How the new money is making the NHS sicker

During her 11 months undercover in the NHS Harriet Sergeant found farcical management, chaos and ineptitude

Published: 8 February 2004

But nobody cares or comes when you call. Young doctors stare at computer screens. Nurses hurry past or reply brusquely. The place is shabby and chaotic. Nobody appears to have authority. You have entered a time warp and have been transported back to an era where consumer choice and individual rights count for nothing. In a corner a young man is banging his head against the wall. You might have been mugged, had a car accident or a heart attack. Whatever the cause, you are the latest victim of the management crisis in the National Health Service.

There is a huge gap between what the government says is happening and the experience of the ordinary patient. This gap is caused by the inability of hospital management to manage. Nobody from the chief executive down enjoys the sort of authority taken for granted by any small business.

Even your local corner store can sack someone incompetent. Not the NHS hospital. Political correctness, the power of the unions and centrally set targets take precedence over patients’ wellbeing. Their care is almost incidental.

I spent 11 months looking at the management of six different hospitals. I interviewed chairmen, chief executives, middle management, consultants, matrons, sisters, nurses, porters, cleaners and, of course, patients. I sat in on management meetings and shadowed frontline staff. I have also arrived as a patient at casualty more than half a dozen times.

The forthright manager of a busy London accident and emergency department was clear what took up her time and energy. It was not the violence, the sheer number of patients or even staff shortages — bad as these are — but the bureaucracy and “endless meetings”. An emergency would come in. She wanted to be on the shop floor but instead would have to attend “a bloody meeting about cleaning the bloody department”. She spent only one-fifth of her time with her patients. Cleaning and maintenance took up most of her energy, to little effect. Despite all the meetings, she had no authority; if a patient vomited, she had to clean it up because the cleaner refused to touch it.

The lack of management authority reveals itself in the sheer arbitrary nature of NHS care. A patient will experience in one day, often in one hour, disorganisation and indifference side by side with first-class care and kindness. There is no incentive for a nurse to check an old lady for bedsores except her nurse’s professionalism and humanity. And no punishment if she forgets.

The lack of managerial authority starts at the top. Unlike consultants, nurses and even porters, chief executives are unprotected by a powerful union or medical institution. As one remarked: “The average lifespan in my job is 2Å years so I can’t afford to concentrate on just my hospital. I have to be out there networking.” Out of the four chief executives I interviewed, three are no longer in their posts. This hardly promotes the strong and effective leadership required to run a hospital.

All the chief executives I met, whether of successful three-star hospitals to hospitals with no stars at all, made the same complaint. They suffer from Whitehall’s “overbearing presence” and its constant demand for information, form filling and target setting.

One chief executive of a zero-rated hospital complained that responding to “a string of arrogant messages from the centre” took up 20% of his time — yet had taken up only 5% five years before. That very day the Department of Health had e-mailed him asking that five points on waiting list times be answered by 11am the next day. “It’s micromanagement to a ridiculous level,” he said.

Middle management does no better. I emerged from one hospital board meeting befuddled by the sheer numbers of initiatives that have seen a huge expansion of NHS management with debatable benefit to the patient. The whole meeting had been about compliance (apart from a passionate debate on staff parking).

These initiatives divert resources. One non-executive director explained: “We are forced to make appointments that should be way down on our list of priorities. Each initiative requires a whole department of management. It is stopping us from hiring the nurses and consultants that we urgently need.”

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