Anyone involved with hospital medicine in the UK should read this report by Harriet Sergeant, written with the financial support of the Centre for Policy Studies and published in 2003. It was written following interviews with chairmen, chief executives, middle management, consultants, matrons, sisters, nurses, porters, cleaners and patients over an 11 months period in six hospitals (3 in London, 3 outside London). It is a damning report which verbalises what we all know - there are too many managers who have little insight into what is involved with clinical care, and who instead, are obsessed with targets (and presumably their bonuses). To some extent they have to be as the government showers unacheivable targets like confetti.
"Managing not to manage" contains numerous observations and quotations. Here are a selection:
Three years ago the Department of Health itself admitted it did not even know how many managers it employed or what their roles were. This year they have changed their definition of an NHS manager to make the increase in their numbers, one suspects, less obvious.
Unlike doctors, nurses or radiologists, management numbers have shot up. Between 1995 and 2001, the number of senior managers has jumped by 48%, and the number of managers by 24%.
By one estimate there are now 270,000 managers, administrators and support people working in the NHS – rather more than one to every one of the 185,000 NHS beds.
The problem lies not with doctors, nurses, cleaners or other staff, but the management and organisation of the hospitals.
If a private hospital was to have the same management-nurse ratio as the NHS it would either have to recruit a further 143 management, administrative and support staff; or sack 186 of their 240 nurses.
Management nearly always work in a separate wing or building to the hospital segregated by a lawn, a tennis court or, in one case, a Japanese garden. They are tranquil, often attractive places that have little in common with the hospitals they serve.
Again and again, chief executives told me their first priority was to appoint a new manager to ensure they were complying with the latest government initiative.
The Government has created a Kafkaesque situation. Hospitals are recruiting more and more managers to monitor care which fails to improve partly because of their appointment. It is not a new situation. Nearly every reform of the NHS has led to an increase in administrative staff.
The changes introduced by Keith Joseph in 1974 had needed, for example, a 30% increase in clerical and administrative staff. By the early 1980s some local health authorities admitted they had no idea how many staff they employed.
The people setting targets at the senior level suffer from, ‘a lack of real world delivery experience and this is shown time and time again.’
The wife of a member of the Cabinet, for example, had a minor operation on the NHS. She by-passed the waiting list and, for security reasons, did not go on the ward but had her own room. When she left, she presented her nurses with a bottle of bubble bath, ‘As if she thought we all took our baths together,’ remarked one.
Even consultants employed by the NHS are wary of using it. One who has worked in the NHS for 20 years said, ‘In the past we all knew we would get good care on the NHS. Five years ago I took out private medical insurance for my family. That’s what I think of the NHS.’
The TUC has certainly made its choice. In the past Bill Morris, leader of the TGWU, and John Monks, General Secretary of the TUC, enjoyed private medical insurance.
More than 3.5 million of the TUC’s 6.8 million members now hold some form of private medical insurance. It is a higher proportion than any other socio-economic group in the UK. Unison, the biggest trade union in Britain representing people who work in public services, displays on its web site what it wishes to deny to the general public: membership of a private health benefit scheme.
The chief executive of a Three Star hospital in the West country made the same complaint. The week after Milburn made his speech on foundation hospitals, they received a letter from Whitehall. Were they interested in foundation status? The note arrived on Tuesday. They had to prepare a response by 5 p.m. on Wednesday.
Another chief executive pointed out that four or five years ago, his hospital had to achieve fewer than 20 targets, ‘and we were pretty clear what the big ones were.’ Since then performance targets have risen to ‘a ridiculous level.’ At any one time he is responsible for achieving 420 targets.
In the financial year ending in March, 2002, remuneration for chief executives varied according to trust size from £72,500 to £114,500. More than half of NHS trust chief executives could have received double figure percentage salary rises last year and nearly a quarter 20% or more. But no one outside the hospital boardrooms will ever know.
A senior non-executive director described some of the managers in her trust as, ‘not up to the job.’ This did not mean she could sack them. ‘The NHS,’ she explained, does not like facing noise.’ Another remarked, ‘Time and time again I have said, “So and So is incompetent,” only to be reproved, “Yes but they are awfully nice.”’ The easiest way of getting rid of these ‘awfully nice’ people in an organisation as huge as the NHS is to promote them somewhere else.
The Government provided one hospital with £750,000 for an MRI scanner. But as the chief executive pointed out, ‘it cost us £1.1 million to install. Running costs are on top of that. The extra has to come out of our capital programme. So we have to cut out something else.’
So, in the peculiar NHS world where, as Frank Dobson remarked, ‘everything is a priority and nothing is a priority’, the chief executive of an NHS hospital asks himself one important question ‘I can’t afford to fulfil all these targets. So which five targets can I be sacked for?’
No other organisation worth more than £45 billion would allow £100 million units (the average cost of running a hospital trust) to be managed by people who have little or no management background except a diploma in health management.
A porter in the West Country had this to say on his hospital’s middle management. ‘We have 20 to 30 managers. Half of them don’t know what they are doing. They hang around the coffee shop and get in my way when I am trying to push a patient through.’ One of his patients, an entrepreneur, raised his head to stare, ‘If I had that many managers,’ he remarked to the porter, ‘My company would be bankrupt.’
Senior officials admitted they had no idea how many managers worked in the NHS or what were their roles.
And figures released in June this year by the Department of Health show the numbers of managers in the NHS soared by three-and-a-half times the rate that nurse numbers rose between 2001 and 2002.
In its 1995 yearbook, the Institute of Healthcare Managers listed 1,700 health service job descriptions. This year the figure has increased to an astonishing 5,529 and includes 41 different types of service manager and 50 different categories of project manager. They are all engaged in meeting Government targets, collecting data for the Department of Health, writing reports and checking their trust is compliant with various Government initiatives. What they are not doing is looking after patients.
The non-executive director explained, ‘We are forced to make appointments that should be way down on our list of priorities.’ When this happens ten times, the hospital finds itself with ten different initiatives, each of which requires a management department to implement them. ‘it’s a disaster.’
The constant re-organisations, I was told again and again, sap morale and breed cynicism. Since its inception 50 years ago, the NHS has been in a state of revolution. No NHS White Paper, for example, has ever been carried through in its entirety.
Middle managers made the same complaint as top management. Too much time is taken up by the, ‘obsessive desire for information’ from the Department of Health. ‘You’re ruthlessly pursued for information,’ said the waiting list manager of one hospital.
Hospitals are taking on administrators just to collect information. NHS management journals are full of adverts for information analysts, service planners, user and patient access managers alongside programme facilitators, emergency service facilitators and shared care facilitators. Statistics have to be collected weekly and sometimes even daily on emergency admissions, day case surgery, trolley waits, bed occupancy rates, numbers of cancelled operations and so on. The NHS Confederation pointed out that even getting the required detailed information on just one of these statistics can take up to 200 pages.
The Head of Treatment Management Systems in a hospital in the West Country agreed, ‘I am so busy reporting that I do not have time to get on with any work.’
Information gathering does not come cheap. Salaries for these new managers can reach £60,000. Their appointment at the expense of front-line staff goes part of the way to explaining the discrepancy between spending on health care and the benefit to
patients. Between 1999 and 2001 hospital funding increased by 21.5%, but the number of completed treatments rose by just 1.6%.
Clinical staff complained repeatedly of management stonewalling their ideas to improve patient care or increase efficiency. Years passed, meetings were held, opinions solicited but nothing happened. One young surgeon recalled being told to go away and write a business plan.
‘Good managers work with doctors – but so few do,’ said one auditor.
The Irish sister had scant respect for new nurses, ‘They picture themselves at a computer or with a doctor on his rounds. They are horrified to discover that 90% of their time is doing things for the patient.’
There is much more, so I urge you to read the whole report.