Intended for healthcare professionals


The “redisorganisation” of the NHS

BMJ 2001; 323 doi: (Published 01 December 2001) Cite this as: BMJ 2001;323:1262

Managerialism, the culture, is the albatross around the NHS' neck.


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

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

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

Competing interests: No competing interests

01 December 2001
Steven Ford
Haydon Bridge. NE47 6HJ