Knives are out for NHS managers. The case of Lucy Letby – the nurse convicted of murdering seven babies and attempting to kill six other infants – has become yet another opportunity for NHS loathers to expostulate against it. “NHS management is a bullying, incompetent cult,” proclaims a particularly virulent assault in the Daily Telegraph, ending: “If its managers remain untouchable, how long before there’s another Lucy Letby?”
As I wrote after Letby’s conviction, this was a horrifyingly freakish criminal case. The “lessons must be learned” impulse risks becoming a general stampede against NHS administrators. Of course, the inadequate should be removed, but beware cheap rabble-rousers looking for “savings” by cutting feather-bedded public bureaucrats, pitting them against saintly frontline doctors and nurses.
One problem: a third of hospital chief executives are clinicians, so stoking culture wars between medics and managers is tricky. Do doctors and nurses go to the dark side when taking on managerial roles, or is it rather a good idea? Prof David Oliver, a former clinical vice-president of the Royal College of Physicians, notes that in the Letby case, “the chief nursing officer, chief executive and division director at the time of these events were all qualified nurses. The medical director was a registered medical practitioner.”
He says that in recent maternity unit scandals at Morecambe Bay, Nottingham, East Kent and other recent stories where clinical whistleblowers weren’t properly listened to, “there were either general managers with clinical qualifications or clinicians with management roles involved”.
When the clamour goes up for managers to be regulated and registered like clinicians, remember how many are already under General Medical Council or Nursing and Midwifery Council rules, with a duty of candour, transparency and openness. Registering all managers might be a good idea, but it might also be yet another regulation added after every scandal, never re-examined to see if patients became safer. Nor does professional registration protect against bad practice.
Stacks of reports find the NHS undermanaged: the NHS Confederation finds that “at approximately 2%, managers are a very small proportion of the NHS workforce”, compared with the 9.5% of managers in the outside workforce. A little history: when I wrote a book on the NHS in 1976, based in the Royal London, there was scant management. Mighty consultants ruled their fiefdoms, fighting among themselves. A humble secretary, medical director and matron ran day-to-day business in a “consensus management model”, failing to hold the ring.
The 1980s brought chief executives to shift more control to managers, but the old tussle continues. The NHS graduate management training scheme is the most oversubscribed, says Alastair McLellan, editor of the Health Service Journal, its tough tests picking the brightest and best, too often poached later for higher pay outside.
Ministers arriving clueless or business leaders taking non-executive directorships often decry NHS inefficiency. Pull this lever, hire a private consultancy, lift everything above average and bingo, problems solved. Nick Hulme, one of the most respected chief executives, told me he was gratified when one of his non-executive directors from a large company recently apologised for thinking running a trust was as easy as running a company. On the board, he’d seen the fiendish complexity of managing hundreds of wards, units and departments, HR, data, estates, finance and more: a private company has one bottom line, a trust answers to patients, staff, politicians and public.
Hulme runs East Suffolk and North Essex NHS foundation trust, and is interim CEO at Norfolk and Norwich: when we spoke, he’d just apologised to a patient whose operation was cancelled for the third time. Like all CEOs, he’s besieged by complaints from staff who are overworked or say they are experiencing bullying or missing out on promotion. Coping with rivalry within and between units is everyday life. Managing very clever, very dedicated doctors and nurses all demanding more from scarce resources is hard.
Ensuring whistleblowers get heard above that daily noise of staff takes experience. He has a £2bn budget, 22,000 staff and oversees 15,000 patients a day. He says it’s the best of jobs, but sometimes he’s outspoken: recently, he said the government should consider “the next generation, not the general election” and was affronted by a rebuke from some Whitehall junior.
Meanwhile, on another planet, rightwing journalists sharpen their knives. Listing NHS failures, they say they want “reform”, undefined. Heavyweight Andrew Neil, in the Mail, is typical, demanding a European-style insurance system, “with private spending by people to supplement state spending”, without asking if the public want it. His calls for “choice” and “competition” omit the whole Andrew Lansley reform catastrophe under David Cameron’s government. He says he has no “details” of his reform, just its “broad shape”, but like all of them, what he leaves out aren’t “details”: how does it raise more cash, who pays, how much, at what administration cost, for what unequal treatment?
Bemoaning the supposed “black hole” of NHS spending, they gloss over deep cuts per capita to NHS spending. Nor do they explain why the NHS they inherited in 2010, in its best-ever condition, has fallen into such a state.