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January 11, 2007

Comments

dsquared

[couldn’t the NHS be better run simply by increasing the degree of worker control?]

which workers? The doctors, the nurses or the adminstrators? (Or are the administrators not workers in this taxonomy?) Surely conflicts and lack of co-operation between the functions was the whole theme of this series, and I don't see how that process is going to be managed without managing it.

chris

I left that question open because it is an open question. All I'm doing here (and in most of my posts on managerialism) is asking the question that no-one does ask: why should managers have unquestioned control over organizations?
In theory, ultimate control could lie with consultants, with managers being administrators answerable to them. Or it could lie with some mix of consultants, junior doctors and nurses, or with patients' groups. The question is: which structure works best? I just don't see why this is such a stupid question that no-one thinks it worth even raising.

ian

*In other words, the progress that was made came from empowering staff, not from bringing better management.*

Isn't empowering staff of itself, better management? The managerialism you - rightly - criticise is in reality a substitute for the real thing.

dsquared

Chris, did you watch the Gerry Robinson show? The entire program was about the fact that the consultants did, in fact, run the show, and that the adminstrators couldn't, in fact, tell them what to do for the most part. Not only that, but the consultants formed little cliques (surgeons vs anaesthetists, etc) against each other. All of the ideas that Robinson introduced were being blocked by consultants, anaesthetists and nurses who didn't want to change working practices that suited them, or who didn't want to give up "ownership" of their patient. Robinson's entire role there was to try to put people in rooms together and force them to iron out their differences. Were you watching a completely different program from me?

dsquared

And also, it wasn't from empowering staff. The big improvement in waiting lists came from persuading the peadiatrics consultants to take on two more patients per clinic. That was an issue of industrial relations. The big thing that Robinson wanted to achieve but didn't was to make staff show up on time for operating theatre, and it turned out there was no effective sanction to make them do this.

Marcin

The message I took from this was that hospitals would be better run if they adopted the structures used by law firms or chambers: the management are the handmaidens of the (senior) professionals, and serve at their pleasure, but they rarely actually interfere in their decisions, and if they have to, they are likely to fire them. Equally, the profit motive focuses minds: the senior professionals (consultants) should take the surplus of the hospital, and the hospital should be paid in a sensible way for the treatment of patients.

dsquared

????

[The message I took from this was that hospitals would be better run if they adopted the structures used by law firms or chambers]

law firms? Law firms are the most notoriously dysfunctional organisations I can think of. I'd be happier running the NHS along the lines of brothels or crackhouses!

sanbikinoriaon

I think most of the patients might enjoy that, too.

Katherine

Law firms are the most notoriously dysfunctional organisations you can think of? How so? They are dysfunctional in their own way, but law partnerships, like accountancy partnerships, have proven to be a very resilient structure for "managing" professionals who often have an inflated sense of their own abilities and importance, not unlike, say, consultants.

dsquared

In the sense that they are extremely resistant to necessary change, they have some of the most poisonous and appalling industrial relations practices around, and most importantly, they aren't very good at delivering the right quantity of services to the clients at the right price. Look at it this way; when did you last hear of an in-house *medical* department?

Bishop Hill

I'm surprised nobody has picked up on the consultant saying that the same surgeon got through twice as many patients while doing his private work as he did when doing his NHS work.

We need the profit motive.

Katherine

The fact that you get in-house legal departments doesn't have anything to do with the viability or not of law firms. Does the existence of in-house marketing departments mean that marketing companies are crap?

And what is your source for saying that law firms aren't very good at delivering the right quantity of services to the client at the right price?

chris

D2 - the claim that "the consultants did, in fact, run the show" supports my argument. Under the present arrangements, consultants have power but little responsibility, whilst managers have responsibility but little power.As there's no feasible way of disempowering consultants, why not give them the responsibility for running hospitals that their power gives them.
Shouldn't businesses be run by those who provide the most important asset - and it's the consultants who do this?

dsquared

[As there's no feasible way of disempowering consultants, why not give them the responsibility for running hospitals that their power gives them. ]

Because they have neither any interest in being administrators, nor any particular skill in doing so. And because this would reduce the amount of time and energy available for clinical work. There certainly is a way of disempowering consultants, because the actual organisation of hospitals in the USA provides a model.

[Shouldn't businesses be run by those who provide the most important asset ]

In general, no, not at all. This would have mining companies run by geologists and oil companies run by wildcatters. Or many other companies run by salesmen. Or software companies run by programmers (this last one is a nearly-certain recipe for failure). Administration and planning, particularly in large organisations, is a separate and different skill. This is Alfred Chandler stuff. Look how much better American universities (in general, managed by specialist administrators) do than British ones (in general, managed by committees of academics).

I really think that this is a case where your excellent analysis of hammers has led you to misidentify a screw as a nail; the critique of managerialism has crept beyond its borders into a criticism of management. Any generalised attack on managerialism which ends up suggesting that the Chandler/Sloan/Taylor managerial system is fundamentally incoherent or flawed, really has to come up with an explanation of how these managerialist idiots managed to provide the golden age of American industry (and indeed, how General Electric still works today). I'm sure you've read Drucker on this and I guess it might be in the book but at the moment, I don't think you're giving managerialism anything like a fair shake.

Planeshift

"We need the profit motive."

It would certainly cut waiting lists. Those who could afford it get the operations, those who can't die.

ChrisA

As a free marketer I find myself surprised to be supporting the idea of socialised medicine, insurance based systems in practice seem to cost lots more and result in unecessary treatment. But it would be nice to see some customer responsiveness in the NHS. I was always impressed by the argument in Jared Diamond's Guns, Germs and Steel about how the countries of Europe, because they were fragmented, were able to come up with much more innovation than giant China with it's single political system, where a solution could be imposed by a centralised leadership. Consequently I have always thought that the NHS should be broken up into many small units, answerable to local politicians at level of a county say. Then if one of the local counties wanted to try something different, like having consultants manage the hospital it could be easily tested. Others would then follow if this was successful.

Kevin Carson

"Any generalised attack on managerialism which ends up suggesting that the Chandler/Sloan/Taylor managerial system is fundamentally incoherent or flawed, really has to come up with an explanation of how these managerialist idiots managed to provide the golden age of American industry (and indeed, how General Electric still works today)."
--dsquared

That's a bit like saying "anyone who suggests turtles can't climb really has to come up with an explanation of how that turtle wound up on top of the fence post."

The giant oligopoly corporation functions within a state capitalist framework that subsidizes most of the diseconomies of large scale, and (through patents, cartelizing regulations, etc.) insulates them from the worst competitive penalties for excessive size and hierarchy. Without subsidies to centralization and accumulation, I'd expect to see an economy primarily of small-scale manufacturing for local markets.

The average Fortune 500 Corporation "competes," if you want to call it that, in an oligopoly market dominated by a handful of firms that share the same dysfunctional organizational culture, and are managed by the very same MBA types who received the very same curricula in business school.

One might as well have asked how Gosplan and the industrial industries managed to "work" in, say, 1950. A better question would have been how could they possibly *not* work, under the circumstances?

Re Chris' throwaway line on workers' control, I think *any* form of stakeholder cooperative would be better at dealing with agency and informational problems than a professional management representing the state as absentee owner. Ideally, NHS hospitals should first be decentralized to local control, and then organized through some admixture of consumer cooperative (patient representation) and worker self-management.

Eric H

[Any generalised attack on managerialism which ends up suggesting that the Chandler/Sloan/Taylor managerial system is fundamentally incoherent or flawed, really has to come up with an explanation of how these managerialist idiots managed to provide the golden age of American industry (and indeed, how General Electric still works today).]

In order: what Kevin said, WWII, and inertia. The original Sloanist/Taylorist organization, GM, rose thanks to Ford's personal decline and WWII. Toyota's car business was put on hold for the war period (which lasted a lot longer for Japan than 1941-1945). GM got a 20 year head start by being on the victorious side in a war that also devastated Europe, but is losing the lead rapidly, so it's hard to say that GM's model was superior. IIRC, the only profitable units in either GM or GE are the lending businesses.

But the greater point is Kevin's about large corporations operating in a state capitalist framework. I'm currently reading Marc Levinson's The Box, and it is amazing how, at every stage of the development of the shipping container, the ICC, Port of NY Authority, and various wartime and maritime subsidies and rules shaped the game.

I'm a great deal less optimistic about workers' running the business than I am about patients' cooperatives, but I do believe that decentralization is part of the key.

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