Cowper’s Cut: Why the MBA method to NHS reform may fail

The recent party conferences highlighted again the extraordinary situation in which we find both the main national political parties.

Labour’s conference was obviously the more confident. Its leader Jeremy Corbyn may have lost the general election, but has won his party for as long as he wants it. There were mixed messages on private finance initiative – shadow Chancellor John McDonnell vowed to bring all the contracts back; shadow health secretary Jonathan Ashworth promised a review that might buy out one or two.

De-selecting GPs? Really?

In the margins of Labour conference coverage, Guardian journalist Andrew Sparrow reported that MPs have been informally discussing the possibility of letting the public vote to deselect GPs with whom they are unhappy.

This is not official policy. It is, however, an insight into how some Labour MPs are thinking, which is to say not much. Mr Corbyn told his conference, “the kind of democracy that we should be aiming for is one where people have a continuing say in how society is run, how their workplace is run, how their local schools or hospitals are run. That means increasing the public accountability and democratisation of local services”.

Oh, Jeremy Corbyn. Oh, Corbynistas. Setting aside the hog-whimpering stupidity of such a notion at a time when the NHS is short of at least 5,000 GPs, the direction of travel Mr Corbyn describes will run up against the classic dilemma Nick Timmins brilliantly summarised recently, channeling Tony Travers: ”if you ask the British electorate if they want more local control, the answer is almost always yes, but with that goes with an almost Reithian belief in shared standards and equity. These two desires are almost impossible to deliver in tandem; more local control will almost inevitably lead to more variation”.

Quite. There is also piquant irony in seeing Mr Corbyn reconcile himself intellectually with one of the founding principles of NHS foundation trusts, against whose creation he consistently voted.

The great aphorist La Rouchefoucauld held that “hypocrisy is the homage vice pays to virtue”. And Labour’s policy hypocrisy on the NHS pales into relative insignificance given the state of the Conservative Party’s Manchester psychodrama.

There was much to enjoy, from the entertainment of sugar behemoth Tate and Lyle sponsoring the conference lanyards to health secretary Jeremy Hunt’s game of ahistorical effort to pretend that Conservative health minister Sir Henry Willinck founded the NHS. (Yes, that sound you can hear is energetic rotation from the graves of Beatrice Webb, William Beveridge and Aneurin Bevan.

Oh and justice minister and GP Dr Philip Lee told a fringe that the NHS and state pensions are “a Ponzi scheme that’s about to collapse”. Which was nice.

Dropping an E in Manchester

We are unlikely in the near future to top the perfection of the visual metaphor for Prime Minister Theresa May’s speech in watching the backdrop slogan ”A country which works for everyone” literally falling apart.

And it’s clear that what happens at conference doesn’t stay at conference, as Boris Johnson briefs The Telegraph that he will just refuse to go if Mrs May sacks him, while Brexiteer ultra Bernard Jenkin attacks the Treasury, and by implication Chancellor Philip Hammond.

This, ladies and gentlemen, is the government.

The MBA approach

Yet were that not enough, the Care Quality Commission’s new chief inspector of hospitals Professor Ted Baker showed how to win friends and influence people in his letter to hospital chief executives about accident and emergency performance and safety, accompanied by a high profile and heavily briefed media interview, in which he stated that some A&Es have a culture of “learned helplessness … (where staff) “just pile the corridor full of patients”.

Professor Baker added, “the model of care we have got is still the model we had in the 1960s and 70s. That is the fundamental thing that needs to change; we need a model of care that is fit for the 21st century and the population as it is now”.

There is a tension between the sensible themes of the Baker letter and the briefing to the media of a “tough message” on the NHS. Managers say that they are experiencing this as national system leaders going through one of their inevitable if unedifying bouts of an MBA approach: management by admonishment.

As I have previously observed, this MBA/management by shouting approach is not really helpful. The Baker letter summarises some good practice in obvious areas: it offers nothing on what to do about them.

Chief executives do tend to know that they have problems in A&E performance, and many think that they know what those problems are.

The important twin gaps for the NHS as a system are firstly, in the analytical capacity and capability to confirm that the problem in question is actually the root cause of bad performance; and secondly, in the quality improvement capacity and capability to resolve the root cause problems affordably, durably and reasonably quickly.

Sorting these things out would probably help. Management by admonishment probably won’t. It’s displacement activity.