The “who’s in charge” question isn’t straightforward in many organisations, including the NHS, points out Andy Cowper as he tries to answer the question

DELIVERY MAN: Who’s in charge here?

MANUEL: No - charge later, after sleep!

DELIVERY MAN: Where’s the boss?

MANUEL: I boss!

DELIVERY MAN: No, where’s the real boss… the Generalissimo?

MANUEL: In Madrid!

(Fawlty Towers, episode 2: The Builders)

In his 1983 report for the government of Margaret Thatcher, Sainsburys boss Roy Griffiths wrote “we believe that a small, strong general management body is necessary at the centre (and that is almost all that is necessary at the centre for the management of the NHS) to ensure that responsibility is pushed as far down the line as possible, ie to the point where action can be taken effectively.

“At present, devolution of responsibility is far too slow because the necessary direction and dynamic to achieve this is currently lacking. Staff within the Health Services have to be assured that when changes are being made, demands made on them will as far as possible be part of an orderly management process.

“Government and Parliament must be sure that, whatever level of resources is allocated to the NHS, the means to effect the necessary changes are available”.

Griffiths’ report was the catalyst for the creation of NHS management as it has been ever since. He is a significant figure, who noted in that report “At no level is the general management role clearly being performed by an identifiable individual. In short, if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge”.

Who’s in charge here?

When you’re trying to understand the plumbing of power in any organisation, you have to find out three crucial things. How does the money flow? Who can block changes? And who’s in charge here?

In reality, the “who’s in charge” question isn’t straightforward in many organisations, public, private or third sector. Obviously, most organisations are hierarchies (where they really should be at least as much networks), and obviously there are job titles that sit at the top of those hierarchies.

But every organisation works within a culture (and of course, creates its own culture). And cultures can put a lot of power into the hands of the people who are in management theory not supposed to be in charge here.

Just now, the UK’s culture feels like it is souring and suspicious. The EU referendum mirrored the devolution referendum in Scotland by unleashing corrosive and embarrassing levels of political lying and dishonourable conduct. The global financial crisis left us with a significant overhang of government debt, the practical consequence of which had until recently been a general political acceptance of austerity. 

Unsurprisingly, after nearly a decade of public sector austerity, things are fraying.

I get the impression that the question “who’s in charge here?” is gaining in currency in the NHS. And like all of us, that question comes with its own baggage, most notably the implied follow-up question “And once we’ve found them, what’s the plan?”

The Manichaean Candidates

Are politicians in charge?


“Strong and stable” prime minister Theresa May is scarcely in charge of her own Cabinet. The unedifying spectacle of this subprime premier trying to impose a Brexit consensus on her warring ministers is a three dimensional, real time metaphor for our fractious and fractured politics.

Having valiantly resisted Mrs May’s efforts to move him and having taken back control of social care, health secretary Jeremy Hunt could be forgiven for rewriting his already expanded job title to “secretary of state for health and social care and being Teflon”.

I’ve already suggested that Mr Hunt is largely making the best of dear old Lord Lansley’s reforms to the role by becoming the national director for advocating patient safety and making Monday morning phone calls to troubled trust chief executives. 

That’s not the same thing as being in charge, for all Mr Hunt’s remarkable political durability.

The general feeling in the NHS seems to me to be that the service is expecting political leadership and vision in much the same way it would huddle round a match for warmth.

Eclipse of The Sun King?

So is the Sun King of Skipton House, NHS Commissioning Board chief executive Simon Stevens in charge here?

Well, he’s more in charge than anybody else – being in control of a lot of the discretionary budget. Clearly, a front line mired in messy reality has started to fire some flak at the Five Year Forward View for its aspirational nature feeling pretty remote.

The point here is that most of what’s actually described in the Five Year Forward View is solid, sensible stuff that we actually want the health service to deliver. The confounding variable is that there is a big bit missing, which is the theory of change – the “how the bloody hell do we get there from here?”

The reality is that in an era of political pygmies, Stevens is forced to spend ludicrous amounts of his finite time and effort in financial arm wrestles with the Treasury munchkins and the politicians. He also has to drip feed the truth to select committees, the media and the public. Both of these are fairly demanding activities.

That truth is that Stevens did not get what he asked for in resources, and the implicit “baggage” truth is that without some double running costs for funding (as well as a clear theory of change), moving the NHS on from its current configuration to something better fit for meeting changing, growing health needs is going to be a slow process.

An awkward answer

And so the current chaos in the service will continue until we have the following:

  • A proper understanding of why there are significant chunks of dysfunctional culture in the NHS, and a plan to fix it

  • A comprehensible and deliverable theory of change

  • A durable solution to the workforce crisis, which will create some much needed oversupply and medical unemployment

  • An appropriate and durable increase in NHS resources to enable the above

If we were about to get all of those, then somebody would be “in charge here”, and the service would have cause to feel hope that the current pressure could foreseeably abate.

We’re not about to get all of those. This means that I have some uncomfortable news for HSJ’s readers: the answer to the question “who’s in charge here” is simple.

You are.

Good luck.