerial (as opposed to professional) expertise operating at the top of these large and complex organisations, professional skills alone will prove inadequate to meet the task. Should we be surprised if some doctors and even nurses of the future disclaim responsibility for managerial failures on the grounds that they have not been given sufficient mangerial training and development for these roles now thrust upon them by both default and design, and no my name is not Cassandra? |
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Paul McDonald, senior lecturer (research) university college worcester wr2 6aj
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I read with interest the article by Smith & colleagues. I do not agree with their assertion that the changes are the least debated. The language of 'quality' has been the currency of the NHS debate for the past 25 years, and the current transformations are but the latest chapter. Managers are acutely aware that this perpetual, ongoing and very public dialogue will result in changes in the definition of 'quality'. Consequently, they also know that this will cause inevitable systematic changes in the way they work. This is the very nature of modern NHS management. I further think that it is a little simplistic and unfair to state that this government has never trusted or valued NHS managers. It may be more accurate to say that the government knows that there will always be an element of covert resistence to imposed political solutions amongst some of its NHS managers. I am sure that those who have worked in NHS management are able to recall acts of policy sabotage both at authority and regional level. Sadly, many of these political solutions are no more than knee-jerk retorts to NHS failings in 'quality' and this can undoubtedly be frustrating and unsettling for managers. However, if managers do not lead and facilitate these reponses then the government will continue to do so. |
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Steven Ford, GP Haydon Bridge. NE47 6HJ
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Sir There are unwise assumptions being made by almost everyone involved in the NHS. Recent governments, under the false assumption that it was a 'good thing', have first imposed a Byzantine management structure on the NHS and then, possibly by reason of misdirected zeal and/or fawning regard for popular approval, ill-used it - hence the disillusionment hinted at in this editorial. The management cadre uncritically accepts the assumption that it is a 'good thing'. It is brimming with reforming zeal or consumed with lust for influence, preferment and honours or afflicted with improbable degrees of naivety or, as is evidenced by a proportion of academic tracts, committed to a world view of itself in lordly splendour over the untermensch who do the real work. There is reason to believe that it may yet achieve a schism in the English language - certainly its discourse strays farther from normal English usage on each succeeding day. The shop floor population, from consultant to work-experience student - clinical and all other functions, has assumed that, in its Stakhanovite striving to complete the greatest possible volume of work to the highest possible standard, it was working in the intended manner. Not so. There are far more important tasks with which management is ever eager to trip, impede and entwine - impenetrably prolix and wholly redundant documentation by the barrow load, interminable and routinely fruitless meetings (often in locations remote from the workplace and in out-of-hours time), an endless blizzard of idiotic faddish novelties to perplex and distract the workforce and newly minted fandangles for every occasion. The electorate has been beguiled into assuming that someone somewhere has the 'right idea' about how to provide a health service and that all ills are amenable to intervention. It is profoundly unfashionable to say so but the only effective strategy for managing a huge complex machine like the NHS is muddling through and, recalling a recent BMJ article on complexity, this can be rephrased as giving the complex machine simple instruction sets and letting it work. By all means dress it up with shiny neologisms if your job depends upon it but do not be tempted to believe your own flummery. Doing what works means first letting go of the reins. The hardware (buildings and machinery) and organic (staff)requirement can be either dictated by available resources or assessed on the basis of population and geography. Ad hoc local variations and a reasonable margin of redundancy in the system are essential if it is to work. Rigid single models of structure and process to be applied nationally will reliably fail. For ministers and panjandrums in the DoH or even Regions to aver that they know what is best for Wick, Anglesey, Exeter and Neasden is profoundly foolish. Building the structure from the consumer upwards offers real possibilities. Explicit and probably unpopular limits must be placed on demand. Consumers must contibute to the success of the NHS by using it appropriately - without out this cornerstone all else is vain. The future of the NHS depends mostly on the users who can destroy it by overwhelming it. The workforce morale can be promoted by non-interference (political and management) and the efficient provision of resources. Some respite from the constant drip of criticism from above would be welcome too. Management should have four roles. First, as a firewall between government and workforce - to intercept, sanitize and promulgate in documents of rigidly limited length and frequency the ideas from the DoH and government and to return, marked 'BS', all the nonsense. Second, to determine the local requirements from workforce and public and then beat upon the DoH until the pain causes the required resources to appear. Thirdly, it should administer the resources into place so that when the shop floor worker holds out a hand the correct tool is ready waiting. Fourthly, management should be the invisible and inaudible but ever present and reliable support for the shop floor - not lord and master but faithful ally, helpmeet and defence against adversity. The extent of the intrusion of the culture of managerialism, as presently constituted, is directly proportional to rate of destruction and loss of functionality of the NHS. All aspects of the NHS need and should welcome radical and continuing reform, including management. Yours faithfully Steven Ford |
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Paul Reid, GP 284 Lees Road Oldham Lancs OL15 0NA
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Editor The Government tells us that it wants to give front line clinicians more say in determining local services(1). What sort of managerial example is it setting when it leaves staff not knowing whether they will have a job next April, never mind where or what it will be. Reassurances have not reached the grass roots level in any effective manner. Having spent some time in the Health Authority on a public health fellowship this year I am appalled at the way the reorganisation has been implemented. There is no evidence base, no acknowledgement that it is stifling progress and the necessary legislation will not even be in place to implement the changes by April. At the same time the central control is escalating exponentially. The performance management controls and traffic light system mean that the options for innovative local practice are marginalised to non recurrent funding and likely to be unsustainable. Add this to the workforce voting with their feet and moving from health authorities and PCG's to established PCT's and other secure jobs it is no wonder managers are disillusioned with the reforms. If I wasn't writing to a medical journal the phrase 'piss up in a brewery' springs to mind. There is immense enthusiasm for the NHS to succeed but it will only work if this can be harboured effectively. Management of change is a part of our working life and it is about time the government started making it part of theirs instead of the Victorian attitude currently being displayed. I only hope the same mistakes aren't made in the review of out of hours services - GP co-ops being something that has both improved services and our quality of life. Paul Reid (1)Shifting the balance of power |
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Gordon Pledger, retired Director of Public Health Newcastle upon Tyne
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This brave editorial highlights the unprecedented micromanagement of the NHS by central government. Statements by the Secretary of State that Primary Care Trusts and Hospital Trusts will have more freedom are undemined by the creation of a comples set of structures between Trusts, where the work is done, and the centre. There will be supraregional directors of health and social services, Government offices with directors of public health, 30 Strategic Health Authorities to monitor performance. public health observatories, a modenisation agency, a development agency, an information authority, a retained organs commission,, and tsars for a number of specialties/diseases. (and these are the ones that I have heard about). Older observers will note that the structure of the NHS has almost gone full circle back that of 1948 except that hospital management committees are now hospital trusts, and local authority health departments are now primary care truats. The big difference is that instead of 15 regional health authories we now have a highly complex intermediate tier. About the only good poitn after 50 years is that general practitioners are now prepared to be more involved with local planning and management. If there is to be yet another inquiry into NHS management it shoudl focus on the actions of the "centre". After all it is not clinicians and managers who have reduced capacity by refusing to allow an adequate number of beds and opertaing theatres, got staffing numbers wrong, underfunded socaial servcies departments, failed to ban tobacco advwertising, and repeatedly reorganised the service over 25 years with major disruptions, expense, and loss or demotivation of experienced staff |
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Adrian Midgley, GP Exeter
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I used to worry about these things, and then I reflected upon what will happen the day after the NHS collapses in its present form. I'll come in to my general practice, a building I own, and sit in my chair, in my room, and my patients will come to see me. I think this applies to most if not all of my colleagues, and do you know, I think my specialist colleagues will find much the same in their rather more complicated facilities. There might have to be some sort of change out at the Reception desk, but that doesn't seem too complicated to arrange. So, anyone who finds themselves in charge of managing a piece of NHS has a problem, and anyone who is worrying about how to divide inadequate resources fairly among too many people has a problem, but if they are good at it, the day after the deluge they could well be offered a job. So order more imaginary divisions into the line, send more memos and plans to join those yet unread festering in piles in the administrata, patients come to see doctors, not managers nor politicians, and without an NHS they will not cease doing so. I think it is not this governments fault, the iceberg was in sight when they were elected, and even if they had hung a left instead of rearranging the deckchairs it wasn't stoppable. Probably. |
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Charles Normand, Professor of Health Economics London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT
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There is no question that there is much wrong in the organisation and management of the NHS. The government's error is to think that it can solve the problems with structural change. A lesson I leaned from 9 years on a hospital board was that it is only possible for management to make radical changes if the basic environment is stable.In our case some radical developments took place in the way services were delivered,which contributed to solving problems of waiting times, responsiveness to patient needs, and quality of care. These happened with the support of clinical staff. There is no perfect stucture. Function is more important than stucture. The focus should be on making the existing arrangements work. An important starting point is to learn to leave it alone. |
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Peter Barling, general practice oswestry st107hr
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You quote level of 80% dissatifaction with the recent NHS plan which I would like to take issue with.At a conference for general practitioners which I chaired, the subject of the NHS plan was discussed over a three hour period.The lecturer was an expert on the NHS plan and medical economics.At the start of the lecture,the question asked was ,"do you approve of the NHS plan".Of the 50 general practitioners present,one approved,three abstained,and the rest disapproved.When the same question was asked at the end of the lecture,presumably having understood the details of the plan,all the delegates voted disapproval of the NHS plan.This group from all over the UK showed 100% dissatifaction. |
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Ahmad Risk, eHealth Consultant at WHO Brighton BN3 2JD
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The more likely scenario is that GPs will leave the NHS. NHS managers will metamorphose and stay as they always do. Risk |
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Professor Sian Griffiths, President Faculty of Public Health Medicine, 4 St Andrews Place, London, NW1 4LB
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Editor Your leader on disorganisation of the NHS failed to make reference to another group on whom the current structural changes are having a profound impact - those in public health. The majority of NHS public health specialists working in England found out their jobs would be changing from a speech by the Secretary of State in April. They too are also suffering from low morale along with the professions and mangers as described by Smith. The major problem they face is making sense of yet further structural change in the delivery of the public health function – and the seeming indifference to their professional as well as personal futures. The problem is not that public health is not relevant, for there has never been a time at which there is more discussion of social and health inequalities (although much of this comes from other government departments, for it is the Chancellor who champions the need to improve children’s health through addressing child poverty). Rather, the problem is the lack of discussion and debate within the NHS about how best to deliver public health programmes which will deliver these changes. The media focus relentlessly on acute care and hospital. Just as there is no evidence that the reorganisation will improve performance, there is none to show that one of the biggest reorganisations of the public health service will improve the public’s health. Our difficulty with the current reorganisation is that the majority of public health specialists- doctors and those from multidisciplinary background- work at one or other of the tiers currently being reorganised. Since last April they have not known where they will be working on April1 2002. The response that they will all have a job is just not good enough. Working in public health within the NHS requires a long-term view. Successful practice is based on relationships with a wide range of people, not least the members and officers of local authorities and community leaders with in the voluntary sector. These relationships build up over years and these are the links which will help build the closer joint working necessary to work with local government colleagues. They do not make the headlines but nurturing them is crucial to delivery on local strategic partnerships, key to delivering the NHS Plan. For some in public health this reorganisation is one too many. Whereas civic society is based around democratically elected members for a geographical area, PCT boundaries in many parts of the country have developed from GP practice base. The relationships built up between DPHs and their civic partners are thus dismissed, and no one PCT will now cover large cities such as Birmingham or Sheffield. There is the not only the risk of confusion but failing to value wisdom and expertise in the rush to restructure. There can be solutions. For example, PCTs and public health specialists can work in networks which reflect local government boundaries wherever possible. ( ) There are also public health opportunities in the new roles for PCTs and regional government offices, not just for specialists but for all working at this level. There is also the opportunity to develop multidisciplinary practice as debated in this journal. But if this reorganisation is not to weaken the public health function there will need to be time, energy , resources and active demonstration from ministers and other influential players of the importance of this agenda. This means not only the general political philosophy of addressing poor health through economic investment, but through demonstrating care and concern for the professionals who have to deliver these ambitious aims. Sian Griffiths, OBE
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