Intended for healthcare professionals


Bury the bill

BMJ 2011; 342 doi: (Published 26 June 2011) Cite this as: BMJ 2011;342:d4050

It isn't the number of bureaucrats, it's the complexity of the system...

Believers and opponents of NHS reform might find common purpose in
opposing the revised health bill because it is now a baroque mess from any
point of view.

But one of your reasons for opposing the bill is complete nonsense
and propagates one of the worst myths about the current NHS. While the
newly revised structures proposed in the bill and their baroque
compromises with anti-reformers will leave us with a bureaucratic tangle
somewhat akin the the pre World-War-1 Austro Hungarian Empire, there are
nothing like enough managers to staff such a system. The proportion of
managers (or bureaucrats) is likely to be one of the smallest in any large
or complex organisation on the planet (it was already very low before the
government announced its populist target of cutting management costs by

The balance of evidence (see the Kings Fund report on Leadership and
Management) is that the NHS was under-managed before the cuts. The
likelihood is that the future NHS will struggle to manage the baroque
complexity of the new structures never mind actually delivering any
improvement in productivity or quality.

Competing interests: No competing interests

07 July 2011
stephen black
management consultant
pa consulting, london sw1w 9sr