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Something rotten in the state of Denmark

February 24, 2015

By Basket Press

A return to the topic of management culture is needed to expand on previous posts, highlighting, via selected snapshots from my career, the extent and duration of problems, especially as Francis 2 refers to the Health Service Journal’s “be nice to managers” campaign. Pro tip, HSJ: when managers stop bullying and harassing staff we might revise our views, not before. I emphasise this is not “knee jerk manager bashing” but views formed over 30 years of observation and experience.

Often NHS management is a closed, self-selecting, self-serving group to which only those who espouse the current party line or belong to an “in-group” gain entry.

When I was a student, promotion in nurse management required belonging to the same church as the Director of Nursing Services mentioned earlier...Unless it was just coincidence that all the nurse managers just happened to be members of that church.

In another job we had a service manager whose partner was appointed team leader. This relationship was well known within the organisation, including to more senior management, and yet the former was allowed to investigate the latter’s team during a Severe Untoward Incident inquiry. And to continue acting in a supervisory capacity. Worse, the manager was the appointing officer when their partner got the team leader post. And this was OK with the trust. As was this manager sending details of another team leader post, only open to internal candidates, to a drinking buddy in another trust, then appointing said buddy over two very good internal candidates…And doing the same again six months later. This manager didn’t like me much, as I publicly disagreed with or challenged what they said when I had evidence that they were wrong. I wasn’t a drinking buddy: I couldn’t stand the stench of corruption.

The Griffiths Report, which introduced general management, let the genies of short-term thinking and performance related pay and bonuses out of the bottle with consequences I hope he didn’t intend.

In the early ’90s, after acting as ward manager, before I did it permanently, I applied for the NHS graduate management trainee scheme (I had a degree before entering nursing). I was lucky enough to get a first interview, despite claiming my success in arguing for a budget increase to employ more nurses as a management achievement on my application (financial pressures and the need to cut costs have been around as far back as I can remember).

At interview I “forgot” where one of the panel worked when asked about spending priorities for a general hospital. Oh, it was all QALYs this, dialysis that, commonest complaints the other, hip replacements, and all the boring things having more effect on most people, so spend for the benefit of the greatest number. If only I’d stopped there. However, I criticised the spending plans of a local hospital, known to be putting most of its money into a new cardio-thoracic unit dependent on extra-contractual referrals from across the region, pointing out that all it would take was another trust anywhere nearby to open a similar unit and their financial model would be wrecked, so it would be more prudent and better for more of the local populace to spend differently. One of the panel was the manager for said unit…I didn’t get a second interview, which may, of course, be total coincidence.

Inevitably a couple of years later a neighbouring trust DID open a new cardio-thoracic unit and took much of the regional trade, with predictable results for the first hospital, which were still apparent in its finances for many years. The above-mentioned manager was long gone by then: short term, careerist thinking.

I don’t claim to be brilliant, but the flaws in the financial model were obvious. It was clear to me, a staff nurse qualified 4 years, that there was a potential problem. Why wasn’t it apparent to the existing managers? Or did it not fit the short-termist world view?

Another example of the closed group of management: there was a service manager vacancy in my area, a promotion opportunity. I got the job description to read. It was the worst written and least comprehensible document I have seen (30 years in the NHS – lots of appalling writing and opaque language there), and there was no mention of managing a clinical service, only supporting senior managers. Correct me please, but I thought the NHS exists to deliver clinical services and managers are there to enable clinicians to do that? Wrong! Managers only assist more senior managers and clinical services, for which the rest of us think they are responsible, aren’t relevant! I didn’t apply, as I couldn’t make sense of the gibberish (neither could a proof reader I showed it to), but someone thought they could and that they wanted to do whatever it was they thought they’d read.

This person was a serious micro-manager, behaving appallingly towards staff, up to and including laying hands on an admin worker (yes, assault!), via making defamatory comments about me and a colleague, later withdrawn without apology, and insinuating I had somehow corruptly inflated my grade. Complaints of bullying and harassment were made by senior staff, including me; junior staff felt they would not be taken seriously and didn’t complain. The investigations were shoddy, breaching trust policy, revealing that some people would play fast and loose with the rules and bend over backwards not to find against a fellow manager. Appealing the initial decision was treated the same way. I dread to think how much time was wasted by clinical and admin staff because of this person’s behaviour – everyone consulted their union, even if they didn’t complain. Now think about the “principles” espoused by Francis and the lack of anything to make them close to enforceable.

I am not suggesting we don’t need management, more that the management we have is misguided, ineffective, has aims counter to those of clinicians or patients, diverts resources from patient care. Quality of management has an interesting effect on health outcomes as the London School of Economics has found. Yet the good management identified is far away from common experience, which further questions what most management is for if they cannot identify and put those good practices into effect.

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