The politics for managers in all four UK health services are tough, and the fiscal squeeze and a forthcoming general election make them tougher.
To give themselves a fighting chance, managers must do the unexpected and be visible and assertive in the political debate. For this to work, each manager must use his or her voice over three closely related issues - the role and value of managers in delivering effective, safe and dignified healthcare, the cost and numbers of managers, and the impulse of all parties to promise cuts to bureaucracy.
The Great Patriotic Twitter against foreign attacks on the NHS is petering out. Given the renewed pledges to the NHS from everyone, the parties will compete on spending and managerial competence. Each wants to say they will maintain or even increase spending and manage the service better. Managers will be asked to work the budget harder and get more from less - and they themselves will be seen as a spending item.
Let’s be open about management costs, benchmark them, and keep them reviewed. Set pay for very senior managers objectively
Managers have not done brilliantly on the political scene, for good reasons. One sympathetic MP once explained: “We can say and do what we like about you; and you can’t say or do a damn thing about it”. He realised the NHS is a quasi civil service, in which democratically elected politicians are entitled to call the shots and it’s career suicide to publicly take on your actual or potential big bosses.
Furthermore, managers are passionate about their jobs and they worry about putting their own interests first. This anxiety pays a handsome compliment to the public service ethos of managers, but is often unnecessary.
So managers need to do the unexpected. Politically neutral does not mean non-political. There are bodies, such as the NHS Confederation, NHS Employers and trade unions like my own that can fire the bullets, but we need the ammunition. Now is a good time to start or resume feeding into your membership organisations.
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Serious politicians know management matters. They will listen to serious argument, but to do anything they have to hear one from managers. This is where you can get active.
The public does not accept the role of managers so it will feature in any election debate about the NHS. We need to explain what we do in plain words. We have the skills and experience to get more from less, keep standards rising, and care for all our staff and the communities we serve. We put the interests of patients and service users first. Think of anything we want to achieve and managers are key in making it happen. Most recently, we have the Boorman report, so much more than the national media’s sicknote culture write-up. Our role needs explaining in concrete terms, with lots of examples from you.
Those who argue management is the root of problems should not be given their customary easy ride. They should be asked how they will steward the huge resource and staff of the NHS without managers.
Next, the rising number of managers and the costs of employing them. Someone will deploy this tired old barometer of how bad things are in the NHS. Of course these figures say little in a system that has tripled in financial size with hundreds of thousands more staff. We should be ready for open debate about numbers - around 3 per cent of staff - and costs. Managers are not running a job creation scheme for themselves; they want to run lean operations. They tend to be the most self-sacrificing of health workers. Who else would put up with the number of reorganisations we undertake?
Let’s be open about management costs, benchmark them, and keep them reviewed. Set pay for very senior managers objectively. But we don’t want a return to national targets on either numbers or costs of managers. They destroy more than they save, whether we’re talking about money, skills or the loyalty and dignity of managers.
So those who bang on about numbers should be pushed into wider debate about whether the NHS is overmanaged or undermanaged, and what the right proportion might be in different organisations.
Finally, bureaucracy. Managers complain incessantly about the bureaucratic burdens placed on us by other parts of the system. We must not be tongue tied about what changes we would like to see made. Now is a good time to make suggestions to politicians.
The political impulse is always to take out bureaucracy. Politicians should work in partnership with managers to achieve this. Critically, measure twice, cut once, as my woodwork teacher used to say - advice we routinely ignored: “Ooh, Sir, it’s not long enough now”. Likewise governments rush to act, normally just as the last changes are bearing early fruit. After a couple of years, most governments reform their own (long term) health reforms, often losing skills but not costs. “More for less” on the frontline. How about “less is more” in the DH?
All the parties must be asked: How will you buck the trend of all governments and stop yourself tying the service up in red, blue or yellow tape?
Will an assertive approach work? Who can say? But what can be said is that doing nothing and trusting to luck will have predictable results for managers. At the very least being assertive makes you feel good about yourself. And it’s fun.