Andy Cowper acknowledges that NHS management is hard and the political environment is insufficiently multipolar.

Good news has arrived, along with the rain: there is a new euphemism for the NHS management SNAFUs.

Let’s all chant it together!

No, not “we can do this!”. Your new mantra for summer 2018 is “it’s a system problem”.

 - “Oh, Treasury have shat their pants that all the Department of Health and Social Care 6 per cent loans will never, ever be repaid!”

- (Nods sagely) “It’s a system problem”.

- “Oooops! The troubled provider we’ve been blithely ignoring and doing nothing about for years is going to have it’s accident and emergency closed!”

- (Strokes chin) “Yes, that’s a system problem”.

- “Lordy! Providers that are dreadful employers are haemorrhaging staff at a rate of knots!”

- (Taps side of nose) “A system problem, if ever there was one”.

- “Gosh my old boots, the NHS Commissioning Board and NHS Improvement are getting into leadership development despite having no demonstrable experience or excellence in the field!”

- (Polishes glasses) “A classic system problem. Classic.”

NHS leaders: deny all individual or organisational responsibility for anything, anywhere, ever by using the phrase “it’s a system problem”. That’s 2018’s workaround sorted.

You’re welcome.

The beigest euphemism

“System problem” tends to be the beigest euphemism possible for “I genuinely don’t have a clue what I’m talking about or doing here”.

Now of course, genuine systems problems do exist and arise. Increasing real terms funding by 3.4 per cent when the NHS needs at least 4 per cent is perhaps the most obvious, but there is also the lack of matching workforce supply and demand, having to prepare for a no deal Brexit… there are a lot of candidates.

Those are not what I’m describing here. What I am describing is a depressingly common trend in parts of the system infrastructure. I won’t call it the system leadership, because these people don’t lead anything – except for their more competent colleagues, whom they lead to despair.

There is a particular kind of individual in NHS management whose very purpose seems to be to avoid taking decisions and responsibilities.

These people are, by no coincidence whatsoever, enormously fond of meetings. Nor are these empty raincoats averse to a bit of management jargon that makes the activities of administration seem outdoors-y. These are the outside-the-box-thinkers, the blue-sky-what-if-ers: they are the deep divers who never go into a depth greater than a puddle and who will never, ever get the bends.

They are enormous impediments to getting the NHS to work better – and indeed, to work as a system. As such, people like this are the real system problem.

The problem with turning almost everything into an ersatz “system problem” is that nothing ever becomes anyone’s responsibility. Doing away with accountability is just about the worst way possible to try and run anything: it is a recipe for anarchy, not administration.

It also means that less experienced people don’t understand their jobs properly. The diffusion of demarcation also makes it far too easy for the ownership of problems to be avoided. The phrase “it’s a system problem”, when (as so often of late) wrongly used, is an Anderson Shelter where the confused, the incompetent and the mediocre can hide.

‘Ooh, but aren’t you calling for a blame culture?’

Um, no. I’m not calling for a blame culture. I am however calling for a “finding out buffoons” culture. The two are not the same.

NHS management is basically a complex set of interlocking and interacting problems, some of which are wicked issues. There are a lot of moving parts: fixing one thing without understanding it deeply can break another thing with remarkable ease. It’s like a complex car engine.

If everything is “a system problem”, then nothing is: the phrase loses all meaning, and becomes a mantra. So, why don’t we have a hard look at the people using the empty phrase, and discern the active from the passive?

That is why root cause analysis is so important as a tool to do this work properly. We can never quote the great H L Mencken’s line from The Divine Afflatus often enough: “There is always a well-known solution to every human problem: neat, plausible and wrong.”

The Apptitude for improving the system

Improving the system has been quite the theme this week. Giving his first dose of evidence to the Commons Health But Social Care Committee, Matt “The App” Hancock said, “We need to go forward in a spirit of collaboration not competition. I do not want a big legislative shake-up, but if proposals put to me have consensus then I would consider them. Doctors, not lawyers should decide what’s best for patients.”


The trouble with the status quo is that we’ve reached the point where the governance is broken by the chosen workarounds, which are non-statutory and can’t hold budgets.

STP footprints and accountable/integrated care systems have been convenient fictions to break down the statutory reality (but in practice, phantom notion) of legally distinct organisational islands of providers and commissioners.

(There was always the duty to co-operate on foundation trusts under the 2003 Act, but hey, who remembers that far back? That is ancient history.)

Matt The App also told the committee: “Sometimes you don’t need a stick, but a big carrot and an arm around a trust to get them out of special measures. However, that doesn’t necessarily mean more funding. Trusts need to manage themselves out of their problems.”


If not mmmmmmmmmmmmmmm.

I suspect that more full time staff, including those on loan, may have been quite a chunky contributor to getting out of special measures. And the notion that some troubled trusts are going to manage themselves out of special measures if there is a nice incentive and a big hug is an heroic assumption. It’s not clear to me that those trusts have the ‘apptitude’, even if they have the appetite.