Everyone I talk to assumes that managers in the health service must be sweating.
The forthcoming assault on “the bloated NHS bureaucracy” is heralded by everyone every day.
The failure to distinguish bureaucracy from management ties the hands of governments and managers alike
The Department of Health productivity team warns the “cash-releasing” juggernaut will be rolling first over non-clinical jobs. Andrew Lansley and David Cameron want to slash the creepy-sounding “central bureaucracy” by a third. HSJ surveys of finance directors confirm that managers and administrative staff are going to get it. Even Polly Toynbee endorses CBI thinking on the savings to be made from finance, HR and payroll - blimey, now you know your card’s marked.
So managers must be on the ropes, mustn’t they? Well, you’d think. But the evidence from surveys and talk paints a very different picture. In fact, the morale of most managers is probably as high as it was a year ago, and it was high then. They are happy in their jobs, most of which are clearly defined. Most believe they are fairly rewarded for the work they do. They feel even more supported and valued by their own managers and by their teams. Slowly but surely, personal development and appraisal is improving for them. They are positive about the future of the NHS, and have made a long term commitment to it. Nearly every manager would recommend a career in the health service to a member of their own family.
There is a downside. A significant minority of managers don’t feel this way. Nearly half don’t get the training they need. Managers still work too many hours. But, overall, the message is upbeat.
On productivity, managers were among the first to accept the Wanless assumptions. So, with or without the banking crisis, the £20bn challenge interests and motivates them.
And paladins of productivity take note. Middle managers are already working with their teams to deliver stuff on the ground, ie, the “granularity” beloved of policy wonks and, presumably, sugar refiners.
As its greatest victims, they also have answers of their own to that nasty bureaucratic bloat. Here are some of their ideas.
- Reduce the number of targets - by far the most popular measure. Few want to do away with targets altogether, but fewer, switched from process to outcome, is what we want.
- Cut the number of initiatives. Operate a “one in, one out” system where a new priority has to knock out an old one.
- Harmonise the regulatory bodies and aim for one set of performance information for all.
- Each organisation must keep reviewing management numbers and structures, although don’t do any more top-down reorganisations.
- Don’t keep politics out of the NHS, but change the way it affects the day-to-day work of the health service.
- Be positive. As one colleague said: “Set in place a programme of empowerment and celebration to shift the culture of the NHS, so people don’t need to create overly bureaucratic processes to avoid blame and recrimination.” In short: “Cheer everyone up and stop moaning.”
- Trust managers to deliver. Give them greater autonomy and the accountability that goes with it. This would cut bureaucracy and let managers get on with the job they are paid for and want to do.
- Emphasise local accountability. Remove any one or more of the elements of central reporting and set local health services free.
This is not some job creation scheme for managers. They accept some of their number might be doing the wrong sort of work in the wrong places. But it might be an idea to talk to managers before turning the ignition key in the juggernaut or slashing your third.
It is always intriguing to see politicians throw the baby out with the bath water. The failure to distinguish bureaucracy from management ties the hands of governments and managers alike. The public scorn, private encouragement approach of many thoughtful politicians has been the meagre ration of managers for years. But the strategy is self-defeating, besides being dishonest. All the unqualified attacks on bureaucracy erode the credibility of managers with the public and with other staff. Perhaps no one has suffered more from this than clinical managers who also need to prove they haven’t gone over to the dark side.
Politicians are undermining the capacity to deliver their own policies. It’s easy to see why they do this. When it comes to managers, for the public, any is too many. On the other hand, the public also knows that when things go wrong managers must carry the can. Therefore there is some scope to attack bureaucracy while leaving the management standing. Scope to develop a more sophisticated view of the front line, which includes non-clinical jobs.
Interestingly, Andrew Lansley has come closest to breaking the mould by talking about “lean and high quality management”. But even he didn’t quite feel able to place this directly alongside the recent Conservative announcements on the “central bureaucracy”.
So here’s my proposal. Every politician serious about delivering reform or productivity should wear one of those 1980s jelly bracelets. They are again being worn by teenagers in a variety of colours, each with a possible meaning that terrifies parents. Perhaps healthcare politicians could wear grey. It would indicate to those in the know that: “I hate bureaucrats, but I love managers”.