Second opinion

Why the NHS needs less professional management

Amateur managers have their faults, but professional ones proliferate unforgivably

9 May 2015

9:00 AM

9 May 2015

9:00 AM

I once had a medical secretary who, aged 65, was about to retire. She had been a secretary for about 45 years and was extremely competent. She knew how to spell and punctuate and never reduced my letters to gibberish; she was also well-read. And she was very good with the patients.

Three weeks before she retired, she received the order from her ‘manager’ (she hadn’t needed one for more than nine-tenths of her career) that she attend a course on how to answer the telephone. She pointed out that she was about to retire, but the manager could, or would, not see the absurdity of the idea, let alone how wounding and insulting it was to a woman who was, in her way, quite distinguished.

Of course I understood what was going on. The hospital had contracted a ‘consultant’, almost certainly personally known to a member of the bureaucracy, and possibly a former employee of a nearby hospital, to teach ‘telephone skills’. It needed as many staff to attend the course as possible to justify the expense.


That was a good few years ago, but it was a herald of things to come. It was a fine example of the professionalisation of management in the public service — in effect the legalisation of corruption — that was one of Mrs Thatcher’s great legacies, and of which Mr Blair, wittingly or not, took political advantage. The road was open to the creation of public-service millionaires and the diminishment of the distinction between the public and private sector, so that the two are now almost impossible to disentangle.

Any reader of Henry Marsh’s book Do No Harm will realise that my anecdote is not merely anecdotal: an anecdote that can be repeated in a thousand instances, by a thousand people in a thousand different circumstances, ceases to mean nothing but itself. Rather, it reveals something essential about the world in which we live.

Henry Marsh is a neurosurgeon, and no one who reads his book would doubt that he is a man of the highest calibre, standing and probity. Yet he was obliged — obliged — to attend a course on empathy and communication given by a man who had risen from the ranks of the hospital kitchens to lecture senior neurosurgeons, among others, on how to speak to their patients. (I am all for rising through the ranks, but not where opportunities are systematically created for the economic benefit of ambitious mediocrities.) Mere brilliance is no defence against the highly motivated idiocy of bureaucrats posing as shopkeepers.

The absurdity to which Henry Marsh was humiliatingly subjected (and humiliation is an essential part of its purpose, for humiliation leads to docility) is the apotheosis, and not the deformation, of professional management in the public service. It arises from a crude and one-dimensional theory of human motivation — in this case that the motivation of a manager in the public service can beneficially be made the same as that of one in a private business. (Even in large privately owned businesses, as James Burnham pointed out as long ago as 1941, the interests of the managers have long since ceased to be identical to those of shareholders, a fact of which Mrs Thatcher appeared to be oblivious, and which helped to bring about the banking crisis. She was predictably no match for the dimmest manager of Boghampton Social Services, once that manager was freed from the straitjacket of a salary structure and could pretend to be a businessman or woman, complete with strategic — never tactical — planning and business models, the development of which necessitated team-building weekends in country hotels and away days in pleasing locations.)

Before management became fully professionalised, managers in the public service — and while there is a public service there will have to be managers of it — were often inefficient and sometimes incompetent. But at least they had no vested interest, as they do now, in inefficiency and incompetence, in the insolubility of all problems and in the creation of new ones. They might not always have been the sharpest scalpel in the operating theatre, but generally they were well-intentioned, and had few reasons to
be otherwise.

The solution is clear. So long as we have a public service — and I leave aside the contentious question of how far health care and other services should be publicly or privately funded — what we need is amateur, not professional, management. The highest echelons of any public institution must be composed of volunteers. At most they should be rewarded by the refund of their bus fares to and from meetings, and perhaps a CBE or two; under no circumstances should they be rewarded financially. Furthermore, the professionals under their direction should live in fear of them, for example of dismissal in the event of incompetence. No more away days, no more team-building, no more strategic planning, no more business models. Let bureaucrats be bureaucrats — in proper circumstances, a perfectly honourable if not high calling — not ersatz businessmen.

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