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

“The healthcare system is populated by bright, dedicated, well intentioned people. Now is the time to surface that talent in meaningful leadership positions across the NHS and, together with smart processes and enabling technology, allow the best mediocre healthcare service in the world to become truly the very best”. Professor Aidan Halligan, 1957-2015

My late friend Aidan Halligan’s brilliant phrase has been ringing round my head since I quoted it in last week’s column. If there were ever a man the NHS simply couldn’t afford to force out of a job for telling the truth, Aidan was that man.

There we go. That’s political silence for you.

As all staff and managers know, there is a lot of mediocrity in the NHS, and there is also a lot of excellence. What is interesting is that there seems to be very little curiosity about the conditions of production of each.

Mediocrity and excellence have one vital thing in common: both of them are a habit.

It is commonplace to say ”no one goes to work to do a bad job” – and who knows? It might even be true. You never hear people say ”no one goes to work to do a mediocre job”, and that’s for a good reason: we all know that a not insignificant number of people do exactly that.

Yes, even in healthcare. Yes, even in the NHS.

This is why recruitment, retention and training are three of the most important things that any organisation can do.

‘That’ll do’

Let’s be quite clear though: we are not only talking about an NHS or even a public sector characteristic here. I use private sector businesses all the time (hell, I am one), and competent, good service is becoming more remarkable by its rarity. (Yes, I live in London; no, the police haven’t started looking younger.)

But mediocrity, wherever it is found, is defined by the “that’ll do” tendency. It is where intellectual and physical laziness meets can’t-be-arsed-ness.

So we should be curious about what causes mediocrity. What are the soils in which it grows and thrives, and what climate does it prefer?

Obviously, we should ask ourselves the self-same questions about excellence.

Medicine is science; management is performance art

The longer I observe the NHS, the more I reflect that while medicine is based on but not limited to science, much of healthcare management in the NHS is very much like performance art.

It’s not a thing most people even consider. It tends very much to be its own little world. And it does not tend to be demotic.

The Gods that changed

Then there is the politics. So much politics. It took me some years to work out why smart, senior people who knew there were real and serious problems in the NHS would never discuss them in public. Doing that is to offend against The Gods Of Politics, as Aidan found out.

The Gods may have changed, and now we worship a deity in the shape of the Sun King of Skipton House, NHS Commissioning Board chief executive Simon Stevens, but I think there remains a core problem in a system which is incentivised to give the “right” answers to The Gods.

But back to medicine being a science – science is the striving towards excellence, accuracy, replicability, intellectual honesty – or it is nothing. Just ask Andrew Wakefield.

The ungraspable nettle

So it’s curious that so few scientists (which is what medics are) should have felt that the nettle of NHS management is graspable.

Now we should be very clear that not every clinician has to want to go into management (they went into clinical practice for good reasons). The seminal work of Michael West and colleagues about the importance of well-functions clinical teams to quality and safety still doesn’t seem to have got the attention it deserves.

Perhaps part of the reason is that NHS management is a wildly diverse skill set. There are some technical skills – finance, of course, but also blocking and tracking waiting lists and queueing theory, as well as the all important anthropology requirements of a professionally tribal world.

Oh yes, and there is how to learn about the way colleagues work emotionally, and how to support and guide them.

This is emphatically not a call for mandatory guidance on “motivational training”, nor for “resilience classes”. It is perhaps to acknowledge that NHS management is hard, that the political environment is insufficiently multipolar.

Oh, and that our old friend culture is a crucial ingredient in the conditions of production of mediocrity – and of course, of excellence.