But why would a doctor know how to run the NHS?

Here are six ways to save the NHS, Mr Hunt. Trust me I’m a doctor

They’re big on management training, finance, MBAs, in medical school these days are they?

We know you love a jumble sale, but try not to flog off too much more of the NHS to the nearest snake-tongued bidder with fistfuls of notes. Private entities should not be taking public cash to provide public services. Every penny that becomes profit for shareholders is a penny that should have been spent on the NHS.

Ah, no, obviously not.

Just to make sure for dimmer readers, the correct comparison is between the greater efficiency of a private, profit making, organisation, and the amount that it skims off in that profit. It’s possible that a private company isn’t more efficient than a bureaucracy – this really does actually happen. There are also times – and this too really does happen – when the private company is more efficient. And more efficient by more than that profit margin.

The trick is to know when which case applies, not a flat insistence that profits are money not being spent upon the delivery of goods or services. That last would be just to betray one’s entire and total ignorance of finance, management or even reality.

45 comments on “But why would a doctor know how to run the NHS?

  1. Every football fan thinks they should be made manager for a day.

    In football at least, managers are drawn from the ranks of former players; though they were rarely distinguished players. Those who can’t, manage?

  2. Private entities should not be taking public cash to provide public services. Every penny that becomes profit for shareholders is a penny that should have been spent on the NHS.

    Two ways of looking at a public service. One is as a provider of services to the public. We usually want said service provided in the best and most efficient manner possible. Regardless of who is providing it. The other is as a series of sinecures for people who never have to do any real work again. Naturally it is not hard to see which most NHS doctors would prefer.

  3. I thought the “master of bugger all” was evidence of inability to manage. It’s definitely evidence of wanting to be a “management consultant”, most of which consists of telling vastly more experienced people how to pick their own noses.

    Most management, scratch that, all management (perhaps the sole exception being selected adminny type activities if cheaper staff are available), is really better done by people who have done the job, not those with a theoretical knowledge of management bullshitese.

  4. ‘The NHS is all about the people who work there, beleaguered and exhausted as they may be.’

    May be not.

  5. ‘The NHS is all about the people who work there, beleaguered and exhausted as they may be.’

    In a private service, it would be about the patient.

  6. Most management, scratch that, all management (perhaps the sole exception being selected adminny type activities if cheaper staff are available), is really better done by people who have done the job…

    …and are too lazy to do it themselves. Like me, for instance.

    Management is largely about doing a lot of upfront work to get plates spinning, then sitting back and giving the plates a flick every now and then letting them do the actual work, and reacting if and when a plate crashes to the ground. The downside is a manager – in theory, but rarely in practice – is accountable if those plates stop spinning for whatever reason. The last thing you want to see managers doing is running around like blue-arsed flies once the initial setup is done. If they’re doing that, they are likely micromanaging and/or firefighting and aren’t really managing.

  7. “Private entities should not be taking public cash to provide public services”

    I wonder where the limit is for this, particularly in terms of what the public will tolerate or what left-wing politicians will agitate for.

    GP surgeries is one example but perhaps not a great one since surgery profits are basically another way of paying doctors.

    Pharmacies? Medical-specialist temping agencies? The drug companies? Opticians and dentists? Think this lot are all pretty safe, if only because of the scale of the effort that would be needed to acquire them.

    Cleaning agencies? Management consultancies? Private ambulances and blood testing labs? I think there would be folk arguing that lot should be brought in-house who would get a sympathetic hearing from the public.

  8. Andrew M,

    I think it’s more about the blend of skills. Great players have all their eggs in the playing basket. Managing a team means you have to have other skills like leading people, understanding the overall game.

    The best programming team leaders were good programmers but not great ones, in my experience.

  9. Great players very often try their hands at management and don’t seem to do all that well. It’s just a different skill set. Managers need to be brain clever in a way that players do not. We know Shearer would be a shit manager.. not just because he briefly tried and failed, but because his punditry makes it clear he knows how to be a dirty striker.. and fuck all else. The only thing he could offer his midfield would be tips on how the dirty striker likes to receive the ball. That’s not enough. Listen to Martin O’Neill, on the other hand, and he’ll explain how the whol game is being played. He was a good manager.

    Ferguson was an average player. Clough was outrageously good, but without much play at the highest levels. Wenger and Mourinho never played. On the other hand, Pep was a top pro.. if not a superstar. That the greatest managers of all weren’t great players does not mean they simply excelled at the lesser role. That’s like saying Shillton (shit manager) kept goal because he couldn’t kick. Well Kenny Dagliesh (great player and manager) couldn’t catch a cross or get across his area to pluck something out of the top corner. He didn’t need to.

  10. “Private entities should not be taking public cash to provide public services.” – guess that’s most councils scrapping their bin collection contracts then…

  11. I work with the NHS in my professional life. With only a few honourable exceptions, NHS organisations would be better managed by a collection of drunken mice.

    Unfortunately, there are few things as stupid as a highly educated person—especially a highly educated person in thrall to their union. As such, there is a concerted effort by doctors and nurses to attack the Health Secretary—partly, at least, because they lack the balls to criticise their bosses.

    This is unfortunate because it is these bosses—the Trust managers—who really need to be brought to book. Money is wasted at a terrifying rate on, for instance, unsuitable software systems; and the insane staffing levels in, as an example, A&E are a direct result of a lazy failure to understand problems and think (even vaguely) creatively about how to fix them.

    Got a shortage of nurses for triage, for example, in night-time A&E? Then why the hell is a Band 6/7 nurse managing the department? That is what managers are for: put one in, and free up said nurse for triage.

    The above is a very basic example, but it is also a real world one—with a blindingly obvious fix.

    DK

  12. Private entities should not be taking public cash to provide public services.

    With no attempt to justify this claim, it remains just groundless dogma. Statist has statist views; report at 11:00.

  13. “Here are six ways to save the NHS, Mr Hunt. Trust me I’m a doctor”

    I haven’t read it, but I’m guessing one of the six is higher pay for people working in the NHS, and specifically doctors, right?

  14. Ha ha, No 2 on the list.

    I love the way that ‘Pay me more money for doing the same job’ becomes ‘Invest in doctors and nurses’ though. Makes blatant greed sound so positive!

  15. I’ve never figured out why nurses and doctors are managers.
    Sure, the managers need to know what the staff do. They don’t need to know how to do it.
    Get a doctor managing doctors and he’s getting a lot of money for doing non medical stuff.
    Get him doing medical stuff and get the admin done by a manager.
    Staffing, disciplinary, paperwork, meetings to feed down management information – no need for medical staff to do them.

    Was at the local hospital for a scan on the wife a couple of weeks back, 10am on a Saturday morning. The person on the desk was admin, the person managing her was a nurse. The desk jobs are admin, the nurse manager was handling a half dozen desk staff. Why use a nurse rather than an admin manager?

  16. So….. my local council should set up a bakery and a farm and a dairy and an electricity company and a gas company and a waterworks company…. The return of municipal corporatism.

  17. @Jim

    “I love the way that ‘Pay me more money for doing the same job’ becomes ‘Invest in doctors and nurses’ though. Makes blatant greed sound so positive!”

    The sensible use of the phrase “investment” would be to invest more in training them up at areas there’s a skills gap, getting more graduates down the pipeline, and so on. If anything I thought that might suppress pay (at an individual level anyway, and particularly in those areas there are skills shortages). Or is the international labour market for medicine and nursing too interconnected for that to happen, and the NHS just has to pay the international going rate?

    Is the bigger problem for staff retention and recruitment that staff who have got fed up with the job just quit, or don’t sign up in the first place, or is it that opportunities abroad are more attractive? Have the feeling doctors are more likely to go overseas and less likely to switch careers than nurses are but that’s mostly anecdotal.

  18. “Then why the hell is a Band 6/7 nurse managing the department? ”

    For an equivalent position in a (functional) private company, a good manager would be getting their hands dirty while under staff pressure. The admin can wait.

  19. I’m wondering if we can actually test this proposition?

    Surely some of the NHS trust management are doctors and/or nurses?

    Are their fiefdoms any better run? Better patient outcomes? Better use of finances? Better budget management?

  20. 10 years ago Gerry Robinson made a short BBC series called “Can Gerry Robinson Fix the NHS?”. I guess the answer was no.

  21. ‘But why would a doctor know how to run the NHS?’

    Indeed. Doctors know how to run the NHS for doctors benefit!

    It’s akin to lawyers running the government. Gives us such absurdities as “punitive damages” in civil cases.

    Which, BTW, adds substantial cost to health care in the US.

  22. I’ve seen the theory that a lot of the truly great players make poor coaches or managers as they can’t really explain how they can do what they do, a level
    Of natural talent that sets them apart, whereas the guy who had just scrapes in and has to work and hone his lesser natural talent is much more rounded as a coach and manager and can articulate who and what needs to be done

  23. I suppose that a disadvantage of attending the LSE is that, at an impressionable age, one is not subjected to a preposterous barrage of claims that medics know everything. Very revealing, that barrage.

    Two things I learnt about young medics: (i) they are usually clever (ii) they are remarkably uninquisitive.

  24. BniC – yes that’s pretty common across the workforce too. Lots of people can do jobs but they now operate on an intuitive level, explaining the why and how is beyond them.

    A good trainer / teacher can break something down and explain the process. Knowing how can help improve on the what.
    Some big sports stars hire coaches for particular skills, people of lesser skill than them (usually) but better able to explain, show, record, enhance and improve the skill. So while they have a general coach for their overall skills they have a one on one coach for a particular skill they want to focus on.

  25. @dearieme: my experience exactly. When I was up at uni, St Mary’s Paddington was merging with the other three constituent colleges. We met a lot of medical students and they were an intellectually stolid bunch. I think a lot of it has to do with the nature of medicine and the training involved. Probably the chief skill a doctor needs is a good memory, to riffle through the database in his brain and diagnose. But that’s not very conducive to independent thought. Medical knowledge comes de haut en bas. There’s also the God complex: I’m sure a lot of medicos think, “I have the power of life and death over my patients; I am very smart; how hard can running a health system be?” Scientists and engineers tend to be a bit more humble, because they know how intractable complex systems are.

  26. Hospitals, apart from A&E, are essentially hotels with operating theatres attached. Since the vast majority of surgery is elective, maybe the NHS should think about getting in a few managers from the cheaper, bulk, end of the hotel trade. A few Marriott, Hilton National and Best Western executives should be able to get your average hospital demonstrating a smidgen of efficiency.

  27. Devil’s Kitchen,

    “I work with the NHS in my professional life. With only a few honourable exceptions, NHS organisations would be better managed by a collection of drunken mice.”

    I’ve done a couple of software consultancy jobs, so glad it wasn’t just me.

    “This is unfortunate because it is these bosses—the Trust managers—who really need to be brought to book. Money is wasted at a terrifying rate on, for instance, unsuitable software systems; and the insane staffing levels in, as an example, A&E are a direct result of a lazy failure to understand problems and think (even vaguely) creatively about how to fix them.”

    I did something to do with district nurses. The people in charge had no clue. They had no tracking of nurses, patient data in all sorts of places like Excel workbooks. So, a nurse was ill, they couldn’t handle it.

    “Got a shortage of nurses for triage, for example, in night-time A&E? Then why the hell is a Band 6/7 nurse managing the department? That is what managers are for: put one in, and free up said nurse for triage.

    The above is a very basic example, but it is also a real world one—with a blindingly obvious fix.”

    The district nurse service I went to was almost randomly scheduling nurses. So a senior nurse was booked on trivial jobs. Which then meant they couldn’t do jobs, instead of scheduling junior nurses. It didn’t seem like rocket science to suggest assigning the most junior nurse that could do the task in hand.

  28. “Scientists and engineers tend to be a bit more humble, because they know how intractable complex systems are.”

    I never met a humble electrical engineer.

  29. “Lots of people can do jobs but they now operate on an intuitive level, explaining the why and how is beyond them.”

    I consider it a problem of empathy. Not in the altruistic sense, rather an inability to understand the trainee, their current level of knowledge and how to communicate with them.

    I was in management off and on for most of my Big Corporation career. I knew smart people who couldn’t teach anybody anything. Not because they didn’t understand the subject, but because they didn’t understand people.

  30. It would be useful if you defined “efficient”. I do hate the lazy use of this word without any indication of the underlying assumptions. In the context of a healthcare service, what exactly is efficiency? Believe it or not, there are whole text books devoted to trying to decide how to measure “outcomes” in health, and no reliable, quantifiable method has yet been devised. Without this the concept of efficiency is restricted to meaning getting the maximum patient “episodes” or even “encounters” for the minimum outlay. But this tells us nothing about whether these encounters produced a beneficial or useful result, or whether the number of encounters was in any way related to the type of result (given we cannot measure the result in any useful way). So, efficiency becomes a proxy for cost controlling. Here it may be true that the rather simplistic argument about “efficiency” versus profits is valid. But it does completely ignore the much more significant issue of whether the “efficient” spending is actually “effective” in terms of useful health outcomes.

    If I were a snarky blogger, full of ill informed opinion and more knowledge than intelligence or insight, I might be tempted to suggest that your rather facile comments betray your entire and total ignorance of the subject, and of reality.

  31. @Zoltan
    The point isn’t that a private company should be able to deliver better health care than the NHS (although it might), it’s that it can deliver the exact same healthcare at less cost.

  32. I’m fine with this suggestion provided that the “not allowed to make a profit” also applies to doctors, nurses, pharmacists, NHS Managers etc. Whatever it costs to get them into and out of work is all that they should be paid. They are not allowed to make a profit on their day’s labour.

    This would reduce the cost of the NHS to so that the taxpayer could afford the additional cost of having bureaucrats running the thing!

  33. Recusant and James, you are fucking idiots.

    1) Hospitals are “hotels” because British people don’t want to take care of their elderly parents or they expect the government to do it for free. Less than 25% of hospital spaces are related to surgery. Guess what happens in winter – old people get sick so elective surgery gets cancelled because there are no places for them to recover.

    2) If the NHS did not pay doctors, but provided free accommodation and meals and expenses for keeping a spouse and children (you know, the things people spend their salaries on), quite a few of them would actually take this up. After 5 of so years of working in the NHS most idealistic types grow up though.

  34. Scientists and engineers tend to be a bit more humble

    Right up until the moment they step through the doors of a major oil company. I’m telling you, most of our guys would make Trump look like a model of humility.

  35. It would be useful if you defined “efficient”.

    So we can’t define “efficient”. Fine, I get that. But we can define “inefficient”, and point to numerous examples of it. So let’s work on eradicating inefficiencies, rather than striving for efficiency.

  36. “So we can’t define “efficient”. Fine, I get that. But we can define “inefficient”, and point to numerous examples of it. So let’s work on eradicating inefficiencies, rather than striving for efficiency.”

    Nicely phrased: worth repeating often.

  37. ‘They’re trappist monks next to the process engineers.’

    Never met a process engineer who’s ego was so annoying I couldn’t work with them. Now, I knew some process engineer managers who were that way.

    In my business, most process engineers were mechanical engineers by training, with a handful of chemical engineers thrown in.

  38. Zoltan,

    Thing about some “snarky bloggers” is that we’ve spent 30 years working on business systems, both human and computer.

    What I know absolutely nothing about is clinical work, and absolutely nothing about clinical priorities. I wouldn’t argue on those grounds with medical people. There might be medical people who can look at the situation and see problems, but that’s not my focus. My observations about the NHS relate to clinical practice.

    But if your organisation spends £11 billion on a software project that fails, it’s not hard to see that that’s £11bn that could have been spent on better equipment or more clinical staff. That’s what the focus of NHS management should be – working out how to get the most value from staff. And there’s areas where that would be, say, disciplining nurses or training nurses in improving what they do at a clinical level, but it’s also about things like giving district nurses a sat nav so that they spend less time driving, so they get more appointments.

    The NHS complains constantly about the cost of missed appointments, yet the NHS has been very slow to take up SMS reminders, something that everyone from hairdressers to dentists has been doing as a matter of routine for a decade because they know that it reduces missed appointments. Like, projects that take years, when the free market gets this stuff implemented in months.

    But in the clinical field: why did it take an employee of a funeral parlour to spot that Harold Shipman was excessively killing patients? I’m not even talking about murdering people. If you’re managing a thing you have to be tracking the results. Clearly, the NHS wasn’t. OK, it brought that in, but only after mass murder and an inquiry. Or the current thing about excess use of antibiotics and giving out advice. We’ve had computer systems for at least 30 years in business where we record what branches of companies do. It shouldn’t be hard today to have the data on every prescription written by GP practices and to work out who is oversubscribing antibiotics and get onto them.

  39. Over a period of about two years (which should have been a few weeks) I had extensive contacts with the local outsourced, privately run, ENT service. It is, by a large margin, the most inefficient organisation I have ever dealt with in any capacity.

    To give a single example from a long and tedious list: it took them over a year to book the MRI scan it was agreed at every stage I should have. And then they forgot to tell me about it – I found out by chance a few hours beforehand when I phoned to repeat my occasional enquiry into what was going on, and, unusually, a human being willing to look things up answered the phone.

    As someone said, it’s not difficult to point to inefficiencies. But it’s hard to define efficiency in a way that gets the incentives right, whether or not the private sector is making a profit out of what you’re doing.

Leave a Reply

Name and email are required. Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.