The politics of hitting the target and missing the point
Sometimes the politics of British health and social care drives a response to their problems that makes actually tackling them even harder.
In fact, let’s correct that. That happens all the time, but sometimes it is more obvious than others, and this week has been one of those weeks.
In a speech on Wednesday, Wes Streeting, Secretary of State for Health and Social Care, announced his intention to decentralise power and encourage more local managerial autonomy. He also announced the re-introduction of a league table of hospital performance against a set of metrics.
Top managers will be rewarded with more authority and money, while those who fail will hear that dreaded two-word phrase popularised by Alan Sugar in Britain and Donald Trump in the United States.
Streeting is no fool and he knows these plans appear to pull in opposite directions, reinforcing central control while talking up local autonomy. His explanation is that increased local autonomy will be a reward for achievement of national targets.
The problem with this is that the culture produced by the way managers achieve targets will shape how they use their increased power. So don’t be surprised if decentralisation of autonomy stops with them.
It is beyond doubt that there are some NHS managers who should be encouraged to — as John Timpson puts it so elegantly about his own company’s regretted hires — ‘find their happiness elsewhere’. But which ones, and in what circumstances?
In any sector, probably, but certainly in human services such as health and care, the managerial mindsets and behaviours that drive organisations to focus on the carrots and sticks of target achievement are not well suited to supporting the relationships needed to co-create and sustain improvement over time.
By contrast, when organisations create the necessary conditions for their people to work well with professional autonomy and responsibility, so that they can be creative and flexible in pursuit of shared purpose and intended outcomes, both effectiveness and efficiency tend to improve sustainably.
None of this has been recently discovered. You can follow this link to the executive summary of a research project I led for the New Zealand government 20 years ago. Longer historical perspective still is captured in this series of four blogs by Colin Talbot.
So why are Streeting and the government seemingly so intent on repeating old mistakes? That is where the politics comes in.
Although top-down command and control undermines the organisational and cultural conditions needed for the kind of relationships that increase public value over time, it can bring about improvements in some metrics, such as waiting times, over a shorter period.
For example, a decade ago I was commissioned to support an NHS Trust that — no thanks to me — was achieving dramatic reductions in what was then the political imperative of the day, A&E waiting times. The Trust had improved its performance so much that its Chief Executive was later seconded to NHS England to ‘drive’ the national effort.
So what did the Trust need me for? I was brought in by the outgoing chair of the Trust’s board to investigate persistent complaints by staff about bullying by managers, and to make recommendations about how to deal with it.
The atmosphere was such that I decided to set up an external telephone number on which whistleblowers could leave voicemails for me, which several did. One middle manager would meet me only in a supermarket, miles from the hospital, like a spy meeting a contact.
A few members of staff were willing to meet me in a small room the Trust set aside for my use, and I learnt never to arrive there without a box of tissues. More than one did nothing but sob for several minutes in response to my opening question: “What would you like to talk to me about?”
My role there was not extended after I met with the chief executive and other senior leaders to explain what I had learnt and suggest a way forward, and I don’t know how they are doing all these years later with either A&E wait times or bullying.
But I do know this: the powers in Westminster, Whitehall and the offices of NHS England might be able to command their way to improving some metrics of performance over the course of this Parliament. But if that is how they go about it they risk strengthening the cultural obstacles in the way of creating an NHS fit for the future.