General Messenger, who led the Royal Marines’ invasion of Iraq may appear an odd choice to review NHS management, but with the ink barely dry on his new report the Health Secretary reframed its conclusions, using it to suggest a series of new management cuts, a proposal which General Messenger says was not part of his report.

The NHS Confederation welcomed the tone of the report but was bitter about the attack on managers that followed as the Health Secretary, vowed to be ‘watchful of any waste or wokery’, and to divert managers’ salaries to treating waiting lists.

The NHS has a long history of trying to review its management, dating back to when Sainsbury’s boss Roy Griffiths produced recommendations in 1983 to define the role of managers and tipped the balance of power in their direction.

The issue remains serious, with the latest patient safety scandal surrounding maternity practices at Shrewsbury and Telford hospital trust under police investigation after an independent report found that the lives of 201 babies could have been saved with better care.

How such failings occur and remain hidden is a key question for any such investigation, but unlike the Francis and Ockendon reports the Messenger review does not provide analysis on these scandals, or explain the root of these problems. it focuses instead on principle and culture, producing a very simple 7 step prescription which few would disagree with. It does, though, alert to dangerous weaknesses that have become an engrained feature in parts of the NHS.

”Although by no means everywhere, acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system.

The report is an acknowledgement of systemic failure to train, support and value managers,  of bullying and of a culture of blame that persists. It highlights the ongoing and serious problem that the NHS has with racism. A BMA report found 60% Asian and 57% Black doctors citing racism as a barrier to their career progression.

And yet the popular cry is not to improve management, but to clip bureaucrats and their pay. Messenger does not echo this line, a view that is supported by research from Kirkpatrick and Malby who calculate that the number of administrative staff in the NHS is around 25%, with managers taking up only 2% of the workforce, and proposing that if anything the NHS is under-managed. The NHS Confederation points out that in the economy as a whole 9.5% of the workforce are managers, directors and senior officials. They too, pour scorn on the accusation that the NHS is overpaid. “The chief executive of NHS England and NHS improvement who is responsible for the NHS has an annual budget of over 100 billion and the services 1.2 million staff is paid around £200,000.” 

The context of this debate cannot be ignored, and two factors leap out. First, a failed, but huge reorganisation that began in 2012, distracted and created wasteful competition, and second, a decade-long squeeze on funding that left the workforce short of 100,000 staff, and a huge backlog in repairs to buildings and equipment. Money is not the answer to all ills in the NHS, but it is essential to any kind of realistic response to the current challenges, otherwise managers are left in perpetual crisis and systemic change is impossible.  

Roy Lilley, health policy analyst and writer says that, although well crafted the report is wrongly focused on senior management and sees the NHS as “an eco-system, a complex fabric of warp and weft that gives it strength, texture and colour., although well crafted the report is wrongly focused on senior management and sees the NHS as “an eco-system, a complex fabric of warp and weft that gives it strength, texture and colour.

Six thousand small businesses that make up primary care. One hundred and fifty-odd, hospitals independent by statute and a plethora of community, ambulance and specialist services, each with their own world view.”

Primary care and social care seem to be largely absent from the report which is a strange omission given the government’s new emphasis on integrated working – which aims to bring all sides together to plan and deliver health and social care. Within primary care the number of GP partners is declining quickly, so there is an opportunity and  need to invest in new management at the local level to help ensure the integration the government is aiming at.

Overall there has been a warm welcome to the report as it raises questions about how to support the role of management and attack longstanding problems within the service, but questions remain about the deeper analysis and the level of commitment of politicians to change – the Health Secretary’s immediate populist charge, criticised and undermined managers at the very time that all NHS staff need our support.

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