A case study in managerialism

The Grauniad yesterday interviewed David Nicholson, who's just been appointed chief executive of the NHS. The text is illuminating in the extreme, especially in terms of managerialism and technocracy.

David Nicholson, the new chief executive of the NHS in England, took up the reins of office last week and set about dispelling the notion that he might provide the service with a period of consolidation and calm.

Of course not. Change is good in and of itself, because things are different now, and only the managers know what to do about it. History is irrelevant.

When his appointment was announced seven weeks ago, there was a huge sense of relief among managers and clinicians that the job had gone to a person steeped in NHS values. People seemed to think that he was somehow less threatening than the two American managers on the final shortlist, who might have been expected to further commercialise healthcare delivery.

But, in his first interview as chief executive, he has told Society Guardian that it is his NHS pedigree that has made him determined to push through reforms even faster than before. He thinks that up to 60 hospital trusts may need help to survive the pressures of change, as they lose work to primary care services operating in the community - and to specialist tertiary hospitals where the harder cases will be treated. In some cases they may have to be taken over by stronger neighbours with the management muscle to carry through the necessary changes.

Management muscle=people who agree with me and are willing to help coerce others into accepting my ideas.

And NHS trusts in England, both weak and strong, will have to come to terms with a reconfiguration of key services that will reduce the number of hospitals offering a full A&E department, paediatrics and maternity services.

These are three of the hospital services that are most cherished by their local communities. Up and down the land, the NHS will have to handle the job of reorganising them with extreme sensitivity if it is not to spark local revolts that could have huge political implications in the runup to the next general election.

The only really satisfying form of change is that change that affects the allocation of resources. This is because only adding or subtracting power can really affect other managers' constituencies. It's also because the essential currency of managerialism is itself the power to reallocate resources. Resistance to this is of course coded as resistance to inevitable change, which attracts the opprobrium of the whole elite.

Nicholson has been with the NHS for 29 years. He joined as a graduate trainee in the same year he joined the Communist party, which he then saw as the best vehicle to take forward his passionate support for the anti-apartheid struggle. He says he was not a Eurocommunist: he was among the Tankies who did not see an ideological need to distance themselves from Moscow. During the interview, the working-class lad who has reached the top pokes fun at himself by asking how much of this early baggage needs to appear on the civil service security vetting form that is sitting on his desk awaiting his attention. Perhaps former Communist John Reid, Patricia Hewitt's predecessor as health secretary, might be in the best position to advise?

Well, at least he's honest about it. More importantly, why should the head of the NHS have to declare his past political affiliations to the secret services? It's not as if he was going to be trusted with nuclear weapons or the names of informants within Al-Qa'ida. In fact, the most secret documents he will handle will be those subject to commercial confidentiality. These must be secret, of course, to enhance the power of the managers.

Nicholson drifted away from the Communist party and abandoned his membership in 1983. But he has stuck with the NHS in a career that has spanned three phases. For the first 10 years he worked in mental health, mainly in Yorkshire, where he was involved in implementing the policy of closing the old asylums and developing services in the community. He says the lesson he learned then was how it became possible for the NHS to deliver big changes if managers could harness the support of patients and relatives.

He's not, apparently, proud of helping to treat the mentally ill with greater humanity, or to have helped to treat their illnesses more effectively, or even to have saved money. No. He chooses to highlight not what was actually achieved by his management, but the management itself.

For the next nine years, Nicholson moved into the acute hospital sector. He was chief executive of Doncaster Royal Infirmary, one of the first wave of NHS trusts to break free from Whitehall control under Margaret Thatcher's policy of NHS reform. That "liberating" experience taught him the benefits of independence and the need to mobilise support for reform among clinical staff. "Once you engage them and gain their trust, there is nothing stopping you," he says.

Decentralisation leads to efficiency, then.

The third stage of his career, which has led him to the top of the NHS tree, was in regional and strategic health authority management. It was there, he says, that he learned how to deliver change on a grand scale by getting all the bits of the system pointing in the same direction.

But someone has to make those independent units all do the same thing in order to deliver - guess what? - "change". Note that, again, the actual final goals - the strategic aim, the results - are never mentioned. Also note that he is the Vicar of Bray; when he managed a local trust, he was for independence - when he managed a group of them, he was for centralised control.

Nicholson says the NHS is in much better shape than five years ago, thanks to increased resources and reforms to link hospitals' income to performance. But this is not enough.

"People don't feel the reforms are relevant to them. We haven't made sure we connect the reforms to benefits for patients. There is a strong argument for driving reforms forward faster, not slower. That is what we need to do. But we need to make them relevant to clinical staff and help them do the jobs they need to do."

We know what is good for them. The problem is how to make them behave, which is to be achieved by PR.

He says it is already clear that not all acute hospital trusts will be ready to apply for foundation status by 2008, the original target date. Many will not be strong enough to achieve independence without significant reconfiguration. In some areas, the answer might be for the weak trusts to be taken over by the strong.

But:

"I am reluctant to get into [a wave of] mergers across the system," he says. "Very few mergers I have seen in my career have delivered the benefits that people said they would. The problems remain in the organisation. Often these problems are more deep-seated than [can be solved by] having a new set of managers come in."

Indeed. It's almost become a business-book cliché that mergers and acquisitions are usually value-destroying. In today's civil service, being up to date with fashionable management advice is career positive, so Nicholson is quick to pick up on it. But there is so far no sign that mergers are becoming any less common in the private sector. This is because strong structural forces promote them. The end-goal of competition is to crush the competitor and become a monopolist. Joseph Schumpeter's principle of creative destruction. Also, the professionals involved in mergers are perhaps the most strongly incentivised people around - the financial rewards are gigantic.

"I think we will see some of the better hospitals acquiring others that are in difficulty."

Although the problems are more deep-seated than can be solved by having a new set of managers come in, right?

The government's proposals for treating more patients closer to home by expanding primary care would put a big strain on the district general hospitals. "I have not seen any that have to close, but they are going to have to work in a networked way," he says. "And you are going to have to use the ambulance service in a more creative way."

Nicholson does not spell out the implications, but his remarks suggest the closure of some departments, allowing hospitals to specialise in what they do best. Patients may get a better service, but would have to travel further to access it. "Undoubtedly there will be tough decisions to make over the next 12 months to reflect changing services," he adds.

The toughest would involve reorganisation of emergency care, paediatrics and maternity services. A key decision has had to be taken about the number of major trauma centres across England for dealing with the most serious emergencies. That has had implications for the number of hospitals running a full A&E department. Many patients with minor ailments could be looked after better in local walk-in centres rather than A&E.

Similarly, the NHS has had to decide the number of births needed to sustain a 24-hour consultant-led maternity service and the most appropriate size for paediatric departments.

Surely the wrong way round? Wouldn't it be better to decide how much maternity service is needed for the number of births? Classic confusion of target and control.

Were these not the three most bothersome areas of NHS care in terms of likely revolts against closure of local facilities?

Yes, says Nicholson. But he is determinedly optimistic about winning public support for change if consultation is managed properly. Trusts have to ask: are the clinicians on board; will they stand up and argue the case; can the trust demonstrate the health benefits of a reconfiguration of services; and can it say how many lives will be saved, to set against the claims that will undoubtedly be made by protesters that lives will be lost?

"We will be going out to consultation later this year or early next on a whole series of reconfigurations. I understand the politics of it. But this is about the way we deliver care that is predominantly closer to home."

Consultation. The public is to be "consulted" not in order to determine their opinion or canvass their views, but to persuade them to accept the managers' a priori decision. The accurate term would be propaganda. Further, the lower ranks of management are asked to make the professionals - the clinicians - lend their authority to the non-experts' decision. And the whole thing is based not on whether lives will indeed be saved, but whether criticism can be discredited.

His appreciation of the value of "closer to home care" came early in life. Nicholson was brought up in Nottingham, where his father was a plasterer who became incapacitated by emphysema and confined to a wheelchair. "One year he was admitted to hospital 14 times. Then they decided to provide him with an oxygen cylinder and the phone number of a nurse who could come round if there was a problem. In his last two years he was hardly admitted to hospital at all."

The family scattered his father's ashes on the pitch at Nottingham Forest. Nicholson inherited his passion for the club: last year he attended 34 fixtures, home and away. He went to Forest Fields school in Nottingham - a grammar school when he arrived, a comprehensive by the time he left. He played hooker for the city's rugby side at 19 and attributes his uneven facial complexion to experiences in the scrum.

Nicholson has a flat in London where he will spend most of the week, but the family will stay living in Doncaster. He plans to work one day a week from Quarry House in Leeds, headquarters of the former NHS Executive.

Blah, blah, blah.

Nicholson says he begins his period as chief executive with three priorities. "First, we need more discipline and rigour in the way we manage our business in the NHS in many parts of the country: I need to design that."

Stronger centralised control, in other words.

"Second, we need to reposition reform in terms of identifying the benefits to patients."

PR comes first.

"And third, we need to work on leadership. We are not producing people with the right skills to lead organisations and we need to do something about that."

To carry out 1 and 2, more managers are needed. Parkinson's Law in action.

"Unusually, in the developed world we have few clinical people in charge of organisations. We need to change that."

What? Actual experts? Surely not!

"And there are not enough women and black people in senior positions. I need to do something about that as well."

If they are the right kind of experts, clearly.

David Nicholson, the very model of a modern managerialist.