Addressing problems in the NHS: An external perspective

Nick O'Sullivan


In his review of leadership and collaboration in the NHS published in June 2022, General Sir Gordon Messenger talks about the workforce being under ‘incredible pressure’ during recent years. He doesn’t say there’s a fire, but I keep seeing stacks of smoke. Waiting lists at record levels. Nurses on strike. Morale as lows as it’s ever been. Four out of ten junior doctors planning to quit as soon as they can find another job. Hospitals crippled by the failure to tackle social care.
When the NHS was founded in 1948 it was the envy of the world and the pride of the UK. Nowadays most of us will experience, or see others experience, the symptoms of what has to be called a ‘crisis’. 

Key challenges

So how has it come to this? 
There are many root causes. One is the increasing technology behind medical advances, which is fantastic in many ways but is also a challenge for any modern healthcare system.

Drugs and equipment were fairly basic when the NHS started. Seventy-five years on, science and the healthcare industries have produced ever more ingenious answers to illness and health conditions for which there was no cure before. It’s amazing stuff, for sure, but ever-increasing complexity means that new solutions are hard to achieve, cost more, and are relevant to fewer people. The fact that we can cure more and more complex conditions is wondrous, but in an organisation whose guiding philosophy is ‘healthcare free to all at point of treatment’, such a brilliantly ethical position poses complex questions of cost and return on investment. Finding an answer is a truly ‘wicked problem’.

Let’s look at what Sir Gordon Messenger thinks. Two observations stand out, he says. First, “the very real difference that first-rate leadership can make, with many outstanding examples”. Second, “that the development of quality leadership and management is not adequately embedded or institutionalised in our health and care communities”. Contradictory? Not necessarily. It seems to me that the implication is simply that what great examples of leadership and management there are in the NHS is often more down to raw talent in a few than it is through any purposeful design to grow, nurture and develop generate talent across the board. It’s not that the will and the talent to lead and manage well isn’t there, it’s just seemingly not being harnessed as it should be.

The ‘smoke’ 

The Messenger report makes clear recommendations as to how to improve leadership across the NHS to help deliver better outcomes. Here's a recent example of the kind of thing that can be achieved. In December 2022, Croydon Hospital made national news by reducing waiting lists to zero and increasing the number of operations by over 11% per week – all by restructuring the way people work. Evidence, it would seem, that addressing management systems creatively can result in significant and tangible improvements to outcomes. This stuff isn’t just bureaucracy – done well, good leadership and management drive efficiency and high morale, with staff at Croydon saying they, “could never go back to how it was."
Here’s another example, but this one doesn’t work quite so well for me. The Midlands Partnership NHS Foundation Trust also made the news in December 2022 for advertising a job vacancy for a new role, a ‘Director of Lived Experience’. When you read the detail it’s possible to discern what the Trust is trying to achieve but personally, I’m not sure it’s the right way to go. They want the experience of those using their services to be represented at the highest level. The intent is commendable. However, I would have thought every leader has a role in ensuring the lived experience of the people their department supports is considered. Surely the responsibility should be specified in existing roles so that all are held to account, rather than delegated to a third party? I also pity the person who gets the job as I expect they’ll find a number of challenges when they start telling people who are responsible for service delivery what they should be doing without necessarily understanding the constraints of each service delivery department itself. 

Another example are my conversations with NHS workers. All say it is overstretched. And pretty much all say, just as Sir Gordon has, that the leadership and management needs improving. Whether it’s comments about the waste, comments about apparent fear to take responsibility for decisions, or simply poor people skills. Consistent anecdotal evidence provides further ‘smoke’.

In December 2022, nurses in England came out on strike for the first time in their history. One of the key issues is career progression – 43% of nurses are on the top pay band and can’t progress further without changing jobs3. Things like this must be examined to improve the NHS. Addressing issues around ‘conditions’ is likely to mean looking at things like career progression, organisational structure, roles and responsibilities and ways of working, as well as pay – the leadership and management stuff again.

In January 2023, senior NHS executives went on the television news circuit stating the answer was more money or less services. I heard nothing about looking at anything in between these two far ends of a spectrum of options. I worried that low morale of senior NHS executives has resulted in a group think that blinds them to other options, despite the valiant work of people such as those at Croydon Hospital showing it can be done. Options like those medical professionals who contributed to a news article in ‘The I’ think would be worthy of exploration4. The other thing the senior NHS executives did in this round of press engagement was to dismiss claims that developing the capability of its managers would have any impact on the problem. I worried that this was a reluctance to look in the mirror and be honest about what they saw. 

Options

So what are the options for the NHS? 
One option is to throw more money at it. This seems to be the one everyone clamours for. But throwing more money at a system that doesn’t have the capacity to spend it properly would seem a response that is far from guaranteed to deliver the desired outcome. And while I support a pay rise for nurses (they have after all been frozen for some time and need to catch up), simply putting more money towards pay of staff won’t improve the working conditions and factors such as career progression that seems to be putting people off. If I were a nurse I’d be grateful for the pay rise, but equally consider it blood money buying me off to continue putting up with poor working conditions for another few years. No, when it comes to pay and conditions, the conditions aspect should be addressed as well. So how can we improve conditions as well as pay? How can we make sure the funds currently allocated are better utilised and not wasted in poor systems, processes and waste? How can we make the daily experience of staff in the NHS a more pleasant and less stress inducing one?
 
One option is to go to expensive but publicly credible consultancies. They always have the answers – right? If you’ve read my blog on the potential pitfalls of consultancy, you’ll know my opinion that consultants don’t usually hang around for any issues that arise later on, after their initial fixes are applied. They might then called back in to then address the second order issues that have emerged. It can become a cycle of problem, consultancy, fix and back to problem. Great business for consultancies, less good for the NHS.
Perhaps more managers are the answer? Questions about the size of the management layer in the NHS always seem to crop up. Often – and I say this with confidence as both my parents were in the NHS – it’s viewed as having too many managers. Recent research contests this5. Whether we need more or less, perhaps numbers of managers is the wrong thing to get fixated on. A better question to ask might be, how could the NHS develop and get more support for the leaders and managers it already has? Afterall, this would seem to be what Sir Gordon was suggesting and he had a good look at the organisation.
Wouldn’t it be a better option, therefore, to provide more training for the leaders and managers in the NHS already, so that they are better equipped and able to deal with the problems they face, wicked ones included? The current mangers (including doctors and nurses in management positions) have some tremendous advantages after all:
  • They know the organisation better than anyone else
  • They know the issues better than anyone else
  • They know who the key stakeholders are better than anyone else
  • It’s in their interest and that of their teams to get it right and see solutions through – they have more motivation than anyone else
  • They’re in it for the long haul – they’ll be around to see things to the finish, however long it takes
  • They probably care more than anyone else – at least one can assume that as a general rule, by virtue of the fact they’ve already chosen to work in healthcare, their personal values align to the core purpose of the NHS (to provide high quality care) than consultants would  
When it comes to helping to fix the NHS, I’d say improve conditions as well as pay and spend a bit more on giving its leaders and managers – and that includes nurses and other front-line staff – the leadership and management tools they need to do their jobs. I’m with Sir Gordon. PMPT.
I firmly believe that leadership and management can change lives. When it comes to the NHS, it can literally save them. So, let’s see more investment in leadership and management training to get more hospitals achieving improvements like Croydon did, to address the issues Sir Gordon picked up on, to provide better healthcare for all of us, and to restore the NHS to its rightful place as a jewel in the crown of the UK!
Winter has come and hopefully will soon be easing. The NHS has the summer to try and reconfigure itself for the future and ahead of the next winter. Here’s hoping it uses that time wisely. 

Useful links & articles:

Health & Social Care Review
for a collaborative and inclusive future

Inside NHS hospital which treats more patients than before
and has no backlog despite 7.2m on waiting lists

How to we solve the nurses'pay crisis?
Career progression - a key issue for nurses

Doctors offer a 9-point plan

to save the NHS from collapse

Over or under managed?  
Myth four: the NHS has too many managers
Created with