“Great spirits have always encountered violent opposition from mediocre minds.” Albert Einstein
Not all managers are ‘mediocre and meddling’ but some are. I was told by a English NHS consultant last night how nurses in his outpatients clinics are now clocking him in and clocking him out, and gives him permission to leave the clinic when he’s done his allotted time, instead of frontline nursing. Also, he is now expected to stay on site in his 40s during certain hours at night. This has actually caused much resentment across the Consultant workforce in his Trust, such that the managers bombed in their recent staff survey apparently. But these results are not going to be made public. It is easy to target ‘coasting’ from clinicians in the NHS, but it is overwhelmingly clear there are hotspots of meddling, mediocre poor management in the NHS, of overpaid NHS managers making the wrong decisions, but making the wrong decisions quite efficiently for their generous salary. That is why they will never become leaders.
One good aspect about the Francis Report is that the NHS seems to be able to tolerate failure. Failure on quite a large scale – distressed relatives of loved-ones who saw patients drinking water out of flower vases, and clinical regulatory authorities which have yet to make a single sanction years down the line. For all the discussion about the independence and autonomy of entities within the National Health Service, as the toxic culture which might have caused this disaster appears so widespread, it has been argued that there is little point in ringfencing the blame. The problem with this approach is that it is possibly tantamount to be giving up on ‘contagion’, and indeed it is most unlikely that Mid Staffs represents an isolated locus of pathology within the NHS. There is still the unresolved issue about the use of ‘gags’ and ‘supergags’, paid for through the tax payer, of NHS managers, and an overall acceptance that we have to put up with a culture of mediocrity in management in the NHS.
It is very hard to think of ‘great managers’ in the NHS, partly because managers are supposed to be doing things right rather than being identified for doing the right things. Therefore, you are more likely to identify a “good manager” because a disaster has not happened. And yet you never hear of anyone (who isn’t on the NHS graduate management scheme) who says, ‘Yeah, I really want to be a NHS manager’. Compared to a leading cardiologist or brain surgeon, nobody says, ‘I want to be the next David Nicholson’. This is because David Nicholson can be said to be the epitome of ‘coasting'; of someone who is virtually unsackable, as he is surrounded by too many ‘supporters’ in the establishment who ‘need’ him to implement these unpopular, costly, flawed reforms. Whilst the salary for junior doctors is far worse, and the conditions considerably worse (for example a week of nights, often carrying ‘the arrest bleep’), junior doctors on-the-whole are highly motivated people. This of course will be unknown to Jeremy Hunt, who never trained in the NHS, or many on the corporate healthcare lobbying circuit, but this is the reality of gifted people in the NHS. If anything, the brilliance of these junior doctors has been potentially suppressed by relatively poor pay for anyone who has completed effectively a seven-year intensive degree, and the sheer knowledge and skills required to ‘make it’ in medicine far outweighs those needed to command a bonus as an investment banker.
It is not uncommon for junior physicians who wish to train with the “best”, for example be on the clinical firm of Sir Richard Thompson, President of the Royal College of Physicians, in gastroenterology, or Professor Sir Ian Gilmore, the previous President, a hepatologist. However, the mediocrity culture of management is striking here. People who want to train with Sir David Nicholson probably do so more because they consider themselves using it as a passport to getting a well-paid position in the NHS, rather than the fact they wish to ‘train with the best’. Indeed, if you wished to be superb in management in the NHS, many younger people would prefer to do a sabbatical in Harvard Business School, and work with someone like Professor Clay Christensen, Professor of Innovation at Harvard, or Professor Michael Porter, Professor of Strategy at Harvard, than work with Sir David Nicholson. This is possibly an unintended consequence of a deep-seated ethos of mediocrity in NHS management.
When you look at the actual business management and leadership literature, you can see immediately the intimate relationship between leadership and dissipation of mediocrity. Take for example the effect of Fox Conner on a young Eisenhower; Fox Conner is a shining example of ‘one-to-one’ nurturing of a junior talent by somebody senior who wished to give up some of his time. Conner first met Eisenhower in 1919 at the Infantry Tank School at Camp Meade and the two men immediately developed a great mutual respect. Following his promotion to brigadier general in the Regular Army April 27, 1921, Conner took command of the 20th Infantry Brigade in Panama. He invited Eisenhower to join his staff and for three years Conner conducted a systematic course of study for Eisenhower that ranged from extensive readings in military history to daily practical experience writing field orders for every aspect of the command.
Mediocrity was probably at most about a sixth of Jeremy Hunt’s famous speech. However, it has generally been interpreted as a demoralising influence on the workforce of the NHS at a critical time, from a person who is known to have said disparaging things about the NHS, and who indeed is reputed to have not wanted the Danny Boyle item in the Olympics ceremony which he raved about at the beginning and end of that speech. The problem was that Hunt cames from a position of low integrity in criticising the medical profession. He has never worked as a medical professional in the NHS, so has no moral fitness-to-criticise about mediocrity in the NHS. Furthermore, he didn’t as such offer any solutions. This is exactly akin to a GP who tells you you have a cancer, but changes subject before he or she gets a chance to tell you about a possible treatment. Maybe this is because Jeremy Hunt knows the problems over his treatment: there is no Fox Conner figure to look up to. There is a plethora of people who’ve done the Jeremy Hunt job, like Hewitt, Dobson or Milburn, but who have not been there for a very long distance; they can perhaps offer their ‘expertise’ elsewhere. These are people who are unlike the junior doctors who qualify into the NHS at the age of 24 and possibly become Consultant at the age of 40. Secondly, Hunt cannot point to a single NHS manager who is not mediocre; who is a great visionary, or who has been known to be NHS management equivalent of Fox Conner. To be honest, Hunt has very little experience in NHS management himself, but this may be a growing trend in how the UK is run (take for example the report of a headteacher at the weekend who has never taken a lesson, indeed cf the Secretary of State for Education.)
Of course, these criticisms do not, in themselves, invalidate Jeremy Hunt’s argument. One of the major problems that the NHS, whilst it cannot be elevated to a position of immunity from criticism, is repeatedly cited as one of the most efficient health systems in the world; for example the US which spends much more has worse outcomes. And the corollary of this is that there is plenty of mediocrity in the private sector; indeed many ‘fat cats’ are truly ‘coasting’ as their shareholder dividends rocket from a flatlining performance in a market where it is impossible to fail (such as privatised gas, water, or telecoms). But medicine and nursing are professions, and Hunt’s language is inappropriate, because pervasive in Hunt’s thinking is that he treats medicine and nursing as commodities, parts of which can be readily packaged for private equity companies to make a ‘fast buck’. That is the distorted perverted concept of ‘wealth creation’, popular with some. That is possibly the biggest threat to the NHS becoming ‘mediocre’, and restoring dignity to a battered pair of professions at a time when they have been undermined by a complex reform they never asked for, would help to motivate its workforce. Calling them ‘mediocre’ from a position of relatively little authority, however, is utterly futile.
