Everyone has a plan until they get punched in the mouth
Mike Tyson, boxer
...no plan of operations extends with any certainty beyond the first contact with the main hostile force
Helmuth von Moltke the Elder, 19th century Chief of the Prussian General Staff
The NHS swings between bouts of centralised power in the hands of ministers and decentralised decision making by its regions and units in repeated attempts to achieve its goals. But it never seems to achieve the goals desired. I suspect its leaders (both politicians and bureaucrats) have never learned an important lesson that many military forces learned the hard way.
The current NHS white paper proposes a great deal of new centralisation of power in the NHS, a major reversal of Blair-era reforms which tried to decentralise decision-making. My best guess as to why this is happening is that ministers feel the NHS is not achieving what they want and the only effective way to do so is to take back power. This is wrong. Though it is far from obvious that decentralisation worked either and the real problem is a fundamentally misguided view of how to get things done in a big organisation that has persisted in the NHS for decades.
Other big organisations have taken a different approach. Many militaries learned the hard way how to achieve their goals and how they did so provides useful lessons for the NHS.
The fundamental idea that governs the NHS is that people should "follow the plan" and do as they are told. They should achieve things by following the how of the plan and are frequently judged on whether they follow the right process to achieve the goal. Metrics are often if not usually process metrics not outcome metrics. This philosophy of management (or culture) has persisted over time despite major changes in the structure of NHS management which has swung from centralised to decentralised and back over the last few decades.
This follow-the-plan philosophy is how many militaries used to exercise command and control in their troops. This was how the British military worked at the start of WW2 until the outcomes forced a major rethink.
A good illustration of the problem is the campaign in North Africa. Until the decisive defeat of the Afrika Corps at the second battle of El Alamein, the British forces were repeatedly defeated by a vastly inferior German and Italian force (the Allied forces almost always outnumbered the Axis forces in men, tanks, guns equipment and had far fewer persistent shortages of supplies). According to the insightful analysis of Stephen Bungay (in his books Alamein and The Art of Action) this was not–as is often reported–because their leaders were better (though Rommel was an excellent tactician) but because the command and control doctrine of the German army was far superior.
A simple way to understand why is encapsulated succinctly by the Mike Tyson quote and at more length by Moltke: rigid plans are derailed by the messiness of reality which discombobulates the plan as soon as the enemy doesn't act as expected. The British army doctrine at the start of the war demanded that soldiers follow the plan, in detail. Junior officers were disciplined if they deviated from it. Following the orders in detail was the goal. The Germans didn't do that. They knew what Mike Tyson and Moltke knew: the details of the plan fall apart as soon as you meet the enemy. Instead, the Germans issued objectives for all levels of command about the key goals rather than detailed plans about how to achieve the goal. All levels of officers were given wide discretion about the how. They were expected to innovate when they saw the reality on the ground as long as they pursued the key goal they had been set. This led to persistently better decision making in actual battles leading to their inferior forces often winning key engagements with the rigid, hidebound Allied forces (at least until the allies had overwhelming superiority).
German command doctrine (now called Mission Command and widely adopted as a central philosophy by the modern US and British armies) was that a detailed plan is derailed by real events (like getting punched in the face or when the enemy doesn't act as expected in the plan) so tactical innovation in response to reality is far more likely to achieve the goal than blindly following the details of out-of-date orders cooked up by commanders a long way from the action.
But this is pretty much how the NHS works. Goals are not set in terms of outcomes but in terms of following the plan. Do things the way the centre tells you to. And suffer punishment if you deviate from the process, which we will measure. And they won't measure the outcomes because that is far too hard to measure in the short term. The centraising plan will make this worse, not least because it is the equivalent of a frustrated Churchill demanding direct control of the deployment of individual tanks in the desert because his generals were not winning their battles. The NHS has rarely tolerated local innovation that delivers better outcomes and often seems to regard innovation as "rocking the boat" or "deviating from the process".
This is a critical failure. Unless the NHS radically changes its management philosophy and culture from one where following the plan is rewarded to one where local leaders are rewarded for achieving better outcomes by innovating, it will never get better at achieving better outcomes however the overall structure is changed.
The NHS plan should focus on the management culture not the structure. It should define the broad goals (outcomes) desired by the government or the leadership and leave the front line leaders to find better ways to achieve those goals. And it should radically cut the process ("do things this way") metrics and use more achieve this outcome metrics. And don't forget culture change: culture may reappear and control the results even if the structure is new. A change in management structures will always be trumped by a persistent management culture.
It cannot be said that the military have always remembered this lesson. An analysis of the army's poor performance in the second Gulf War pointed out that Mission Command is not very useful when you have no idea what your mission is (see the introduction to The Good Operation which also has other useful conclusions about public policy that don't seem to have influenced the NHS plan). Perhaps this too is a problem affecting the NHS. Which suggests that the NHS might have been better analysing why it frequently fails to achieve better outcomes before writing a plan that reinforces the very cultural problems that make innovation and flexibility so difficult.
