NHS fat cats have blood on their hands Labour has fed the bureaucracy machine

So, NHS England chief exec Amanda Pritchard has finally fallen on her sword. After less than four years in her £270k-a-year post, bruising criticism of her leadership by two influential Commons committees, and a series of meetings with health secretary, Wes Streeting, the embattled CEO has quit leaving behind a health service in crisis. Prichard’s replacement, Sir Jim Mackey, has been tasked with axing thousands of jobs at NHS England. Let’s hope most of them are suits — the exact people who’ve run the service into the ground for the past decade.

Hospitals, after all, are obviously life-and-death places for patients. But for doctors, too, a day in A&E can be professionally fatal. If I miss a case of meningitis, or fail to spot a heart attack, the consequences are swift and severe. I’ll be front-page news and facing the GMC before my feet touch the ground. But now imagine that my mistake isn’t personal: but institutional. Imagine, that I’m a manager in a failing hospital, and that my administrative incompetence results in dozens of avoidable deaths. What can I expect? At worst an early retirement with a generous pension, or maybe even a move to another job elsewhere. 

Welcome, then, to the topsy-turvy world of NHS management, a world where failing doctors are ruthlessly punished but higher-ups go free, safely hidden behind trendy buzzwords and laptop screens. Combined with the rising pressure on clinicians to take on ill-suited management roles, and it’s no wonder things so often go wrong. Yet amid the misdirected expertise, and the vast gap between administrative priorities and practical patient care, another future is possible — one that finally puts a price on failure from corner offices to A&E, and bolsters patient care as well. My hope is that Sir Jim can usher this in. After all, he’s been annointed by Streeting presumably because he’ll implement the minister’s reforms, something Pritchard was either incapable of, or unwilling to do.

But I shan’t hold my breath. First of all, there’s Britain’s peculiar faith in lived experience. I myself have been asked to give opinions on budgets worth £50 million: not because I know much about accountancy, but because I have a medical degree. I’ve elsewhere been roped into chairing departmental budget meetings with barely 15 minutes to spare, all in front of dozens of bureaucrats. You might say fair enough: I am a physician. To which I’d respond: I may know my way round a kitchen, but that hardly means I’m the next Nigella. The results of this dilettante approach are, anyway, predictable. I’ve worked with a physiotherapist who made crucial decisions about mental health provision, and a former occupational therapist who oversaw sophisticated IT projects. No wonder Labour has said the NHS wastes some £10 billion a year.

Contrary to the cliches, meanwhile, digitalisation isn’t a panacea here either. In my trust, fewer than 20% of management meetings now happen face-to-face. Teams meetings have become the norm, with anywhere from six to 24 people attending virtual sessions. Perhaps inevitably, these hospital knockoffs of Celebrity Squares are anything but efficient. With so many faces crowded on screen, actual decision-making soon grinds to a halt. 

And if expecting doctors to moonlight as managers is bad enough, virtual bureaucracy also encourages the banality of management-speak. It’s easy to mock phrases like “we’ll circle back” or “it’s a game-changer” — let alone those senior managers who come to meetings decked in out in expensive jewellery and think TEDx talks are adequate replacements for actual knowledge. Yet if I hear “360 approach” so dizzyingly often it can feel like I’ve just stepped off a fairground Waltzer, linguistic inertia is far from a joke, as crises around staffing or beds become abstract “challenges” to be solved via PowerPoint. 

Certainly, the human and financial costs here are staggering. According to NHS Resolution, compensation payouts in 2023-24 amounted to £2.8 billion. These losses have a human face: the Shrewsbury and Telford Hospital NHS Trust maternity scandal saw avoidable deaths and injuries to hundreds of babies. Nor are in-patients the only ones to suffer. Valdo Calocane and Axel Rudakubana are just two of the violent individuals to cause mayhem after being failed by Britain’s mental health bureaucracy. 

Disasters of this kind are very rarely punished: the incompetence at Shrewsbury and Telford certainly wasn’t. The fundamental problem is that NHS accountability isn’t evenly distributed. Those most exposed to scrutiny are often the ones with the least time to defend their decisions, even as those making the most consequential choices remain safe. In the former case, I’m thinking, frankly, of people like me: doctors and nurses in A&E where every mistake is immediately clear and transparent. 

Yet senior managers often exist in splendid isolation, something that equally extends to some of my fellow clinicians: thanks to departmental tribalism. I’ve seen mental health patients spend days in my A&E while psychiatric services appear powerless or unwilling to intervene. Yet if I turn around and ask pointed questions, my colleagues in mental health will look at me slack-jawed. Even when psychiatric services repeatedly fail to identify high-risk individuals — who then go on to commit violent acts — accountability often seems to evaporate in a fog of committee meetings and “lessons-learned” excuses. 

This, in short, is far more than bureaucratic inertia: it’s a catastrophic breakdown in care that’s costing lives every day. It’s also indicative of a political correctness that allows the weak-willed or weak-minded to use accusations of “bullying” as a mask from which to obscure their own ineptitude.

All this hints at a paradox: the NHS is both too centralised and too fragmented. While NHS England maintains tight control over major policies and targets, individual trusts operate with significant autonomy in their day-to-day management. To be fair, the powers-that-be aren’t oblivious here. In July 2022, NHS England announced plans to cut up to 6,000 jobs as part of its merger with NHS Digital and Health Education England. The plan was to reduce organisational costs by 30%, with most cuts focused on senior management roles and back-office functions. 

In practice, though, junior administrative positions largely felt the squeeze, while senior management layers remained mostly intact. The organisation unsurprisingly continues to operate with Soviet-style sluggishness, where measuring paperclip usage gets the same attention as patient outcomes.

Does Wes Streeting have a clue what to do? True, he has warned NHS “fat cats” that they’ll be sacked and blocked from taking another job in the sector if their hospitals fail. But I have seen no evidence of this actually happening. If anything, since Labour came to power last July, I’ve seen an increasing number of managers cavorting around the NHS estate as if they’re untouchable. Certainly, this jumbled approach to who really matters is obvious in my own work. If my trust overpays me due to a clerical error, they’ll recover the money within days. But when they owe money to staff, the affair can drag on for months. 

All the while, the NHS feels increasingly out of touch with global trends. The triumph of people like Donald Trump hints at a shift away from mangled managerialism — and towards robust, direct, accountable leadership. Though the NHS certainly doesn’t need to embrace authoritarianism here, it should recognise that the days of diffuse responsibility and endless Teams committees are numbered. For all its flaws, and just like the President himself, the US offers a model here. When American hospital administrators preside over systematic failures, they face real consequences, up to and including criminal charges.

Why not bring some genuine accountability to our hospitals, then? Mandatory dismissal for managers and doctors whose decisions lead to serious patient harm. From there, those 2022 reforms must finally be pushed through. With 10,000 new managers in a decade, Sir Jim clearly has plenty of room for cuts, a move that would equally reduce the gap between suits and frontline staff. Forcing personnel to meet in person would doubtless help too. Given over 1,000 qualified GPS have left the NHS in a decade, the least their bosses can do is turn up to work, especially when their collective pay packets have swelled by £1.1 billion. No less important, healthcare urgently needs a total overhaul of management recruitment, ending the practice of promoting clinical staff without training and qualifications — let alone expecting them to sub into complex meetings with literally minutes to spare. 

At the very least, incompetent managers should surely face the same consequences as incompetent doctors. Sometimes it’s the bureaucrats who have blood on their hands.