Intended for healthcare professionals


Turning up the heat on the NHS

BMJ 2021; 375 doi: (Published 29 October 2021) Cite this as: BMJ 2021;375:n2618
  1. Nigel Edwards, chief executive
  1. Nuffield Trust, London, UK
  1. nigel.edwards{at}

It hasn’t worked in the past and won’t work now

Recent weeks have seen England’s secretary of state for health become more activist than we have seen for some years. Sajid Javid’s announcements have included the sacking of managers in failing organisations, a review to “shake up” leadership led by a retired general, and instructions to general practitioners about face-to-face appointments with a pledge to “fix” those identified as not delivering.1

These policies seem to be based on a view that the problem is a lack of motivation or competence, and that the solution is a regime of “targets and terror” with naming, shaming, and, in the case of managers, replacement.

Evidence from recent NHS history suggests this diagnosis is wrong and that the treatments will have little benefit and serious side effects.

The secretary of state’s attribution of differences in performance to leadership is based on his observation that some areas with similar funding and demography perform better than others.23 But this ignores many other factors that affect performance. The main predictor of current organisational performance is recent history. High performing hospitals seem to have better managers,4 but this may be an effect rather than a cause because well performing hospitals are more attractive to high calibre staff.

Inadequate buildings, corrosive relationships, rural and coastal locations that are difficult to recruit to, and other external factors all make poor performance more likely, for reasons independent of the quality of leadership. Evidence that changing leadership leads to much better performance is weak.5

The value of further reviews of leadership is unclear. Two have been completed in the past six years, by Stuart Rose6 and Ron Kerr.7 Neither review found major deficits or problems with the quality of senior NHS leadership, and both called for more consistent support for managers. They note problems with frequent reorganisations, “a culture of blame,” and excessive regulatory burdens.

The current focus on the top leadership also fails to acknowledge the importance of supervision and management further down the chain of command. Frontline leaders are vital to both day-to-day operations and improvement of services,8 yet they are often overlooked or castigated as bureaucrats. The current discourse about executive leadership misses the critical importance of those below this layer, and also those above it who set the NHS’s aims and parameters—government ministers themselves.

Javid is far from the first secretary of state to hope that managers brought in from other sectors will make a transformation. This aspiration featured in Roy Griffiths’s report in the 1980s910 and later in Alan Milburn’s idea of “franchising” in the early 2000s,11 which focused on inviting private sector managers to run failing NHS organisations.

While the NHS can learn some lessons from other sectors, the scale, complexity, and political nature of the health service limits the applicability of ideas and interventions from elsewhere. Politicians have been unwilling to sanction the higher salaries needed to hire executives from business, for example, through fear of media and political criticism of “fat cat” pay. While some managers from other sectors do make the transition, many of those imported into the NHS during the Griffiths reforms did poorly.10 The franchising idea also failed to work effectively, and the few examples that were implemented ended prematurely.1213

A focus on naming, shaming, and heavy handed performance management is also nothing new, and often creates dysfunctional behaviours such as gaming, short termism, bullying, erosion of trust, and reduced staff morale.1415 The failures at Mid-Staffordshire hospitals showed these behaviours at their worst.

Recent announcements on general practice in England provide an even clearer example of attempting to improve services by subjecting key groups of staff to public criticism.16 Evidence suggests that this approach is unlikely to achieve the best results. Staff engagement is key to improving organisational performance,17 and undermining those the NHS depends on is unwise even if it seems politically attractive in the short term.

Public messages briefed to the press referring to “hit squads” and “league tables”18 have a negative effect on staff that cannot be offset by the more nuanced communications that tend to follow later through internal NHS communication channels.

More thoughtful analysis of NHS problems is required, along with better engagement with those already working on them and more consideration of what has and hasn’t worked in the past. Ministers must also accept the reality that the NHS is on the brink of a crisis and needs to build on the sense of common purpose and commitment that carried it through the pandemic. The continued functioning of the service now depends on this. Much more effort should be directed towards developing positive and productive relationships throughout the NHS, rather than singling out particular groups of healthcare professionals and bullying them into hoped for improvement.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.