The outgoing chief executive of regulator Monitor has accused the government of attempting to ‘micromanage’ NHS organisations in a way that damages motivation and creates a ‘dependency mindset’ among leaders.

  • David Bennett accuses government of taking away provider chief executives’ freedoms
  • Outgoing Monitor chief unconvinced by Jeremy Hunt’s argument that “better care costs less”
  • Sceptical that NHS will get support it needs to make £22bn efficiency savings
  • “Huge mythology” has built up around NHS competition rules

David Bennett made the comments in an exclusive exit interview with HSJ, in which he was critical of the approach taken by health secretary Jeremy Hunt.

David Bennett

David Bennett said his role at Monitor ‘wasn’t a real chief executive’s job anymore’

He warned that the government was withdrawing “more and more” freedoms from public sector chief executives in the service of austerity; dismissed Mr Hunt’s argument that “better quality care costs less”; expressed scepticism that the NHS would get the government support needed to deliver £22bn savings; and said the ministers were “failing to support their own legislation” on health service competition.

Mr Bennett stepped down from his post last week, ahead of a planned merger of Monitor and the NHS Trust Development Authority to form NHS Improvement.

Asked why he had not wanted to become chief executive of the new organisation, he said he had been at Monitor for nearly six years and there came a point in any such role where it was beneficial to have a change of leadership.

But he added: “The second reason was that I increasingly felt that in some ways it wasn’t a real chief executive’s job any more.”

This was a problem “occurring across the public sector”, he said, and which arose partly from the “understandable objectives” of the government’s austerity programme.  

He continued: “In order to clamp down on costs – or inefficiencies, which I fully support – more and more freedoms to act are being taken away from chief executives in the public sector: things like the ability to hire people and to choose the people you think best able to do a job [and] within reason to pay them what it takes to get them, right the way through to how many desks you’re allowed to have and so on.

“That’s a constraint on freedom of action which a chief executive in the private sector would not recognise – would find frankly astonishing. So I can understand the motives but it massively detracts from the attraction of the job.”

Beyond the need to make savings, he added, the government “strongly desires to have its hands on, to control, the actions of large parts of the public sector”. This too diminished the attraction of the chief executive’s role because it “constrains your ability to develop your own policies and strategies”.

Asked for an example from his own experience, the former foundation trust regulator said: “My view is you do need to give the chief executives of, for example, provider organisations a significant amount of freedom to run their operations in the way they see fit, while of course being clear about what you expect them to deliver, and monitoring whether or not they deliver, and being prepared to step in if they don’t.

“I think the government’s instinct is to micromanage them to a degree that I feel damages motivations. It creates a dependency mindset to some extent. I’m exaggerating for emphasis, but people feel, ‘I’m going to be told what to do anyway so I’ll just sit here and wait until someone tells me what to do’.”

Asked if this attempt to exert greater control was not an understandable response to the sharp decline in finances and performance seen across NHS providers, he replied that he accepted the FT policy as it was conceived was too light touch for current circumstances.

“I absolutely felt the balance needed to shift towards intervening earlier, but also providing more support before you got to intervention, and that’s what I’ve been doing over the last two or three years,” he said.

But he added: “The decline in performance, both financial and operational, to a very significant extent arises because the NHS was asked throughout the last parliament to achieve a level of productivity improvement that it couldn’t. And therefore it’s far too simplistic to say they’re performing badly, therefore they must be incompetent or useless, or just not trying hard enough.”

Asked if the NHS would be able to make the £22bn efficiencies expected of it in the current parliament, Mr Bennett detailed the long list of preconditions to the Five Year Forward View’s claim that savings of this magnitude might be possible.

Among other things, it assumed that social care would be adequately funded; that there would be “no new demands on the NHS” from government; that the required £8bn real terms growth in government funding would be “broadly linear” over the period; that the NHS would also get upfront transformation funding; and that the health service would not begin the period in deficit.

In practice, he said, the government had not “so far” desisted from making new asks of the NHS, giving the example of seven day services; it now looked “very likely” that the provider sector will go into 2016-17 with an underlying run rate deficit of £2bn; and “one obviously has to worry” about whether social care will receive adequate funding.

He dismissed the health secretary’s frequently voiced argument that high quality care costs less.

While some aspects of improved quality would “undoubtedly” lead to lower costs, Mr Bennett said, “there’s very likely to be a time lag”.

“The point at which you add, say, more nurses, which has been a big quality push in recent years, may come years before you see the impact in terms of reduced demand on the system. Furthermore, some of the quality improvements won’t result in reductions in costs. 

“If you look back to Mid Staffs, which is really what initiated the drive on safe staffing… some of the really awful things that were happening there were not directly impacting the clinical outcomes for patients, they were just making their spell in hospital truly awful. Now that’s very bad, and it’s good that by putting on more nurses and doing other things we avoid that. But it will cost more.”

On the controversial section 75 regulations on competition in the Health Act 2012, Mr Bennett said that a “huge mythology has been built up, sometimes, I might even say often, by people who either want to make a political point – they want to accuse this government of privatising or something like that – or because frankly they want to use it as an excuse for not making some tough decisions”.

He continued: “Therefore it has become very controversial… In the face of that extraordinary controversy and the ongoing desire of some people to avoid being held to account for making good procurement decisions, I think the current politicians, the current secretary of state, is very nervous about it and worries that it’s a distraction.

“It doesn’t need to be, but enough people are telling him it is or could be. That’s why, I think, they are failing to support their own legislation. But, as I have said to them, they need to be careful, because if they don’t demonstrate more support for it no one will want to enforce it. Why would you want to be a competition expert, broadly speaking a competition/procurement regulator working in the NHS, if it seems nobody, including your own government, supports the application of the rules to the sector? I’m not saying [the government is] saying don’t do it… but there’s no proactive support.”

Bennett: Government 'micromanagement' creating 'dependency mindset' among leaders