Being an NHS manager is a fool’s errand
Authors: Nigel Hawkes
Journal: BMJ (2007)

When ministers talk about “the NHS family,” as they sometimes do, I’m tempted to wonder what their own family is like. Happy families are all alike, Tolstoy tells us, but every unhappy family is unhappy in its own way. The NHS family is unhappy in ways that perhaps even Tolstoy’s commodious imagination couldn’t comprehend.

Doctors complain about the frustrations of working in the NHS and the erosion of professional autonomy. But their position is far more secure than that of senior NHS managers or, heaven help them, the non-executive members of trust boards. It may be unfashionable to take up the cause of the managers—so often the butt of doctors’ anger and politicians’ disdain—and nobody gives a toss about the fate of non-executives, but the way the NHS treats its managers and board members can tell us something about the culture of the organisation, and what it tells us is not good.

A career in NHS management is like a game of snakes and ladders. The trick is to land on all the ladders and move up fast enough to escape from every job to a better one just before something goes wrong. With luck, you might reach the top. We can probably all think of big cheeses in the NHS to whom this rather cynical view of promotion applies.

But what if you land on a snake? This might easily happen if, with a new job, you inherit a problem that your predecessor has managed to conceal. The options are to maintain concealment for as long as possible or to come clean and try to put things right. The proper option will almost certainly land you in trouble. The head of the family, sitting in Whitehall, wants to hear good news, not the rattle of skeletons tumbling from closets. Managers who tackle problems often find themselves blamed for those problems, not praised for taking action. A policy of concealment and inaction is usually the better career move, which explains why so many long running problems go unresolved.

Non-executives are in an even worse position. Their influence is limited, but their responsibility is all encompassing. Although doctors—even, in my experience, clinical directors—can hide from a disaster by saying that it was nothing to do with them, chairmen and chairwomen and non-executive directors cannot escape. They are the scapegoats when things go wrong.

But surely the members of the board run the hospitals and the primary care trusts, so oughtn’t they suffer when those organisations fail? That is what it says on paper. But the model invented by Kenneth Clarke when he first gave trusts independence has been out of kilter with reality for years. In all essentials trusts are line managed by strategic health authorities (SHAs). Command and control are the key words; bullying and threats the method. Non-executive directors and chairmen and chairwomen, though I hate to say it, are treated sometimes as no better than useful pawns in a game whose goodwill, local knowledge, and devotion to public duty are exploited by the NHS until the moment comes to toss them aside.

Consider what happened to three non-executives on the board of Maidstone and Tunbridge Wells NHS Trust when it recently ran into trouble over two outbreaks of Clostridium difficile (BMJ 2007;335:790 doi: 10.1136/bmj.39367.650266.DB). The Healthcare Commission wrote a critical report that prompted the exit of the chief executive, Rose Gibb, and an offer by the chairman, James Lee, to resign. This offer was turned down by the SHA, but when the report played badly in the press he offered again, and the announcement that he was to go helped get Alan Johnson through a sticky afternoon in the House of Commons. So far, so normal.

What happened next, however, shows the NHS at its nastiest. Three other non-executives on the board—a barrister, an academic, and a former executive of British Telecommunications—had not even been in post when the outbreaks occurred and so could not be held responsible. But the Department of Health made no attempt to absolve them from the criticism, and they were portrayed publicly as being party to a failing for which they could not have been responsible. Their offer to discuss the issues with the new interim chairman were rebuffed, as if they had nothing worthwhile to offer. Instead they were criticised for being party to an agreement to pay Ms Gibb a severance package. This payment was overruled by Mr Johnson with a fine show of indignation, as if such a thing had never happened before. The three resigned, saying that the “public scapegoating” of individuals gave them no confidence that their own treatment would be even handed in future and that what had happened raised “serious questions for the overall probity of the management of the health and wider public services sector.”

Who would be a non-executive? It’s a fool’s errand. You can do rather little to control the trust or improve its performance. The department urges you to be “a champion of the hospital,” which is to misunderstand the true role of non-executive directors. And heaven help you if anything goes wrong. From next April, with the passage of the Corporate Manslaughter and Corporate Homicides Act, you might even face a liberty threatening prosecution.

Worst of all, like snakes and ladders, it is almost entirely a matter of luck. Plenty of acute trusts had a higher incidence of C difficile infections than Maidstone and Tunbridge did at the time of its outbreak, but the others evidently threw a double six and got away with it. Their managers may yet reach the top, while Ms Gibb is toast and the non-executives at Maidstone and Tunbridge are pariahs in their own community.

Non-executive directors and chairmen and chairwomen, though I hate to say it, are pawns in a game whose goodwill, local knowledge, and devotion to public duty are exploited by the NHS until the moment comes to toss them aside