De-layering the National Health Service in England

Bureaucracy - Magritte

Bureaucracy by Magritte

The well-known organisational practice of delaying has emerged as one way to achieve public sector austerity. This is to be aplauded, not regretted as it is applied to the English NHS. In fact, those looking to the total costs of running health systems should be taking serious note of what this is all about.

Public sector work has tended to favour layers of bureaucracy, to respond to the tendency of civil servants to do what is called rent-seeking, which in the end means building empires, or expand a sphere of influence. In the regulatory context, it is called regulatory creep, as mandates are progressively, but subtly expanded by rent-seeking regulators.

The end result is large spans of control for civil servants, but little actual progress in achieving public sector objectives and goals. This stifles creativity and further rigidifies individual behaviour into highly structured ways of working — further compounding the potential waste of public money.

In addition, the tendency of bureaucracies to create bureaucracies means that individual jobs are often highly compartmentalised from other jobs, as individuals carry specific dossiers or briefs. The compartmentalisation of government into ministerial portfolios adds additional barriers to sharing work, ideas, or insights across government, further compounding the opportunities to deliver better value for money.

The White Paper on the NHS plus the overall behaviour of the UK’s coalition government reflect a consistent and simple message about the way the public sector should be organised to undertake its tasks. De-layering means removing non-value-adding levels of organisational bureaucracy, layers with the sole purpose of either move information up (or down), or checking or verifying the work of others.

The NHS itself has been too long likened to a supertanker, but a school of fish is what we want — nimble organisations that can respond quickly to change. Instead, some commentators have questioned the proposed reforms, asking what will happen when you need to pull some strings centrally to get things done? What these commentators don’t realise is that healthcare is a complex adaptive system, which means that there aren’t really strings to pull.  Decades of belief in this assumption has produced ill-thought out control mechanisms, and inappropriate and pointless layers of supervisory control (such as Strategic Health Authorities), which really can be only weakly effective at best and destructive of initiative at worst. It is not unusual for SHA staff insert themselves into processes to assert  a measure of control reflecting their priorities, ignoring the real needs of people dealing with a front-line challenge.  Indeed, the rent-seeking behaviour of these quasi-civil servants challenges the validity, the very authority, of those who own the front-line problems in healthcare to actually solve these problems. Before all this, we had the failed Modernisation Agency, the failed NHS Training this, or NHS University that.

The insights in the White Paper have put paid to the assumption that overarching control mechanisms can work, putting the onsus on problem owners to solve these problems. There are proposals in the While Paper which accept the need for flexible and dynamic responsiveness to the local and real-world interface between the patient and their care provider. Many in the NHS will fail to understand this, and as in any organisational change process  there are some people who ‘don’t get it’.  By and large, failure to alter personal behaviours is a recognised barrier to implementing reforms, and many such people will need to be shown the door and encouraged to pursue other careers. The NHS often forgets to bury its dead and it frequently eats its young, meaning that failed bureaucrats get recycled and good ideas destroyed by a controlling culture.

I have immense confidence in the ability of the right people to solve the problems, (indeed of the ability of GPs to ‘get it’). There are also real challenges for the chief executives of the foundation trusts and other NHS providers to demonstrate the necessary leadership and management skills to drive out the costs and inefficiencies that are shot through the system; CEOs will be particularly challenged as they must now actually manage, and not simply administer a publicly funded entity and avoid rocking the boat.

There are too many quangos and other organisations around staffed with individuals from failed agencies so one must be vigilant to ensure that the delayering process does not just turn into a recycling exercise.

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Charles Perrow’s important work, Complex Organisations, highlighted the hierarchical structure of professional organisations and asks important questions about how and why we construct overly complex organisations, and why they can become dysfunctional.