20 Oct


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I would be one of the first to say that the NHS is in urgent need of reform. It does some great work in dealing with emergencies and routine surgery but it does shameful things too. Here I am thinking of the wanton neglect of some elderly patients and the lottery as regards good treatment and the use of efficacious drugs.
I know that there are many, many committed individuals within its ranks but what of the loafers, the untrained and the inadequate? Why do they continue to be employed? For example, what happens to the ward cleaner who insists on wiping toilet seats with the same cloth that she uses to clean drinking jugs and bedside tables? Is she retrained? Is she dismissed? Of course not! What of the doctor who everyone knows is incompetent and who daily reduces his patient’s chances of a swift recovery? Is he reprimanded, retrained or dismissed? Of course not!
The NHS is a truly vast bureaucracy and so tracing accountability and responsibility to its source is a laborious and time consuming task – and ultimately an unrewarding one. Bureaucrats are slippery and pedantic and they know the ‘rules’ and are wonderfully adept at applying them in their own favour. They are expert at dodging the decisions that they perceive as difficult, especially such things as poor performing staff at any level. They are terrified of breaking the legislative framework which surrounds every employer and appear unable to use it to protect patients. They are terrified of being called to an employment tribunal to account for abusing an employee’s gender / race/ religion / whatever rights. And when it comes to consultants then they are utterly untouchable. They dwell at the top of the vast NHS hierarchy and like the generals of 18th century armies their word is law and the ‘troops’ have to follow them into battle regardless.
So poor and even appalling, life threatening practices continue and anyone with the temerity to challenge its serried ranks, anyone who blows the whistle, will be marked out as ‘not one of us’. Not a comfortable position to be in.
Work related stress is rife in the NHS. It can be extremely stressful dealing everyday with illness and accidents. Yet when I speak to NHS personnel it is not the nature of their work that stresses them out – it is the way it is managed and the intolerable demands placed upon them by an incompetent, and often unfeeling, management hierarchy. How many good nurses has the NHS lost through this kind of stress?
The NHS was set up in 1948 and evolved in a management world that was dominated by hierarchical models of the old bureaucracies such as church, state and military – and the command and control industrial models that grew out of the Industrial Revolution. Think back to the authoritarian workplaces of the 1950s and 1960s and the schools too and you begin to appreciate the cultural soil that provided the NHS with its long – so very long – roots. It was a world convinced that the only way to run an enterprise (whether a hospital, a factory, a school, an army) was by rules, analysis, measurement, centralised controls, specialisation, hierarchy and the maintenance of order and stability. And how does an organisation do this? It does it by bureaucratic means.
And so after years and years of government tinkering (a giant bureaucracy itself) and enough money to run a small country we still find the NHS is struggling. Of course, there are increasing demands made on its resources by expensive new technologies and a rising population. But wait a minute. Why is it not able to respond and adapt to these things with flexibility and a practised hand? Answer: because bureaucracies are not flexible and they are unable to respond rapidly and appropriately to swift changes in their environment. So unlike modern 21st businesses, that have dismissed the old notions of management as unworkable in the fast moving global world we now live in, the NHS (like many parts of Whitehall) still clings to the old ways.
And now the government is handing the reins of change to the doctors. Yes, radical change is needed but what do doctors know about management and good modern management practice? What do they know about the nature of bureaucracies? How can they perceive other ways of doing things when they were trained and have practised all their life within a bureaucratic framework? What do they know about organizational transformation and the different schools of strategic thought? What do they know about self organising teams and distributed leadership? I think I may confidently answer that question. I would posit that your average GP, your average hospital doctor, your average consultant knows as much about these things as I know about the treatment of African trypanosomiasis. I would also posit that they have as much experience of handling effective and transformative change as I have of carrying out an appendectomy.
Doctors do not do management.

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