The NHS.occupies a special place in the national psyche. It is a huge organisation with the major economic consequences implied. It is at the heart of politics, with the perceived state of the NHS being a proxy for the popularity of a government.

The NHS.occupies a special place in the national psyche. It is a huge organisation with the major economic consequences implied. It is at the heart of politics, with the perceived state of the NHS being a proxy for the popularity of a government.

The Department of Health/NHS construct is not a conventional organisation, more akin to a federation of vested interests. There are ideas of parts being autonomous and some parts, such as GPs, have always been only semi-attached. There is also a significant component procured from external providers, but we assume it can be viewed as a whole.

The perception is that the NHS is in a mess, crisis, period of change, depending on viewpoint. There is almost a common acceptance that despite huge investment much more should be possible. While there will always be issues around policy, what we appear to have experienced is a period of poor performance in implementation with no clear delivery programme to ensuret potential conflicts between policies are managed. Why?

Our experience is common. We are confronted by an almost continual stream of advice, instructions and demands. Almost any external event, such as a front page story, guarantees a new set of instructions. We hear of some initiatives from the media. Often what we are told to do by one part of the NHS clearly conflicts with another; giving the perception that there is no coherence at the management layer above our trust's. A plan reached after months of negotiations can be only weeks old before it is invalidated by decisions external to our trust.

This conflicts with the experience of successfully managing large complex change programmes. You need clarity of vision - everyone needs to know what they will get as a result of all the effort and upheaval, and it has to be worth it. You need leadership who personify the vision, and have not only the capabilities to deliver the programme but an ability to.reach people on an emotional level. And you need clarity in the structures for accountability and responsibility for day-to-day delivery as well as the change programme. I suggest the NHS falls well short on all of these.

It does not have either the capabilities or the capacity for change, made worse because the culture is hostile to successful change.

Take accountability. In the NHS this is very confused. Our board is not in control of the trust and external people and agencies are entitled to tell us what we must do, and how we must do it. We plan and re-plan very frequently and each plan is assessed externally.

When we suggested the plans ought to at least be considered by our own board this was greeted with incredulity. Executive directors are not clearly accountable to their board and have a mysterious double (or maybe triple - board) with strategic health authority and DoH lines of accountability.

This leads me to the idea that a key reason why things are going wrong in the NHS as a whole comes down to a debate about management.

To illustrate the argument I must use the 'J curve', an illustrative device used elsewhere. The vertical dimension is some measure of performance of the NHS, and the horizontal is some measure of management style.

The graph has another dimension in that it moves up and down while keeping its shape. So if you apply more resource it will improve performance no matter what the management; or performance can fall if some adverse force is applied, no matter how good the management.

It illustrates that if you are not yet very efficient you can improve the performance of an organisation (or the NHS) by adopting a more rigorous management style: shouting at people, enforcing targets and intervention regimes. Sometimes this can give some rapid early improvements and the illusion of progress.

But doing more bad things can only take you so far in terms of improving performance, to get to the really good performance you need to abandon the command and control style.

Most worryingly it shows that to get from the old style to the new style, with all the benefits that will bring, you have to go through a dip in performance and perhaps a period of instability.

The NHS is managed badly. It has neither the capability nor capacity for the efficient management of so many component sub-organisations, especially during a period of change. Some would add it does not have the right culture either.

This has to change if we are to make our NHS the genuinely world class service we all want. I think it could be done, but it would take a radically different approach and some political and organisational bravery.

You can illustrate the kind of changes that would be required:

  • Reduce the number of component organisations by takeovers, not mergers or partnerships;
  • replace the concept of partnership with the idea of integration;
  • split providers from commissioners (implying an end to practice-based commissioning);
  • make all providers genuinely autonomous within a regulatory environment with intervention powers;
  • continue with moves to plurality of supply but without rigging the market and without centrally driven (and disconnected) interference;
  • get rid of primary care trusts, strategic health authorities, overview and scrutiny committees, public and patient involvement forums, and greatly slim down the DoH (use the best peoples' skills to help manage commissioning bodies or provider organisations);
  • fund more independent external research, do not employ large numbers of internal 'experts' at the DoH;
  • have a national accountability and responsibility structure for commissioning of care, both social and health, with a proper board at the top responsible for using commissioning to implement policies effectively;
  • make the local integrated commissioning of care the responsibility of unitary authorities or the county/subordinate borough hybrids, use existing sub-structures to allow some very local variations;
  • use existing democratic arrangements and scrutiny processes, do not consult separately about every change in service and allow providers the freedom to do whatever they choose, free of scrutiny;
  • move responsibility for public health to local government and fund it properly, making it the main driver of commissioning intentions.

It will be argued that this fragments the system and we will not get the redesign and rationalisation and f services that bring economies of scale and efficiency.

Well all I can say is that from my experience there is far more chance of autonomous, business-driven foundation trusts agreeing to collaborate than there ever was from NHS bodies who were actually supposed to co-operate.

Richard Bourne is chair of Essex Rivers Healthcare Trust