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Editor's blog Wednesday 18 May 2011: Kings Fund report lays a wreath on the Tomb Of The Unknown Manager

Much of what we need to know about the Kings Fund's new report into leadership and management is there on the front cover, in three simple words of its sub-heading - 'no more heroes'. I'm assuming there is a Stranglers fan in the publications team somewhere.


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One of the least tasteful things about the current policymakers in the Coalition (a category for which there have been not a few candidates) is their ongoing smearing of NHS managers as "bureaucrats".

It is going to come as a rude shock to - well, not to Secretary Of State For The Time Being Andrew Lansley, because he won't last that long - but certainly to his colleagues and Tory backbenchers that the NHS is going to need just as many if not more "bureaucrats" to make its new system work at all.

Because when it comes to demand management, marginal analysis and activity and outcome measurement, you're talking about a range of things that just don't do themselves.

No. If the NHS is to make efficiency and quality gains to the value of £4-7 billion a year for the next four financial years in a row, then it is going to need excellent managers.

And the NHS has had some excellent managers (not all of them, but not a few): I know a few of them.

And many of them have gone gratefully already, or are just biding their moment to get out of the madhouse of job insecurity, in a revolution that turned into evolution and then was going so swimmingly that it was just stopped.

They have pensions, and equity in their houses, and transferrable management skills. Many of those who are still in post have stayed out of residual loyalty to colleagues and civic spirit. They could make the new system work a bit, but alas! There it is, on hold and uncertain.

Oh, and here's a free bit of management consultancy for Lansley And Company: if you want to really convince people that they should stay the hell out of the brave new world, just call them "bureaucrats" non-stop and demonise them as wasteful.

That will do it. They will reach a point where they wouldn't piss on you if you were on fire (and they got there about four months ago).

Or as Lord Tugenhadt put it neatly in a speech last year, "The government should avoid the mistake of conflating reductions in public sector expenditure with the denigration of those who have to carry them through.".

Should indeed. But didn't, repeatedly.

Anyway, the Kings Fund report is very sensible, and rather like their inquiry into the quality of general practice, confirms much of what is known already.

That's fine: work needs to be repeated to check it's still right.

It's also very well-written, by the wonderful Nick Timmins.

As Kings Fund CE Professor Chris Ham's foreword says, "The bottom line is that an organisation as large and complex as the NHS cannot be run without high-quality management and leadership. This will happen only through a commitment of time and resources and a willingness to value the role of managers whatever their background.".

The report is worth reading: its main recommendations (and a list of killer management facts) are copied below.

■ It is important, now more than ever, to promote the value of good NHS managers and leaders. Denigration of managers and the role they play in delivering high-quality health care will be damaging to the NHS and to patient care in the short and long term.

■ The coalition government’s current plan to cut administration costs by
33 per cent and the number of management posts by 45 per cent must be revisited. There is no persuasive evidence that the NHS is over-managed, and a good deal of evidence that it may be under-managed. While administration and management costs will have to take at least their fair share of the pain as real-terms growth in NHS spending ceases, a more sophisticated approach to the reduction in both is needed.

■ There is appreciable evidence that the NHS is over-administered as a result of extensive, overlapping and duplicating demands from both regulators and performance managers. There has not been a substantive review of the information demands placed on the service and its providers for many years. A review leading to a rationalisation of those demands is essential.

■ Over recent years there has been considerable investment in both management and leadership development. These gains must not be lost in the transition to a redesigned health system.

■ Every NHS organisation and provider must take responsibility for their leadership and management development. This includes the new GP consortia or commissioning bodies. Organisations should collaborate to undertake leadership development where this makes sense.

■ The health service does need a national focus on leadership and management development, potentially delivered through a national NHS leadership centre. This should build on existing good practice in both the public and private sectors. Such a centre could play an important part in facilitating this. It should have the resources to support investment in leadership development of national importance; help to accredit and signpost development programmes; and support the evaluation of these programmes, including
the return on investment from leadership and management development.

■ Leadership development needs to extend ‘from the board to the ward’. One of the biggest weaknesses of the NHS has been its failure to engage clinicians – particularly, but not only doctors – in a sustained way in management and leadership. Individuals within the service, and its providers, need to be given both the ability and the confidence to challenge poor practice. Management and leadership needs to be shared between managers and clinicians and equally valued by both.

■ The service also needs to recognise that the type of leadership the NHS requires is changing. The old model of ‘heroic’ leadership by individuals needs to adapt to become one that understands other models such as shared leadership both within organisations and across the many organisations with which the NHS has to engage in order to deliver its goals. This requires a focus on developing the organisation and its teams, not just individuals, on leadership across systems of care rather than just institutions, and on followership as well as leadership.

■ Board development and recruitment need particular attention, most notably, but far from exclusively, in the case of foundation trusts where governors are to take on a new role as the autonomy of foundation trusts is significantly enhanced.

■ The same applies to the governance arrangements for the new commissioning bodies. The Commons Health Select Committee has recently made powerful points about the need for proper governance of commissioning bodies which this commission endorses.

■ In the light of a run of serious failures of both leadership and management in the NHS, the commission acknowledges the need for a more effective mechanism to debar individuals who have clearly been culpable from holding executive positions in health care. It has reservations about professional accreditation of managers or the creation of a full-blown disciplinary body for them. Boards must ensure that they have competent, effective senior managers and leaders and hold them to account. A national NHS leadership centre should consider whether the effectiveness of senior management and leadership should be considered by the Care Quality Commission as an important determinant of organisational performance and be taken into account in processes for registering and licensing health care providers.

■ Recent debates about management and its costs have already resulted in the loss of experienced leaders at a time when the NHS is facing the biggest financial and quality challenges in its history. It is imperative that action is taken urgently to retain the leaders needed to enable the NHS to rise to these challenges and to invest in the people and talent required in the future. The Commission endorses the view of the cross-party Commons Health Select Committee which concluded in a recent report:

The Committee is mindful that this unprecedented requirement to manage a process of change … will require effort and commitment from NHS managers whose work we believe should be valued, alongside the work of the clinical staff of the NHS. The Committee regrets the fact that the work of NHS management is sometimes the subject of unjustified populist criticism.

High-quality leadership and management at all levels is a prerequisite for a National Health Service that delivers both the highest possible quality of care to patients and the best possible deal for the taxpayer.

Killer management facts
The NHS officially has around 45,000 managers although this figure is not definitive. Many clinical managers (medical directors and directors of nursing) are excluded from this definition.

The NHS sees more than 1 million patients every 36 hours, spends more than £105 billion of public money each year (nearly 2 billion per week) and employs around one and a half million people.

Aside from the banks, the only companies with a larger turnover in the FTSE 100 are the global oil giants, BP and Shell.

If the NHS was a country it would be around the thirtieth largest in the world.

Sir David Nicholson, the NHS Chief Executive, is on record as saying: ‘We find it very difficult to recruit people who want to be chief executives – the average time they spend in post is just 700 days’ Santry C (2007). ‘Clinicians should be groomed for top jobs, says Nicholson’. Health Service Journal, 1 January.

A review in 2009 showed that NHS organisations were subject to 35 different regulators, auditors, inspectorates and accreditation agencies requiring information from different parts of the system. This may have reduced since then with changes in regulation (NHS Confederation and the Independent Advisory Service, 2009)

A survey of 2,000 people in July 2010 by the Local Government Association found that the public’s top choice for spending cuts was NHS managers (69% approval). Despite this, the main services respondents wanted to protect from cuts were ‘Doctors, nurses and other hospital staff ‘(56% approval)