NHS managers get a bad press. In the newspapers they are often simply ‘overhead’, and in our popular hospital dramas, they are the interfering, money-grabbing blocks to good clinical care from heroic doctors and nurses. We blame them when things to wrong and accuse them of being un-necessary when things go right. It’s interesting to think back as to how much their jobs have changed. Looking back over the last sixty years, there have been five ages of NHS management (please don’t treat this entirely seriously!)
Age 1- 1948-1982. This is pre-management era. That doesn’t mean there were no managers, or that the work being done wasn’t valuable, but it does mean that roles were less about management as we would understand it today. In the academic literature this is referred to ‘old public administration’. The key roles at this time were supporting and mediating between doctors (who really ran things), but there are also some breath-taking accounts of committee work concerning the purchase of curtains (no, I’m not kidding).
Age 2 – 1983-1989 – General Managers. In the 1980s Roy Griffiths’ management inquiry asked who exactly was in charge of hospitals, and found no-one (for some reason he didn’t notice it was the doctors). And so, NHS management was created, or more exactly, NHS General Managers, who were meant to be responsible for the running of their hospitals. The key role of General Managers then, was being in charge, but this didn’t really work out in practice – research suggests that they held little power, especially over those pesky doctors. They were, howeve, required to find efficiency savings and contract-out ancillary services such as cleaning (and didn’t that go well). They also had to try and stop doctors from assuming they were there to look after them, as they had been in Age 1.
Age 3 – Chief Executives (1990s). In the 1990s hospitals became NHS Trusts, and General Managers became Chief Executives as they were now participating in an internal market. Except they weren’t really – there wasn’t much of a market, but a great deal of time was spent organising contracts with purchasers and attending meetings. However, Chief Executives had to pretend to be nice to purchasers, and make decision about which franchisees to set up in their hospital foyers. They also had to continue to find efficiency savings and, given their importance, work out how to stop doctors leaving their cars in their parking spaces.
Age 4 – Oppressed Chief Executives (2000s). In the 2000s things turned serious. After the NHS Plan performance management became the defining feature of managers’ lives. Managers were threatened with removal if they fell into low performing categories, and some targets became associated particularly with P45s. Managers therefore became the fall-guys, the scapegoats. Chief Executives moved between jobs more, and we might cynically suggest a key role became working out how to move on before things turned bad, and how to show innovation without destroying your organisation in the process. Ambitious Chief Executives got their Trusts to apply to become Foundation Trusts, but some regretted it later when Monitor, the new regulator, jumped all over them. Older hospitals applied to get PFI builds, and then worried about how to cover the extraordinary capital costs they imposed upon them, especially after the government refused to tolerate budget deficits any more. Without really telling anyone, the government re-introduced a marketplace with non-public providers, and Chief Executives found themselves having to compete for contracts. For the first time, Chief Executives began to find ways of attaching blame to doctors when manifest clinical failure was obvious – but it was time-consuming and difficult to actually do anything about it.
Age 5 – Dynamic Market Executives (2010s). Finally then, we come to the 2010s. Confusion reigns. We have had an election where we were promised no more top-down reform, but a change in government led to a new NHS Bill Key and an extension of the marketplace. However, the government rather bodged the Bill and it is being revised. It seems likely though, that the marketplace introduced in Age 4 will become more dominant. The key challenge will therefore be winning contracts and being competitive in the local health economy, and so working out how to stop the private sector stealing all the routine work. Doctors who under perform will have to sacked. New contracts will have to be won. Working out who to market the hospital’s services to (is it the public? is it GPs?) will become an increasing concern.
So there we are – a flippant journey through 60 years. Haven’t things changed?