Intended for healthcare professionals

Rapid response to:

Editorials Christmas 2012: Editorial

When managers rule

BMJ 2012; 345 doi: (Published 19 December 2012) Cite this as: BMJ 2012;345:e8239

Rapid Response:

Re: When managers rule

Prof Jarman is incisive in his analysis of NHS management culture. Perhaps the most disturbing comment is the reliance on "'shame and blame'" and fear of job loss as quality improvement driver.

These comments would have been recognized by the quality improvement guru Dr W Edwards Deming as "deadly diseases" that are bad for the organization - and bad for the people it tries to serve[1]. Lack of constancy of purpose, an emphasis on short term profits and running on the basis of visible figures alone (only on what you measure) will contribute to significant problems. Similarly, blind reliance on technology can be counter-productive, as can "placing blame on workforces who are only responsible for 15% of mistakes where the system desired by management is responsible for 85% of the unintended consequences".

I wonder if part of the problem is a need for an alternative paradigm for (particularly non-clinical) management, both an aim and a methodology. The ISO 9000 series of standards for quality management define quality as "the degree to which a set of inherent charcteristics fulfils a set of characteristics"[2]. Perhaps less dry and more inspiring is Cindy Jimmerson's definition of the point of a healthcare system:
* To deliver what the patient wants & needs, defect free
* by one, customized to each individual patient
* ...on demand, exactly as requested
* With an immediate response to problems or changes
* With no waste
* In an environment safe for patients, staff & clinicians: physically, emotionally & professionally

This definition makes the patient the principal focus. In terms of a methodology, the EFQM model of excellence[3] may be a useful place to begin, as it includes markers for 'excellent organizations to follow; for example that they have leaders who "inspire people and create a culture of involvement, ownership, empowerment, improvement and accountability through their actions, behaviours".

If we move from the culture of fear, shame and blame that Jarman describes toward a more excellent way, then I think the NHS will be better for both its patients (primary focus) and its staff. It is also far more likely to have embedded continual improvement in all departments with a consequent decrease in waste and increased effectiveness. That is worth striving for.

[1] Deming, WE (1986) "Out of the Crisis". Cambridge MA: MIT Center for Advanced Engineering Study.
[2] BS EN ISO 9000:2005. Quality management systems. Fundamentals and vocabulary.
[3] EFQM Excellence Model, (accessed 31/12/12)

Competing interests: No competing interests

02 January 2013
Philip Pearson
Consultant Respiratory Physician
Plymouth Hospitals
Derriford Hospital, Plymouth