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June 20, 2007



Must say I can't see the shareholders letting them go too far down that road - I fear it's mainly impressive sounding rhetoric which has come across a good idea by accident rather than by design.


But when an organisation gets into new areas of methodology (such as government going from paper and pencil and filing cabinets and basic word processors to e-government methods across the internet), then it needs to create or import new managerial skills. Its that failure to embed those skills in the managerial ranks that bedevils so much of UK public sector at the moment.

dave heasman

I think it's Deborah Orr in today's Indie saying, with examples, that clinicians already are in charge of most of the NHS.

ah,, here 'tis



I am been saying for months that we need something along the lines of an independent board to run the NHS. Only, I have been saying that each county should have their own elected commissioners who would be responsible for NHS services in their county.

As a group they could join up at national level and be responsible for deciding what drugs should be allowed on the NHS so they would replace NICE.

At county level they would decide everything they can while at national level they would all decide on things that effected them at national level such as training (we wouldn't have the fiasco we have now with MTAS) and the licensing of drugs.

If the NHS in one area isn't going very well people will know who to hold to account.

The Jiveman

Interesting post and ideas. However, what of the notion that producer interest groups tend to look after themselves and block effective reform and consumer-centric thinking? Is there not an element here of creating deniability for HMG when things go wrong? Political short-termism creates distortions so increased independence and decentralisation for many public services (and tolerance of some inequalities in favour of innovation and diversity of provision)is a good idea. My real fear is that the common sense idea of 'leaving it to the professsionals' may be only a bit better than the other common sense idea of 'loads more funding will make it all better'. Producer interest groups seldom like change.


"I am been saying for months that we need something along the lines of an independent board to run the NHS."

It seems to me that this would simply replace one set of managers with another set of managers. The NHS would still be managed by someone.

Structural problems in the NHS will remain whoever is at the top of the structure, issuing edicts, and pretending to lead.


[Management is not a general skill that can be applied to any organization, but is instead embedded within particular practices. This means managers must have organization-specific backgrounds]

It really is very hard to square this belief with the day to day reality of management. Most of the companies in the FTSE100 (and for that matter the 250) are run by specialist administrators, and it is as often as not disastrous when anyone tries to do it any other way (think of the myriad disaster stories of biotech firms run by chemists or software firms run by programmers). The entire private equity industry is premised on the idea that a suitably motivated top team working with generalised admin skills and financial controls can often do a better job with a company than the "organisation-specific" top management (ask anyone who's sold a firm to private equity who is in charge, btw).

As far as I can see, this statement is purely and simply an assertion, with no evidence backing it up and not much way of ever turning it into a testable proposition. It gets all the rhetorical force it has from the idea that "managerialism" means that the people in charge of the enterprise don't know anything about what they're doing, which would obviously be a strawman.

I note also that many hospitals in the USA (possibly even a majority), and nearly all HMOs, are run by specialist administrators rather than by clinicians. The idea that (for example) George Halvorson of Kaiser Permanente doesn't understand how to run a hospital, or that he would be better if he was an MD doesn't really strike me as all that likely.



It's certainly the case that you need people that understand financing, cashflow, etc. rather than just a bunch of programmers / biochemists / whatever.

It seems as though successful companies are either run by financial admin types who listen to the tech experts on tech issues, or by tech experts who listen to the financial admin types on finance issues.

Perhaps a reason to favour the first method is that tech experts tend (in my experience) to get more emotionally involved with their big idea (and so will ignore the financial realities).

Kevin Carson

Even industry-specific managerial skills are highly exaggerated. When a hospital hires a new CEO, it typically looks for a resume carpetbagger who has held senior management positions at a number of other hospitals, and has thoroughly absorbed the professional culture of senior hospital management. He may well have all the MBA skills of handling finance and marketing, but view the actual process of providing healthcare as a black box. At the top of the organization, as per R.A. Wilson's observations on the filtering of information within a hierarchy, he is more likely to be influenced by the culture of fellow hospital CEOs than by the distorted flow of information from the productive ranks. He is likely to adopt "best practices" based on the glowing recommendations of senior managers at other hospitals, even though they are as clueless as he is about the internal workings of the organizations below them.

Why not decentralize as much control as possible to the individual hospital, and turn local hospitals over to some sort of self-management (perhaps a stakeholder cooperative controlled by representatives of the hospital staff, patient-members, and the local community)?


[financing, cashflow, etc]

but also "management", which is a different competence from the technical aspects of finance, logistics etc. If you have, for example, a surgical team who don't work properly with the nurses, or an orthopaedics team that treats the scanners as their personal property, or a head of oncology that won't stick to the budgets he's agreed, then someone has to sort that problem out. Some people are better at this than others and the art of being good rather than bad is called "management".

If "organisation-specific knowledge" was what it took to run an organisation, then Larry Summers would still be in charge of Harvard.

[Why not decentralize as much control as possible to the individual hospital, and turn local hospitals over to some sort of self-management (perhaps a stakeholder cooperative controlled by representatives of the hospital staff, patient-members, and the local community)?]

Kevin, this paragraph doesn't match up with the preceding one at all. Even if you did this, someone would have to be in charge of supervising the laundry contract, making the payroll, planning the capital budget and so on. These aren't the sort of things that are done well by committees.

Workshy Fop

Unfortunately, it seems like the BNP have got the most sensible policy on workers' councils helping to run the NHS.

Has it really come to this?


the words "workers' councils" and "sensible policy" have not gone together all that well in the past.


Ah, but the managerial genius of the BNP would make all the difference.


The Deborah Orr article is a masterpiece of assertion over evidence. Many hospital departments nominally have a "Clinical Director" in charge, but many of them don't have any actual power to change the things we'd like them to change.

Still, ChrisD has his head in the sand. Machine bureaucracy survives because it is still one of the most efficient ways to get things done. It isn't always the best, but most of the alternatives have yet to prove themselves.


Two words: Soviet Union.

Can you think of anything that the "machine bureaucracy" of the state does in the most efficient manner?


A former colleague of mine's father worked for many years in what is (I believe) an internationally-operating FTSE100 company, moving up from the lowest levels to reach the board. His reaction to The Office? "It's EXACTLY LIKE THAT!"

Which is worrying.

Matt Munro

If you abandon managerialism what would you do with the great tide of mediocrity, fit for nothing but generic public sector middle management, that nu lab have been churning out of Universities for the past decade ?

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