Intended for healthcare professionals

Rapid response to:

Analysis And Comment NHS reorganisation

Who's kicking who?

BMJ 2006; 333 doi: (Published 21 September 2006) Cite this as: BMJ 2006;333:645

Rapid Response:

Change Management for Changes Sake Creates Artificial Jobs and Takes Clinicians from the bedside.


Nigel Hawkes is to be congratulated for his timely, highly readable
and informative article and the BMJ for continuing to publish topical and
political pieces, which can be cited in any discussion on service delivery
in contrast to some "drier" competitor journals.

As an NHS clinician, I am naturally delighted at the extra investment
put into the NHS by New Labour and completely understand the desire of the
politicians to see some tangible outcomes for this investment and equity
of care (hence the until recent obsession with measureable targets -
however little the "tick box" mentality reflected what was really
happening to patients and however distorting the attendant perverse
incentives). All the same, Hawkes is quite correct in saying that the
elected government has effectively spent a decade re-inventing the
organisational structure it inherited in 1997.

Not only has this been a hugely wasteful process but it has by its
nature created general management posts whose whole rationale is change
management, process reengineering, or more precisely the demonstration
that these imperatives and milestones have been met. It is hard to
conceive of patient care without frontline clinical staff to deliver it,
essential ancillary staff to support it and a core of general managers to
run the operation. However, there are many other posts which would not
even exist without constant change management to oversee or without the
externally imposed structures (such as parallel commissioning by small
PCTs now amalgamated). Despite repeated assertions that the NHS is
undermanaged our yardstick should be to cull all posts whose whole
function is an entirely artificial construct and plough the money into
clinical and support services.

Many of these staff come from clinical backgrounds and have therefore
abandoned their original professional calling and find themselves in a
conflict of interest with their own profession, as well as removing
themselves from the bedside where their skills might provide more tangible
benefit. They are also performance managed on meeting organisational
objetives and therefore face the choice of being "corporate" or "on
message" or making no further progress. Questioning the sanity of the
latest round of performance objectives would be career suicide. Their
rationale is to implement whatever imperative comes down stream.

In the meantime [1] it is alleged that the government have spent £70
billion on private sector management consultancy (money which if kept
within the public sector could have averted the latest round of financial
crises in acute trusts) and more on the sacred cow of PFI.

Real transformation in public services is brought about by the staff
who actually deliver those services. As Maddock [2] said in an article
which everyone should read on transformational leadership in the public
sector. "Those with an understandind of the change management process have
no power to effect real change. Those with the power have little
understanding of the change management process"

David Oliver

[1] "Making Modernisation Work - narratives, change strategies and
people management in the public sector", 2001, Su Maddock. University of
Manchester Business School.

[2] Craig D.[2005] Plundering the Public Sector. How new labour
stole with £70m of your money and gave it to management consultants.

Competing interests:
None declared

Competing interests: No competing interests

03 October 2006
Dr David Oliver
Senior Lecturer, Geriatric Medicine, . Hon Consultant, Physician
Institute of Health Sciences, University of Reading Rg1 5AQ