In addition to the thoughtful and stimulating responses on this sad state of affairs, I feel that there are already some tools available to deal with "difficult management behaviour" or gross professional misconduct. I agree that an explicit set of principles and expectations and regulation would be a step forward as self-regulation by managers does not seem to be working.

I would point out that the NHS does have a code of business standards, that executive level appointments should be through a "good and fit" person test and senior appointment have to be vetted at the highest level. The main issue is enforcing these aspects of self-regulation, does this sound familiar?

Competing interests: None declared

Editor

This is amongst the most important contributions that I have read in the BMJ for some years.

I shall be drawing the attention of others to it.

The necessity to restate the purpose of the NHS - to alleviate the fear of illness, injury, suffering and death - was never more clear.

Management is not and never was on the side of the patients or of the clinicians or of the principled provision of a vital public service or even of politicians. Management is only ever on the side of management.

Efficient administration is what is required. The necessary collaborative impulse between the many functions within the NHS can be best promoted by the advent of telling mutual jeopardy which will abate empire building and the ascendancy of prima donnas.

Yours sincerely

Steve Ford

Competing interests: None declared

Once upon a time there was a farmer called Farmer Brown.

Farmer Brown kept pigs, a small number of happy and contented pigs.
He employed a few farmhands to keep the pigs fed and happy. The pigs grew, the farmhands enjoyed their work and the sun shone.

Farmer Brown knew that the annual show was coming up, so he wanted to make sure the pigs were putting on weight. Farmer Brown got the farmhands to weigh the pigs. The weighed them every week, the sun shone and the pigs got fatter.

The farmer had a rival, Farmer Jones from down the road also kept pigs. And his pigs were getting fatter more quickly than Farmer Browns. Farmer Brown got really bothered about the pigs, he got the farmhands to weigh the pigs every day.

Down the pub that evening Farmer Jones boasted about his pigs and how quickly they put on weight, how they were sure to win fattest pig in the annual show. Farmer Brown desperately wanted to win the annual show, so he ordered the farmhands to weigh the pigs every four hours.

Soon the farmhands were running round weighing one pig after the other and filling in complex charts, they had scarcely finished weighing the pigs and writing down their weight, colouring and skin tone, when it was time to start all over again weighing pigs.

A few days later Farmer Brown went past Farmer Jones’s field. He could hear Farmer Jones in the barn calling out the weight of each pig as he weighed them, so his assistant could write the weights down. Farmer Brown knew Farmer Jones’ pigs were heavier. He was beside himself, the pigs had didn’t seem to be putting on weight so he ordered the farmhands to weigh each pig every hour.

The pigs were not getting fatter.
So farmer Brown arranged for a weighing expert to come in and teach the farmhands how to weigh really really accurately.
Farmer Brown spent hours designing and redesigning the forms to record their weights, and he arranged for an expert in charting and mapping to come and show the farmhands how to record the weights more clearly.

Then Farmer Brown made big signs, reminding the farmhands about the four B’s of pig weighing. Farmer Brown checked the forms at the end of each day. Soon there were so many forms he had to take one of the farmhands off weighing to help with reading the forms.

The farmhands were constantly weighing and filling in forms, filling in forms and weighing. There were smart new forms in triplicate, all beautifully filled in.

Still the pigs were no fatter. Farmer Brown bought big shiny new scales, he sent three of the farmhands away for a week to learn how to operate the scales properly so they could teach the others.
The annual show day approached.
Farmer Brown got frustrated, his pigs were not performing, Farmer Jones pigs were much much fatter. Farmer Brown decided there must be something wrong with the farmhands, so he sacked the two slowest workers and the remainder had to work even harder and even faster weighing the pigs.

After a few more days the pigs still seemed to be losing weight, so Farmer Brown decided the forms must be wrong, He found an internet forum which discussed how they could make the form filling more efficient by moving on to computers. Farmer Brown spent thousands of pounds on computers. Each farmhand had a new handheld computer, but the farmhands had to keep on starting again because the pigs trod on the computers making them go haywire.

Then Farmer Brown hired two more people to check on the farmhands and make sure all the weighing were being recorded accurately, to remind them of the importance of pig weighing, to put up new posters, to tell them to work harder if they hadn’t weighed enough pigs that day, and to check that the weights were correct.
They were all very busy.

Finally a young lad pointed out that no-one was feeding the pigs.
He was sacked for telling tales

Moral: You don’t fatten a pig by weighing it.

Competing interests: None declared

I agree with Heather Wood's analysis but feel her diagnosis of organisational pathology could go deeper. Clearly too many managers in the NHS in England are paying insufficient attention to the interests of patients but we need to understand why.

The culture described by Francis is essentially bullying. This stems from politicians and the culture of the NHS. Survival as a Trust Chief Executive depends on satisfying uncompromising central directives. Those who offer a challenge, in defence of the interests of patients, put their jobs and careers at risk. Some avoid the problem by voting with their feet.

In contrast, those who comply are rewarded. This includes honours and promotion to regional and national posts without open competition or objective assessment.

The technique for silencing managerial dissent is to commission a review by former SHA Chief Executives or management consultants who obligingly fail to find sufficient evidence to uphold the complaint. The regulators are complicit in this process.

Although Dr Wood's own investigation of Mid Staffordshire appears to have been effective, both Monitor and CQC have shown marked disinclination to investigate complex organisational pathology involving alleged management malpractice. The unions tend to focus on securing redress for individual members. The Institute of Healthcare Management is moribund.

Francis decries structural solutions but structure is the architecture for human behaviour. Mindless targets are not the only problem. The English NHS 'market' (now abandoned by Scotland and Wales) provides perverse incentives, encourages competitive secrecy and the associated suppression of unwelcome criticism.

In my view, the NHS in England requires a fundamental rethink, starting with a 'bottom-up' analysis of the organisational arrangements required to support local health gain and integrated patient care. Meanwhile, a cull of those who are skilled in the dark arts of devolving blame to the front line, would send a powerful signal that politicians are serious about putting patients first.

Competing interests: Retired Chief Executive of North Wales Health Authority and of NHS trusts and health authorities in England. Married to a former NHS Medical Director