Read the Thirlwall report on the neonatal deaths at the Countess of Chester Hospital, and two kinds of culpability emerge. Lucy Letby stands convicted of murder. Thirlwall describes a unit in which relations between doctors and nurses at the bedside were collegiate and constructive, but where managers – many originally from clinical backgrounds – were neither. When doctors raised concerns, managers undermined them, and their response protected appearances rather than babies. Thirlwall is clear that if they had behaved better, lives would have been saved. Murderers mean to kill. Hospital managers are meant to do better.
In most of the NHS, the relationship between doing better work and being better rewarded is entirely absent
Isabel Hardman has written, accurately, that Thirlwall’s inquiry won’t lead to change. We have no end of inquiries into poor performance in the NHS, and one doesn’t need to read many to notice that each repeats the last. The problems recur, the inquiries recur, nothing improves.
After thirty years in NHS hospitals, my conclusion is not that NHS managers need to be given more recommendations, but that they need the powers to manage. In its current form, that is not something the NHS allows.
As a newly-appointed consultant physician, I was ushered into management. I was given responsibility for a large hospital’s medical admissions unit, and a role within the Emergency Department, and instructed to improve our four-hour-wait performance.
Quite how to do this wasn’t apparent, and I quickly realised it wasn’t apparent to anyone else either, certainly not those who’d appointed me and had failed to improve it themselves. After a while the NHS sent in an external adviser, a national expert, a surgeon who had pioneered ways of reducing length of stay in surgical patients. He advised me to plan for recovery, and to pursue earlier discharges by remembering that particular operations took a certain number of days to recover from, so one could plan ahead.
My patients weren’t surgical, I explained. We saw them each day and assessed whether they were ready to go home; there was no protocol by which we could know in advance. He nodded thoughtfully. “I’m not here to explain to you how to solve your problems,” he said. “I’m here to plant ideas.”
NHS managers can, with effort, recruit to new posts. But dismissing people for ordinary poor performance is practically unheard of: it takes the most outrageous incompetence. The normal incentives by which businesses operate – paying people more when they perform well, getting rid of them when they don’t – are non-existent. Lacking the levers for change, managers are left with two options. They can accept that they’re helpless, or they can lie.
“Here’s how I do it,” said a grey-haired doctor to me, encouragingly. He’d had a career in senior hospital management and wanted me to do the same. He was excellent, with full insight into the limitations of his power. There had happened to be a surge of admissions 48 hours before. “I’ll walk round the Emergency Department today,” he explained, “and I’ll hug people and tell them they’re doing a good job and I’m going to help create space by pushing discharges. I know the average length of stay is 72 hours, so within the next day everything will improve and people will think I’ve helped.”
Self-knowledge like that is rare, and precious. Much easier to lie to yourself, and pretend that you’re helping. The doctors and nurses who walk the corridors with carpets get rewards unavailable to those whose working lives are spent seeing patients. Incentives predict outcomes, and there is remarkable competition for the management posts whose occupants unfailingly express their regret that they can no longer see so many patients. Even my minor one brought its rewards: my overall pay didn’t rise, but my clinical duties were reduced, so long as I pretended I was doing something.
Management, actual management, is both important and hard. To make an institution run better can be deeply satisfying; to do it in healthcare has the added pleasure of seeing directly that you’ve improved lives, and not just the bottom line. But give people management roles in a setting where they can’t manage reality, and you should not be surprised when they shift to managing reputations and illusions. Put people in dishonest situations and you breed dishonesty.
In most of the NHS, the relationship between doing better work and being better rewarded is entirely absent. Incentives are often misaligned, frequently perverse.
We cannot regulate ourselves into good healthcare. Unless the NHS is redesigned – or replaced – so that authority and responsibility and reward line up, and those who fail are removed, nothing will change. Anything else means wishful thinking, and more promises to learn, in the special NHS sense: promises to be repeated, almost verbatim, by the next inquiry.
That the NHS works as well as it does owes much to the decent managers doing what they can. I asked my grey-haired mentor why he’d ever got involved. He replied that he had seen who else was going to take the job if he didn’t.
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