It's easy to make jokes about managerial incompetence - and note how most management jokes are derogatory.1 'Mushroom management' became an NHS cliche in the 1980s, with managers claiming they were kept in the dark. Now there are seagulls and kippers. The former fly in, dump all over the workers and fly out; the latter, naturally, are two-faced and gutless.
In his dictionary of modern organisational issues, London University psychology professor Adrian Furnham lists some handy management techniques for avoiding decisions and rejecting change, from the temper-tantrum method - where the manager regresses, stamps their foot, appears outraged, if possible weeps with indignation - to analysis-paralysis, which involves never-ending requests for more details. 'Dim, challenged or under-par executives' may even employ emotional blackmail on their employees. It's all intended to distract from the real issue: the boss has no idea what to do.
Like all the best jokes, such observations contain more than a grain of truth, in this case offering insights into behaviour. Under 'public relations', Furnham stresses that organisations can only control what they manage. So when the inevitable PR disaster occurs, he says, 'what the public wants to know is what happened and why; whose fault it was; what the managers did immediately it did happen, and what they are doing now'.
New studies of the internal market claim that while the Thatcher reforms might have improved efficiency, apparently nothing can be deduced about their effect on quality. Some might well ask whether it is really possible to separate the two. Surely poor quality must always be inefficient, in terms of the health and financial costs to everyone concerned?
But as policy analyst John 0vretveit points out, quality is political.2 He argues that the 'ownership quality' are directly related to the power and autonomy of professions, and summarises the history of quality in the NHS as profession-driven in the 1980s, followed by a provider-managerial phase in the early 1990s, leading in the late 1990s to the present purchaser- consumer phase.
0vretveit goes on to point out that, 'like much else', quality has never been planned or co-ordinated in the NHS, claiming that it suffers from a proliferation of unco-ordinated activities with little evidence of effectiveness. Emerging evidence that equal opportunities and race awareness are slipping off trust agendas confirms this.
Simmering away on the back burner, the new complaints system seems to have become another casualty of the preoccupation with structures rather than outcomes. While trust managers battle with waiting lists, and health authorities struggle to set up primary care groups, experts feel that complaints-handling is muddling along in a state of virtual anarchy.
My experience of participating in the process at various levels has convinced me that almost everyone involved has a different idea about what they are doing and why they are doing it. First and foremost, little or no investment was made in training, particularly for senior managers and chairs. Some panel chairs view the job as a nice little retirement earner, have no experience of chairing meetings and can barely produce an adequate report.
Another neglected issue is the role of non-executives. Many are relics of the previous regime. Issues of equity, rights and accountability do not loom large on their horizons. Some even perceive their role as keeping complaint numbers down, avoiding panels or 'protecting' their trusts from litigation. Complainants do not see them as independent.
Even the concept of using complaints as an opportunity for monitoring and improving quality has - with some honourable exceptions - failed to take root with managers. But without top-level commitment and agreed in- house procedures, junior staff can be left floundering and complaints will quickly escalate up the organisation.
All these issues, plus examples of good practice, are covered in recent guidance from the Cabinet Office's successor to the Citizen's Charter.3 The British Standards Institution has also produced an excellent document on managing complaints.4 Currently out for consultation, BSI's examples of system monitoring, audit and review are relevant to the NHS.
At the time of writing, the first contract for monitoring the NHS procedure is about to be awarded. But one organisation is already evaluating its operation, outcomes and effectiveness from the complainant's perspective. Supported by an advisory group of experts, the Public Law Project, a registered charity funded by the National Lottery, aims to increase the accountability of public decision-makers. Based at London University's Birkbeck College, it will report in autumn 1999 and intends to identify processes which are working well.
Despite all the rhetoric about involving the public, there is strangely little recognition that complaints handling is the crossroads where public involvement, clinical audit and managerial performance come together. But without such acknowledgement, thousands of pounds of public money in terms of management and professional time are being wasted, while the public continue to be seriously short-changed.
1 Furnham A. The Psychology of Managerial Incompetence: a sceptic's dictionary of modern organisational issues. London. Whurr Publishers. 1998.
2 0vretveit J. Proving and improving the quality of national health services, in The New Face of the NHS, Ed P Spurgeon; 2nd edition. London: Royal Society of Medicine Press 1998.
3. Cabinet Office, service first 1998. How to Deal with Complaints. Publications line: 0345-223242.
4. BSI. Guide to Positive Complaints Management DC/98/402 550; draft for consultation. Available from BSI Customer Services, tel: 0181-996 9001.