Published: 03/11/2005 Volume 115 No. 5980 Page 12

The current turmoil in the NHS, with the government introducing a storm of incompatible policies, is a major challenge for NHS managers.

The primary question raised by this is 'can managers be expected to be able to productively use the fruits of the IT revolution?' Or is the government spending over£6bn on data that managers have neither the skills nor inclination to use?

Managers, be they non-clinical or clinical, are driven by a government agenda that is short-sighted and focused on the headlines in the Daily Mail and other organs of inexactitude and popularism. The government has invested heavily in the NHS, but the pace of change and the apparent inability of managers to 'act smarter' frustrates Number 10.

This frustration has grown over the past year, with government investment not just in the private sector but also in creating excess capacity. They believe that increased capacity will facilitate contestability and choice. Some critics believe more capacity will induce additional activity and expenditure inflation, particularly when used in conjunction with payment by results.

Managers react to policy change stoically, recognising they are paid to do what Whitehall tells them. They laugh when recalling the decentralisation rhetoric of past health secretaries Alan Milburn and John Reid. They recognise the game is about meeting the centralist prescriptions of Number 10 and its agents: Richmond House, the Healthcare Commission and Monitor.

With targets to meet and forms to complete, managers have little time for local strategy to diminish gross variations in practice.

The unsurprising consequence of managers' narrow work focus is that they are virtually unprepared for the quantitative revolution that ministers are planning for them, which will facilitate further the effective management of the universal local problem of variation and inefficiency.

Gnarled veterans of NHS management will remember the 1977 priorities document published by the Department of Health. This advocated the increased use of day-case surgery as being better for the patient and the taxpayer.

Nearly 30 years later, NHS performance on day surgery remains uneven. Many managers continue to ignore the evidence and practice of saner trusts, thereby damaging patients and the exchequer.

Inefficient trust boards condone inferior clinical practice, but are not made accountable for the damage.

To vary is human, but variations in healthcare remain gross even though they have been well documented for over three decades. Routine use of safety engineering techniques to control remain sparse at board level - see www. sixsigma. com for elaboration of this approach.

Less gnarled management survivors will recall Professor John Yates. He emphasised the existence of large, unmanaged and costly variations in practice for three decades from the mid-1970s. But he was ignored. Indeed one intellectually challenged Tory secretary of state cut Professor Yates' contract when he annoyingly suggested that, with better management of local bottlenecks and few additional resources, NHS waits could be cut substantially.

The challenge remains the same.

The NHS does not need more resources as it already wastes vast sums every day. Such inefficient management should not be condoned. But it is. Recall for instance the York work on consultant practice variation. The problem remains much the same now after spending£2-3bn on pay increases!

Blair's response to such inefficiency is to 'redisorganise' the NHS. This is sad, but to be expected of a Whitehall that has still to grip the issue of how better to give local managers the means and motivation to weed out variation that causes waste in exchequer funding and damages patients.

The emerging NHS Institute for Innovation and Improvement is disseminating the variations, but do local managers have the skills and incentives to change?

They have ignored the issue for 30 years by demanding more resources.

But what they really need is the gumption to clean up local performance using the evidence base.

Can they really change? Let's motivate them with the certainty that after 2008, NHS funding growth will be minimal, so they should learn now how to sweat their assets. .

Professor Alan Maynard is director of York University's health policy group.