Wes Streeting said the fat cats would be gone when Labour came into power. If anything they've increased. Photo: Christopher Furlong/Getty.
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.
Sorry Dr Jones, but this is patently untrue.
Perhaps if you missed such cases repeatedly, you’d rightly be deemed incompetent and sanctions would occur. Doctors miss diagnoses or misdiagnose every day, because they’re human. It’s part and parcel of clinical care and it’s recognised that perfection doesn’t exist. Single incidents of failure to diagnose such as you claim here absolutely do not have the consequences you attribute to them. If they did, the BMA would be bogged down in such cases within hours.
So – why make that claim? If it’s to make a point about the differences in accountability between frontline clinicians and management, that’s a point which deserves a more serious introduction than an outright untruth.
“an outright untruth”.
Well at least you didn’t use that terrible word ‘misspeak’*! But come on it was an outright LIE was it not?
*Beloved of Hillary Clinton and far too many others.
I admit it: i was being uncharacteristically circumspect!
My point was made with a degree of circumspection because the issue Dr Jones raises deserves to be aired.
Thanks, she obviously got “carried away” as we used to say.
I, to my chagrin, have been a frequent offender on that score!
I doubt very much you’d be up before the BMA; the doctors’ union. You’d be up before the GMC; the regulator.
Correct!
So administrative incompetence and general poor practice at the Shrewsbury and Telford Trust saw multiple deaths and injury to hundreds of babies.
So that happens without a supposed serial killer nurse. Or have they merely not found one to blame it on yet.
I suspect lessons were learned.
The case that there has been a gross miscarriage of justice, that she was scapegoated, it really quite strong and I am glad that there are those working hard behind the scenes for this case to be at least re-examined.
Health administration is a career choice. As far as I know, there is no university course offering education in health administration. What exactly are the qualifications of the people managing the NHS? It would be interesting to know. I suspect the growth in NHS bureaucracy is linked to the growth in graduates in whatever degrees following the Blair expansion in university education.
I have a suggestion about employment across the board. Everyone is to be self employed and we do away with all other classifications of employment. No contracts, no holiday pay, no benefits, nothing. You agree to fill a role and if you fail, your exit is simple and can be immediate. You earn better wages. If you don’t turn up you don’t get paid. If you call in sick you don’t get paid. Millions live like this perfectly well myself included and I am a long way from the overpaid and unaccountable government bureaucracy. The responsibility to perform is on your shoulders and you must do it or you’re broke. This socialist idea that you’re owed work on your own terms is the problem. Do your job and do it well or get out. Make yourself useful or fail. The end of entitlement culture is required to sort this out because it’s not just the NHS having this problem.
Couldn’t agree more. Since 2005 I have run my own business and workers in the state just don’t understand. (Including travelling time) I probably worked a 60 hour week for several years with nobody telling me to slow down. Many times I was ill but I had to carry on to avoid letting customers down. Once I had to stop and the money stopped as well. Then you learn what work is all about.
You’re not really selling it to anybody.
Apparently “throwing battery into someone’s face” is to be recommended according to one (large) former NHS employee, now turned BBC comedian.
I can tell you. They are very largely internally promoted. They know the vernacular and idiosyncrasies of the NHS but the not much about customer care, client satisfaction. business generation or financial management.
There will be no reform of the NHS under this government. The NHS is one of Labour’s biggest supporters.
No. It will go on. And on. Hoovering up money while lurching from crisis to crisis.
But AI will save the NHS money right?!
Again that will be a no. AI would ultimately mean losing jobs the unions won’t like that. No the unions will have them all stood outside the hospitals performing some cringe inducing dance routine while wearing ‘save the NHS’ branded merch. What is it with the NHS and dancing?
No. The directionless bloat will continue under Labour.
Couldn’t be more true, Left politics created this problem and keeps it going. The NHS as an idea is entirely justifiable. A small donation from each taxpayer to maintain a healthy workforce overall is legitimate. It needs to be done pragmatically not ideologically. Healthcare is not a human right, it’s a system and like all systems it succeeds or fails depending on how its designed, managed, funded, and used.
People in and around the NHS model cannot solve this.
Their only experience is of a huge centralised monopoly model. Exactly the model no other developed country uses. For good reason. Monopolies never function for the clients’ benefit. They are always inward looking. They always generate bureaucracy.
Every European Country has better health services than the UK. None are state run monopolies. Virtually all are privately provision funded by state provided insurance.
That completely changes the dynamics. Patients hold the cash. Doctors want and need to see them. And keeping your customers matters because they can take their insurance money elsewhere.
“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.”
Really? REALLY?
What about ‘Dr Ali Shokouh-Amiri who removes women’s ovaries for giggles and without knowledge or consent? He’s still working after admitting to it!
https://www.womenshealthmag.com/uk/health/a63850304/doctor-removed-ovaries-without-consent/
“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…”
I repeat: “a world where failing doctors are ruthlessly punished but higher-ups go free…”
Not unless the doctors and the NHS management can pin it on a nurse! Look at the increasingly shaky Lucy Letby conviction.
The only way change will take place in the NHS is if we have another Thatcher who will face these down.
Cull these overpaid technocrats, measure their productivity, dissolve their self hatred by declaring DEI dead , force declaration of only two sexes. No more funding of trans, body dismorphia , no more tummy tucks, Ozimpic pandering and worship of ADHD at 50. End their promotion of victim hood and publication of notices in any language but English. No more ‘trust’ , who trusts them, revert to health boards run by local people not corporate Scharlatans, here one day off the next. Get real.
An outstanding article. Thank you for saying this.
The British attitude to management is very strange. In a previous job, I was the only ops position in my discipline in a very small team; there was enough work in my very niche area for me to get on with. But immediately management became obsessed with me doing financial stuff – something I’m completely unsuited and unqualified for. The U.K. produces (as far as I can tell) lots of qualified accountants, and very people in my field (that’s due to demand rather than anything especially impressive about me) – they could easily have found someone to do budget stuff, whereas it had been a bit of a struggle to fill my role.
This pattern has been repeated to some degree in most jobs I’ve had. I reckon the UK’s dreadful productivity could be greatly improved if people were able to stick to the jobs they initially applied for.
Is this so as to provide career opportunities for existing medical staff? Rather than bring in more competent people from outside?
Are male nhs managers heavily into drug dealer chic – or is the author subtly letting us know something else about NHS managers?
Tut! Tut! They’ve appointed A MAN (gasp!) to succeed Amanda Pritchard!
This is contrary to DEI/Woke precept.
I think one image from my professional network sums up the current status of the NHS fir me.
It was an image of maternity ward nurses celebrating gay pride day. They had even taken time to bake lots of muffins with rainbow icing…awww!
Except child birth is typically the domain of heterosexuals, and the last thing I want to see in any branch of public services is that sort of identity politics bullshit, and especially not in a ward for delivering babies. It smacks of the worst, stubborn, judgemental Marxist crap that despises the family unit. How many pregnant mothers and supporting fathers (of any orientation) want to see the nurses devoting that much time to DEI? Is that really in their top priorities? Extremely doubtful.