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Stop wasting taxpayers’ money on management consultancy for the NHS

BMJ 2014; 349 doi: (Published 10 December 2014) Cite this as: BMJ 2014;349:g7243

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It must be comforting to live in a Manichaean world where management consultants are devils and doctors are angels. It makes solving the many problems of the NHS so easy.

Unfortunately it isn't the real world. So the nice easy solutions that emerge from this world-view will provide great comfort to the naive but do nothing for the patient.

I don't want to be a naive apologist for the consulting profession. Some work done by my fellow consultants is rotten and naive, but no self-respecting consulting firm would shy away from a proper evaluation of whether its work was any good. Moreover, no firm would get any repeat business if the people paying for the work were not at least a little satisfied with it. The industry can't force the NHS to buy its wares.

I'd certainly vote for more accountability and transparency for the outcomes of the work done by management consultants. Perhaps adopting the same levels of transparency as that for medical consultants where the outcome of their interventions are widely published for all to see. Oh, wait. Sorry, I'm guilty of living in a dream world. Many medics (though thankfully not all--I won't make the mistake of assuming the whole profession thinks alike) have bitterly opposed transparency around measures of outcomes. Their lobbying bodies have argued that simple measures of, for example, surgical mortality would be too complicated to be interpreted fairly by outsiders. Oliver's argument might be a little more balanced if he admitted that measuring the results might be as hard as it apparently is in medicine rather than being a conspiracy to avoid accountability.

Or perhaps there is a conspiracy to force the use of consultants. Everyone, it seems, hates the regulator Monitor. They spend on consultants and encourage others to do so. Perhaps it is because many of their executives are ex-consultants and want to feather their nests by bringing more business into the industry. Oliver, I think, wants to hint that this is a sign of deep corruption. But the top ex-consultants at Monitor are mostly people who have left well-paid consulting jobs to take much less well paid public sector jobs. Unless we now have some new theory that having once worked in consulting fundamentally corrupts the soul, it is hard to sustain the allegations Oliver makes. Maybe some consultants are public spirited enough to leave the profession and take lower salaries while trying to do some good of the NHS?

He also criticises Monitor for spending much more than it used to while conveniently failing to mention that the health bill just about tripled the range of its responsibilities and activities in the NHS. Imagine if a consultancy report criticised a hospital's dramatically increased A&E spend but failed to mention that it had opened a whole new department. That's the level of Oliver's argument here.

The really big argument, though, is that in an organisation as big as the NHS surely we can find enough talent to do all the stuff we currently pay consultants for. This isn't an unreasonable argument and even some management consultants think the NHS should do more for itself. What Oliver leaves out is the context. The NHS is one of the most under-managed organisations of its size and complexity on the whole planet. It was seriously under-managed before the health bill (see, for example: ) and the health bill imposed significant further cuts in a mission to "reduce bureaucracy". The NHS sometimes seems to hate managers as much as it hates management consultants. And, as a result, it just doesn't have the managers to do even basic things well. So when new strategic challenges emerge they are forced to hire outsiders.

David Oliver could have argued that the NHS needs more and better qualified managers to deal with its major problems and that aiming for this would enable a significant reduction in spending on outsiders. Instead he makes the childish argument that we should should just stop spending on things we don't like and this will result in magical improvements in the service.

This is thinking fit only for childhood fairy tales and not for serious debate about how the NHS is run.

Competing interests: I work for a major management consulting firm that often works for the NHS. The views in this article are my own.

18 January 2015
stephen black
management consultant
major consulting firm
biggleswade, sg18 0qa