Surely the highlight of the NHS Confederation conference for managers was to hear a secretary of state for health say in an important speech that there was a need for 'high-trust' relationships within the NHS and a commitment to the 'learning organisation'?

No matter that the words had probably been written for him by a trusted adviser or that they have the ring of fashionable management-speak about them.

It is the first time I can recollect that a minister has ventured into such territory and offered such insights. And it is to be hugely welcomed, for as the government moves into its implementation phase with a focus on delivery it is essential that proper attention is given to the management task and how it can be strengthened.

The starting point both for encouraging high-trust relationships and organisational learning must be a shared understanding of what constitutes an appropriate management style in an environment of extreme turbulence and uncertainty.

As some commentators have pointed out, the government's modernisation agenda for the NHS and other public services is curiously old-fashioned in a post-modern (and post-Fordist) era.1

This would certainly explain the outmoded (and Fordist) focus on hierarchy and top-down central control which risks stifling the creativity and innovation the government so desperately wants to unleash. Only if the government moves from a fixation on the modernisation agenda and considers an alternative post-modern approach is it likely to achieve its stated objective and release untapped talent.

Post-modernism draws on best practice in professional-style organisations. A premium is placed on nurturing sustainable relationships and on self- organisation, and there is a minimum of rules, regulations and management layers.

Paradoxically, the more complex the environment the simpler the organisational and managerial forms needed to navigate a course through it.

But though the actual structures may be minimalist in design, the behaviour within them is highly complex and sophisticated. Relationships based on trust are everything. It then becomes unnecessary to micro-manage all the details.

It is ironic that at a time when we ought to be learning from the best of professional organisational forms, the government is seeking to corral professionals using inappropriate managerial methods. It doesn't matter how we describe adaptive organisations. Chaos theory, complexity science, open systems, network management and post-Fordist thinking are just some of the terms to describe the search for concepts which might help make better sense of how people and systems naturally behave.

But instead of going with the grain, we expend much wasted energy trying to fit people into unnatural systems which assume organisational life is inherently coherent, rational and linear.

Our efforts are spent trying to eliminate dysfunctional elements instead of trying to work with, and adapt to, them.

Little wonder, then, that those struggling to make sense of such an environment feel confused and beleaguered. They are being asked to behave in a post- modern, post-Fordist manner (ie using their innate talents and innovative flair) while being given tools - and having their performance judged according to systems - that remain wedded to a bygone, Fordist age.

This mismatch between rhetoric and reality constitutes a serious fault- line running through the modernisation agenda. The rhetoric is against bureaucracy, while the reality is that an entire new bureaucracy is being erected around objectives and performance indicators.

The term 'contract' may no longer be in high fashion, but it survives in myriad other forms and shares an obsession with rules to be enforced. Until these conflicts and contradictions are resolved the management task in the NHS will remain all but impossible. Indeed, and

catastrophically, the victim of such failure could be the NHS itself.

The over-emphasis on objectives is possibly the most urgent aspect of the government's reform agenda in need of reassessment. The government seems to equate good management practice in the private sector with the achievement of objectives through clear, precise targets. But this is to ignore the unique features of public sector management.

As John Stewart argues, the unrelenting concentration on objectives can distort because the problem of balancing objectives, values and interests is neglected. This balancing act lies at the heart of management in the public sector. Setting objectives is easy, balancing them less so.

The classic work The Art of Judgement, regrettably undervalued, is critical of the goal-setting approach.2

It describes policy-making as the setting of governing relations or norms rather than, as is more commonly to be found, the setting of goals, objectives or ends.

If the new commitment to strengthening management and leadership is not to become dreadfully unstuck as yet further confusion engulfs it, it is essential that a sound theory of public sector management should precede any efforts to equip managers with the appropriate skills. There is, after all, nothing so practical as a sound theory.

Merely aping the private sector (or what politicians assume management in the private sector to be) in the shape of new public management, with its focus on contracts/agreements and on objectives and targets, is not the way forward.


1 Stewart J. Advance or Retreat: From the traditions of public administration to the new public management and beyond. Public Policy and Administration 1998; 13: 12-27.

2 Vickers G. The Art of Judgement. London: Methuen, 1968.