Sir James…


I have news. It’s not great news. Prepare yourself.

DiDo thinks management culture in the NHS is rotten.

That’s it then. The whole NHS management structure dismissed and traduced in one show-off moment at the Health Select Committee.

Not some of the management, sometimes. No, it’s all rotten.

So, to any managers reading this who took work home last night, to any manager who will be at their desk before most of us are out of bed, struggling to make one pound do the work of two, remember… rotten.

Don’t worry, DiDo has a fix… regulation. Yes, more regulation. Mangers must be regulated, she says.

Let’s have a think…

Culture is an outcome. You can only change outcomes by changing inputs. The inputs that create culture are the working environment and operating climate. Which can be changed.

There are two principle issues that destroy the NHS climate.

The first; staff numbers.

I said it yesterday and no apology for repeating myself;

Protect the frontline, fund it properly and make it fun to work there and most of your problems will disappear.

Take the pressure off and the bullying stops, the tensions go away, the mistakes become fewer, quality improves and complaints come down… that’s that.

Employ insufficient people, in a safety critical environment, and you send the message… safety doesn’t really matter. ‘It’ll do’, will do. The workplace environment becomes toxic.

The second; regulation.

Fundamentally, regulation is micromanagement by people who think they can do a better job. If they could, they would. They know they can’t, so they inspect.

Regulation creates fear, tension, pressure and doesn’t work. The CQC has been around for years and quality is no better.

Regulators are a political chimera that have a vague discretionary authority to ‘make things better’.

Generally that means bullying hosptials and others into delivering political policies, knowing full well there isn’t enough money or people to do the job.

Regulators lack the courage to tell their political masters their task is undeliverable and so they become oppressive.

To get the regulators off their backs, organisation’s bosses pass the undeliverable parcel to middle-management, who become heavy-handed and prevail on the people doing the job, to ‘just-go-do-it’ and ‘don’t bring me bad news’.

In 1768 Sir James Porter wrote; ‘Observations on the religion, law, government, and manners of the Turks’. He observed;

‘Fish rots from the head, down’…

… referring to failing organisations and how the blame should be with the leadership… the head.’

In order to preserve their position in the hierarchy, regulators concentrate on ‘harmful’ or bad behaviours. They are not in the business of encouraging constructive or successful behaviours.

Organisations have to fend for themselves, often in environments that make it impossible.

Regulators aim for uniformity of performance, ignoring the asymmetries in geography, economy and history.

And, human failing… since mistakes in complicated organisations, are inevitable.

By lambasting the unfortunate few who make mistakes, future and perhaps worse mistakes get hidden.

So it is… DiDo is going to solve the problems with regulation; a list of management competencies, a data base and an independent tribunal to look at serious complaints.

I would have thought competences are a matter for the employer, a data base, its design and upkeep, for over 100,000 people will run into millions.

We have independent tribunals and complaints mechanisms and by the way; define ‘manager’.

Regulation has not prevented poor NHS performance, neither has it stopped poor doctoring, bad nursing or the collapse of the global finance markets, LIBOR, the Pike River Mining Tragedy in New Zealand, nor the Deep Water Horizon oil-spill in the US.

Neither will it stop a hassled, pressured middle manager, caught in the ambiguity of delivery and too few resources to do it.

Should we wonder at misreporting, ‘creative compliance’, pressurising staff and crushing initiative, innovation and creativity.

DiDo is wrong about the culture of the NHS. Where good people are given the time and space to do great things… they will and they do. She should be;

• Understanding; heuristics, framing, system inefficiencies, status, social networks, climate, ethics, best practice, principles.

• Focusing on; knowledge, risk, uncertainty, assumptions, cognitive capture.

• Agreeing; what counts as success, reputation and trust.

DiDo would do well not to let ambition get the better of her. Stop and think about Sir James.

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Reproduced at by kind permission of Roy Lilley.