The management con

What do bosses do? This old question gains force from two sets of figures released about the NHS yesterday.
First, the number of managers in the NHS has risen by 83.9% over the last 10 years; that compares to a rise of 48.4% in the number of doctors and 26.6% in the number of nurses.
Second, the ONS estimates that health service productivity fell by 2.3% between 1999 and 2008.
Hence my question. A naïve person might think that the purpose of managers is to improve efficiency. He would therefore expect productivity to have risen as the numbers of managers rose. So why hasn’t it?
It could be that the ONS has mismeasured productivity and on some other measure management has improved efficiency. Or it could be that some of the growth reflects title inflation rather than substantial change. Or perhaps there are lags between increased management numbers and efficiency gains. Or maybe the link between managers and productivity is non-linear, and more managers would increase productivity; note that even now, only one in 32 NHS staff is a manager.
There is, though, another hypothesis that fits the evidence. It’s that management is a con-trick, promising - but never actually delivering - increased efficiency. Stephen Marglin's famous answer to my question was right.

Comments

[Matthew]

Or couldn't it be that falling productivity has to be fought by introducing more managers?

[chris]

That's a possibility, Matthew. If, say, the "knightly motives" of medical staff have been declining, more managers might be necessary - because external supervision is needed to replace the internal supervision of professionals' conscience and sense of duty.
But the question is: why might knightly motives have declined? One reason could be the increased managerialization of the NHS. Which suggests a multiple equilibrium problem.

[Matthew]

Does it even need that - couldn't it just be that the running the NHS has got more complicated?

[Chris Williams]

I've got say that if I was asked to estimate the number of managers in the NHS, and what's happened to it over the last 10 years, "Going from 2% to 3%" probably wouldn't have been the answer.

[Guano]

The internal market.

[guthrie]

But surely more managers is unnecessary what with the introduction of modern computer systems and efficient methods of practise?
Or did they get rid of all these beds for nothing?

[[email protected]]

The NHS is a command and control organisation. This means that it is structured in terms of top-down control.

For control to be exercised, managers are needed to direct and organise what staff do. It doesn't work of course. In command and control organisations the understanding that it 'hasn't worked' merely leads to a belief that it is (a) the wrong sort of control (b) a poor manager (c) increased volumes of control.

When organisations study themselves as systems, they begin to see this for the first time. This clarity allows systems designs to free up workers in the frontline to think and control their own work. As this happens, quality increases, staff and service user satisfaction increases and costs go down.

At the same time it exposes the damaging control that politicians bring into the system through well-intentioned tinkering.

[Richard T]

It is likely to be the case that a good proportion of these managers are medical professionals themselves. They will either have been given grandiose new job titles (like many other non medical and support employees) or will be in newly created posts which include Manager in the title.

My take for what it's worth is that these isn't enough good management in the NHS - partly as a result of persistent micro-management by central bureaucracy. The horror stories of filthy wards would not happen if the NHS was actually well managed.

[Metatone]

Treating the NHS as a single entity doesn't reveal everything. I don't have figures to hand, but there are wide variations in where management has grown. I believe in PCTs it has grown much more substantially than in other areas - mainly as they try to grapple with the pseudo-market proposals that are "commissioning..."

However, I think that rather than just questioning the role of managers, chris, you should be up for the challenge of questioning managerial metrics - exhibit 1 - the broad brush way productivity is measured for the NHS. Focus some of your talented scepticism on this number - please!

[Greg]

More managers and more money for the fat-cats at the top of the NHS. Result? Less money for front-line staff and major cut backs to reduce the £20 billion 'black hole'. It is about time that changes were made, such as those proposed by The Jury Team (http://www.juryteam.org/).

Their proposal, which could save the NHS, is that all non-EU citizens should be required to have private medical insurance- at an estimated saving of about £4 billion (http://www.juryteam.org/p07-requiring-medical-insurance.php).

With this extra money to spend, the NHS would not have to make such drastic cuts and urgently-needed nurses could be employed.

[guthrie]

You could just scrap the PFI, that would save a billion or two. As well as preventing pay rises for senior management.

[charlieman]

Has anyone here endured PRINCE2 training? Employers pay £1,000 per head to training providers who teach that a formal method will act as a substitute for business knowledge and training. That is £1,000 not spent on the core business: making widgets.

The message is that you don't need smart workers and that "the process" will deliver productivity. Unsaid, is the requirement for more managers.

"The process" defines that ordinary workers are disposable and replaceable. Their pay is determined by "job role" rather than ability or talent. Jo Useless gets the same wage as Jo Useful. The same rules do not apply to managers; they are rewarded for perceived talent.

(PRINCE2 is allegedly a project management methodology; those who are daft enough to adopt it use similar top-down methodology elsewhere in their businesses. I would vote for any party except the BNP that barred such methodologies from public bodies.)

[Guano]

The internal market. Commissioning. Go and ask you nearest PCT how many staff are in "commissioning" and then try to understand what it is.

[dreamingspire]

PRINCE2 degenerates into PINO - Prince In Name Only - as is well known by agents who do the hiring of contract workers. An associate whose market had died at the end of 2004 turned to an agent and was pushed into a govt project where he asked for the Project Inception Document and found that it did not exist. His agent then explained to him to the PINO method.
The public sector still believes that a good Manager can manage anything...

[[email protected]]

Isn't it funny that even though the majority of government/public sector organisations demand that workers making change (or even all managers) are qualified in PRINCE 2 little has actually improved? Could it be that PRINCE 2 is neither a method for effective project management NOR a method to inform or tell you how to change and what to change to?

It is of course, a rhetorical question....better method required...

[chris y]

The problem in Britain is that Prince 2 has got a stranglehold because it's mandated for all government contracts (it was invented for internal use in the Civil Service), so everybody and their dog has adopted it because that's where the big bucks are. It makes getting a better method widely accepted quite hard.

That and the fact that if it's followed at all closely, it's the most comprehensive arse covering and buck passing system ever devised by human ingenuity.

[jameshigham]

First, the number of managers in the NHS has risen by 83.9% over the last 10 years; that compares to a rise of 48.4% in the number of doctors and 26.6% in the number of nurses.Nhs

Both staggering and frightening, in terms of the quality of patient care.

[[email protected]]

There has probably been an increase in efficiency.

The EU working time directive forces junior doctors to not work more than 45h pw - down from 100h pw or so.

There is also a continual pressure (from management) to reduce the number of sessions a consultant works - many on the old contract can work 13-14, rather than 9-10.

All you can be sure about is that it is a mess.

[Pat Pending]

Lies, damn lies and statistics..

the 26% increase in nurses will constitute far more people (from a much larger base) than the 48% increase in doctors.

The 84% increase in managers could be from a small base therefore the headline not quite as it seems. We need the absolute numbers to make sense of this.

However, I doubt the manager numbers are small..