In a gobsmacking interview with the Institute for Government, Andrew Lansley revealed his reflections on his notorious health bill. He doesn't seem to have learned much. Had he been in charge in 1940 Britain would have lost the Battle of Britain. This is important as his mistakes are still prevalent in government thinking about how to run the NHS. And we need to learn from his mistakes or we will lose the battle for the NHS.
Introduction: thank you HSJ
The Health Service Journal had an interesting juxtaposition of reports in its regular The Primer column on August 23.
The column reviews commentary on the NHS that hasn't otherwise appeared in the journal. On that day it mentioned a gobsmacking interview where the Institute for Government has asked Andrew Lansley to reflect on his time as Health Secretary. But it also reported an opinion blog by me published the previous week on the utter lack of any attention to management in the latest health bill. In doing so they also reminded readers of a much older opinion piece I wrote in 2015 about lessons the NHS could learn from the Battle of Britain (the original blog was written in 2015, the HSJ version–thank you for describing it as "legendary"–was published in 2018).
The juxtaposition of the Lansley interview, my opinions on management in general, and the Battle of Britain in particular set me thinking. My immediate thought was that, if we applied Lansley's thinking on management in the NHS to Britain's air defence strategy in World War 2, we would have lost the battle.
I think it is worth explaining why. Again.
Lansley thinks management gets in the way of effective action
So what did Lansley say?
Not everything he argues in the interview is wrong. For example:
Because in the NHS, there was – and still is, frankly, and it is returning now – a dominance of the provider interest over the consumer interest.
In this, he was and is right. For example, NHS policy for many decades has been to try to move activity away from hospitals and into the community. But the dominance of decisions by big hospital providers has meant that, in decades of trying, hospitals have, if anything, a larger share of the budget than they started with.
And his method was to give decision making power to CCGs not dominated by acute hospitals. And, given the above, this might have been a good idea:
The essential proposition was that commissioning should be led by clinicians and should be the central focus of NHS activity in delivering better outcomes within budgets.
But then he lets his core beliefs out of the bag:
But what you have to understand is that in the Department of Health, many senior positions were filled by NHS managers. And they, of course, had a completely different approach. They hated it all. They hated the reforms; they were the enemy within. Because they saw the reforms as handing power to clinicians, and by extension removing jobs and control from the hands of the NHS management.
His view of managers is something like the Kafkaesque bureaucrats running the world of Terry Gilliam's Brazil.
This is a Daily Mail fantasy rant, not a serious assessment of NHS management. I'm not arguing that nobody in NHS management is like this, but Lansley's view both overgeneralizes and makes a huge error about the role of most managers. The leadership in DH are not like the ward manager who tries to improve patient flow by coordinating the activities necessary to discharge a patient. They are not like the managers who coordinate and schedule activity in operating theatres so all the equipment and people are available at the same time to ensure the surgeon can operate without silly delays. Those managers–the majority of the managerial caste–are more like the transmission in a car: sure, the engine provides power but the wheels don't turn if some of the gears in the transmission are missing.
When it came to his bill, Lansley dealt a severe blow to the managerial caste, attempting to impose 50% cuts in their–already inadequate–numbers by including a limit in the bill for how many managers a CCG could have.
He still seems to think this was a good idea, claiming in the interview that he saved the NHS £1billion a year in management costs. Which he did, but at the cost of both organisational chaos and the ability of his new decision making clinicians to decide how best to spend their budgets and to implement the changes they wanted. CCGs got a new engine but most of the gears in the transmission were now missing. The general consensus was that the new bodies were the equivalent of a friday afternoon Austin Allegro that got through quality control when the QC team were still in the pub.
He wanted CCGs to think differently (I'm sure his grammar is better than Apple's) and to do differently. But, in his naive defenestration of the NHS management caste, he left organisations with no capacity to think or act differently. And it isn't like he wasn't warned.
This thinking would have lost the Battle of Britain
This is where it is worth reviewing the lessons I reported in that piece about the Battle of Britain (originating from military historian and management expert Stephen Bungay).
Bungay's key point is that the myths we tend to be fed about the battle deeply misrepresent the reality. We often assume that Britain won because we had better planes (Spitfires!), clever new technologies (Radar!) and more heroic pilots (Douglas Bader!). These make a cool national myth but one which is close to the exact opposite of the truth.
The Battle of Britain was won because the RAF had by far the best organised fighter defence in the world. The Luftwaffe had great planes, radar and equally heroic pilots. But they didn't organise them well.
Organise is the key word here. The RAF had spent years developing a sophisticated operational process to manage its fighter defence. The management system that coordinated the defence was what won the battle. As Bungay remarks:
In their ‘finest hour’ the British behaved quite differently from the way in which they usually seek to portray themselves. They exhibited a talent for planning and organisation which, in its Teutonic thoroughness, far outstripped that of the Germans. They left little to chance, planned for the worst case and did not rely on luck. Given all this, it is hardly surprising that they won. It is, on the other hand, quite extraordinary that they should imagine they could have won by doing the opposite.
But the people who designed and implemented that management system would be exactly the people Lansley would have fired so the front line pilots could make the key decisions. The very people needed to design and implement the processes that deployed the RAF to maximal effect against the Luftwaffe would be the people Lansley hated. I imagine him saying "We don't want bureaucrats telling the pilots what to do". The front line pilots, in his view, would be the experts who know best how to fight the hun.
But they were not. And we know this because a very similar argument actually raged during the Battle of Britain. The two most important men in "management" roles were Hugh Dowding (who designed the system and was in charge of Fighter Command) and Keith Park (who implemented it and was in charge of 11 group which defended London and the South East). Their flexible and selective way of managing the deployment of fighters was strongly disliked by some famous pilots (eg Douglas Bader, a well known public figure even then) and by the commander of 12 group (which defended the midlands), Leigh-Mallory. Bader and Leigh-Mallory believed that an idea called the Big Wing was superior to what they were being directed to do by Park and Dowding.
Dowding and Park were both moved sideways towards the end of 1940 (luckily after the Battle was won) because the lobby for letting pilots do what they wanted (which included Leigh-Mallory) had better political connections than they did. This was a mistake as later evidence showed Park and Dowding to have been right. And, later in the war, Park did it again in the defence of Malta, thoroughly defeating the Luftwaffe attempts to crush the island's defence. As Bungay remarks:
What Park achieved in the Battle of Britain is in itself enough to place him amongst the great commanders of history. But his performance in 1940 was not a one-off. In 1942 in Malta, Park took the offensive and turned Kesselring’s defeat into a rout.
He was as adept at offence as he was at defence, and, like Wellington, he never lost a battle. His record makes him today, without rival, the greatest fighter commander in the short history of air warfare.
Andrew Lansley would have sided with Douglas Bader from the start. He would have sided with the opinionated front line pilots rather than the people who had demonstrable ability to find the best way to organise Britain's defence. He would have removed Park and Dowding before the Battle leaving the very real possibility that Britain would have lost because of the inferior systems proposed by Bader and Leigh-Mallory.
Why Lansley's naive view of management is wrong
Lansley's comments repeatedly demonstrate that he has no idea of the various roles of management.
One role is to organise the deployment of front line staff. In the Battle of Britain this involved managing the information flow from radar and observers to understand where the German bombers were and deploying the fighters in the most effective patterns to combat them. The naive views of some of the more vocal front line pilots about how best to deploy their planes were wrong. And few, if any, of the front line pilots could have designed the intelligence system that directed them to their targets (Dowding and Park had spent years thinking about the system of deployment not just about how to win a dogfight). Though both had front-line experience, it was their focus on how to manage the battle that made the difference. Lansley seems to assume that front line experience is all that matters and there are no benefits from organising the front line more effectively.
He also misses the role of management and support staff in implementation. (Arguably "support" and "management" are different but they work together to make things happen). He demonstrates this in this quote:
But there were things like the continuation of commissioning support units and the form that commissioning support units took that I would not have done were it not for David Nicholson protecting his own people in the NHS and in strategic health authorities.
Now I am no fan of commissioning support units, very few of which did good jobs, but Lansley doesn't seem to understand anything about what their roles were. Many took over essential roles like managing procurement and the provision of analytics to CCGs and hospitals. I generally think their ability to do such jobs well was deeply undermined by the compromised and confused way they were set up, but, surely, not bothering to do those roles at all would be even worse?
Were Lansley looking at the huge infrastructure necessary to operate Dowding's system for directing the RAF (huge numbers of observers, multiple control centres, many layers of middle managers interpreting and filtering information before making decisions and sending instructions to the pilots), he would probably have slashed it in favour of "more resources to the front line" and more pilots and planes.
The key point here is that the role of management is both about deciding the right strategy and having the infrastructure to make it happen. Lansley's own words suggest he understands neither role. And his actions slashed the capacity of the NHS to do either. Sure, he could claim £1billion a year of savings from ruthlessly deploying an axe to managers, but the resulting chaos and performance degradation show that the "savings" came with catastrophic costs. Incredibly, Lansley claims credit for improvements in the system:
...as it happened, we got waiting lists down to their lowest ever level in late 2012.
which were delivered before his changes were fully implemented and ignores the catastrophic declines that started as soon as his ideas began to take hold (waits for elective treatment and in A&E departments are now worse than they were before the major Labour reforms of the early 2000s). Remember when fewer that 2% of patients spent more than four hours in A&E? Today's NHS in England struggles to get fewer than 2% of patients spending less than 12 hours in A&E.
Lansley would be claiming credit for getting more Spitfires in the air even after the UK had been invaded by the Nazis.
In the interview he demonstrates a stunning naivety about the role of management in the NHS combined with an adamantine refusal to evaluate the real consequences of his decisions. What is worrying is that his views on management are widely held both by critics of his ideas and current NHS decision makers. His structural ideas about the NHS are being dismantled but his naivety about the role of management carries on. The current health bill says nothing at all about management.
Lansley seems unable to learn from his own experience or from history. We desperately need NHS policy makers to do better.
