The NHS is a microcosm of the British economy

 The NHS is a microcosm of the British economy

Mistakes in how the government has managed the NHS parallel the mistakes in managing the economy. Trying to hold down the government budget is constantly approached by making easy choices rather than the right choices. The same is true in the NHS where the capital budget is raided to cover operating deficits. Both are recipes for long term decline.

All governments would like to see a higher growth rate in the economy. The current one wants to increase incentives with tax cuts but need to pay for those giveaways with spending cuts. But, faced with those spending challenges, they often take the easy road to keep the budget in some sort of balance by cutting the very capital projects that might improve growth in the long term. 

The parallel with the NHS is interesting. Growth in spending seems relentless. That growth can be constrained only by improving productivity. But the choices made to keep the budget under some semblance of control hurt productivity, making tomorrow's problems worse. In this way the NHS is like a microcosm of the whole economy, at least in the ways both have been managed in the last decade or two.

The economy

The link is explained by the factors known to affect productivity in the economy and the NHS.

As Sunak explained in his spring statement while he was still chancellor (my highlighting)

"Over the last fifty years, innovation drove around half the UK’s productivity growth.

…our lower rate of innovation explains almost all our productivity gap with the United States.

Right now, we know that the amount businesses spend on R&D as a percentage of GDP is less than half the OECD average.

…

Weak private sector investment is a longstanding cause of our productivity gap internationally:

Capital investment by UK businesses is considerably lower than the OECD average of 14%.

And it accounts for fully half our productivity gap with France and Germany."

His analysis is mainstream economics. But it is worth asking what governments have actually done about either innovation or capital spending over the last decade or two because the same factors matter not just in the private sector but in the parts of the economy controlled by the government.

This chart on total government spending appeared recently in the FT: 

The point is that, when faced with alternative ways to control total government spending, Osbourne chose the easy path of cutting capital spending, not current spending. And that spending on national infrastructure is the sort of thing that leads to long term improvement in productivity (and there is a direct influence on the economics of private capital spending because the future returns on that will be higher if the national infrastructure is better).

But, politically, capital is easier to cut. Who notices the long term impact of projects that might not finish for years and might only show big benefits in decades? Everyone can see this year's budget deficit. The temptation is to take the easy option even though it is the worse option for productivity and growth in the long term. Yes, all politicians, if asked, would claim they want higher productivity and growth: but they are very reluctant to face worse headlines tomorrow about the budget deficit.

Given that UK productivity growth tanked during the Osbourne austerity period, you might think this lesson had been learned. But that is not what the mood music emerging from Whitehall suggests where, in response to the catastrophic reception of the Kwarteng mini-budget, departments are being asked to make sharp cuts with capital spending at the top of the list.

The NHS

How governments have managed the NHS is a microcosm of this same problem. And it has been catastrophic for the long term health of the system.

If tomorrow's NHS is to be less of a financial burden on future governments, it needs to be much more productive (however that is defined: quality and throughput both matter in healthcare). The same factors–innovation and capital–have big influences on future NHS productivity. But how has the budget been allocated in the last decade or two? 

We can compare the NHS to other health systems in how it allocates money to the things that should matter to future productivity. The easiest to measure is capital spending. And, mirroring the problem with spending in the economy as a whole, the big picture looks to be a catastrophe of poor short term choices (for a more detailed analysis see my longer rant here). In an analysis in 2019, the Health Foundation produced this chart:

And said:

"Capital spending is a critical input in health care, with new technology able to transform services and improve workforce productivity. 

The DHSC has proposed a more technology–and data–driven NHS. New technology and IT could improve patient services and increase productivity, but both currently make up a small proportion of capital spending."

 

So, not only does the NHS get starved of capital spending in general but the mix is very light on the things that would typically have the biggest impact on productivity.

The result of this is that the capital employed per worker (an interesting measure of the stock of things that partly determine productivity) is half that of most comparable systems. 

And, according to the National Audit Office, even when the NHS gets allocated a capital budget, it frequently either underspends it or pilfers it in year to cover operating deficits. This is a perfect illustration of the political choice to take an easy path rather than the right one. And one that has, in effect, killed the hope that NHS productivity could improve enough to lower the financial burden on long term government spending. And this has been the chosen path for two decades. It is little wonder that the productivity of the NHS is falling and that the system is creaking under the strain. 

Some conservative commentators are now arguing that the government can no longer afford to keep spending more, as they need to do to stop the wheels from coming off the bus. But those commentators ignore a major  reason for the current need for more spending: the neglect of any attempt to spend the money on the long term things that would make the NHS much more productive and reduce the pressure to spend more to avoid imminent catastrophe. 

And the opposition don't help pull the debate back to solid ground by claiming everything is about staff shortages. There are two problems with this. One is that investment in better equipment and facilities could improve productivity so much the need for more staff could be reduced. The other is that the biggest reason staffing is a problem is not recruitment, it is retention and a large part of that is caused by the poor working environment some of which is caused by the lack of capital per worker. And the constant churn of staff, especially when experienced staff are replaced by cheaper but less capable staff, undermines team productivity and quality, exacerbating the need for yet more staff in some sort of anti-productivity death spiral.

So what?

And this brings us back to why the NHS is a microcosm of the economy as a whole. In order to attempt a rescue of government finances ravaged by the Kwarteng mini-budget, the key proposals to recover the government deficit currently being discussed are to cut things that are easy to cut quickly. Like capital spending. So, instead of spending on the long term things that enhance future productivity, they are likely to cut them further and in ways that damage the very growth they seek. They should have learned from the Osbourne era that that does not work. The easy path then–capital austerity–hurt the national growth rate and made it harder to fund the sorts of spending the government cannot cut if they don't want to lose their core voters (are they going to cut pensions when the most conservative block of voters are pensioners? I don't think so).

As Martin Wolf said in a recent column in the FT (my highlights):

The UK’s longer-term economic performance must indeed improve if the desires of its people for a better life are to be realised. If the government wants to do something useful about this, it might dust off the report of the London School of Economics’ Growth Commission of 2017. Better incentives are indeed a part of the answer, but only a part. This is why systematic tax reform would be desirable. There must also be difficult deregulation, notably of land use. The state must supply first-class public goods, in the understanding that these are a social benefit, not a cost. There must be fiscal and monetary stability. There must be far higher investment in physical and human capital, both public and private.

Neither the economy nor the NHS will be better tomorrow if the investment in the long term is cut. The persistent habit of picking easy cuts rather than the right cuts is a recipe for long term catastrophe (and possibly short term catastrophe too). 

Spending the money well (especially not neglecting long term investment) is the solution to the growth and productivity problem in the NHS and the wider economy. Spending it badly by making easy choices now is not.

PS that cartoon is modified from an original by the late great B Kliban. See some of his other quirky cartoons here: https://www.gocomics.com/kliban

The biggest problem holding back NHS performance is a lack of investment in capital, innovation and management not staff or beds

In debates about what the NHS should do to improve its performance it is common to see benchmarks of staffing or bed numbers versus comparable health systems. The argument is that the system needs more doctors/nurses/beds. This is not the biggest problem. The NHS has suffered far more from a failure to invest in capital, innovation or management. 

Charts like the one below dominate the debate about NHS funding:

The message is simple: the NHS is underfunded and needs to have more doctors (or nurses or more money, depending on which lobbyist is producing the charts).

The implication is that the very obvious performance problems of the system would be solved if only we matched the same level of doctors/nurses/funding as the peer group of other health systems.

There is some debate on the strict comparability of these metrics and that is rarely mentioned by the lobbyists. In fact I once saw Nigel Edwards heckled for pointing out that a major revision on OECD metrics of overall spend on the NHS and comparable systems made the NHS look middling rather than an outlier on the low side. People really want the explanation for poor NHS performance to be simple and, preferably, a conspiracy they can blame on the Conservatives. It is frequent to see phrases like "Tory staffing cuts".  And that is the end of the debate for many.

But, even though the overall NHS budget saw unusually low growth in the decade after 2010, front line staffing increased significantly. The "tory cuts" in staffing led to ~30% more doctors and 15% more nurses:

I don't want to argue that the government is not to blame. I do want to argue that we are looking in completely the wrong place about where policy has been wrong.

There are far, far bigger problems than not having enough front line staff. And the real problems that front line staff experience are often consequences of those other failures. Worse, those other failures get almost no attention and the topics that do get attention distort the debate so much that the biggest and most important failures get essentially no critical attention.

Before I get to the other issues that I argue matter more than staffing, it is worth a quick review of why the staffing benchmarks are not that relevant to NHS performance.

One reason is a lack of strict comparability with the other countries in how they use staff. But a more interesting one is that the implied policy when it looks like the NHS is behind ("fix the staffing, fix the problem") very clearly doesn't work in specific cases. An example is A&E staffing. It has been repeatedly claimed in the last decade that the decline in A&E performance is a consequence of a lack of A&E staff. But the number of A&E doctors rose faster than demand every year since 2010 and the number now is >30% higher than it was in 2010. The number of A&E specialists grew faster than any other for most of the last decade. But performance has declined monotonically over that period. 

In this case it is easy to see why staffing was never the problem. Patients suffer long waits in A&E not because there are not enough A&E staff to treat them but because there are no free beds to move the patients to. This was known in the early 2000s when the 4hr target was set and has repeatedly been shown in detailed analysis of the causes of waits in the last decade (see, for example, this from Monitor). To put it simply, more A&E doctors can't magic up more free beds. They mostly can't even influence the number of free beds. So adding more staff doesn't fix the underlying problem. (I should add that the longer the A&E queue, the more staff are needed to handle it. So the apparent staff shortages are actually a symptom of a different problem elsewhere in the hospital, not the cause of the problem. Adding more doesn't fix the problem.)

So what other errors has the NHS made?

The NHS benchmarks that really matter

Let me tell you the answer before working through the details and arguments. 

The NHS might be slightly short of front line staff but it is catastrophically short of support staff like managers and has a long standing lack of investment in innovation and capital spending. If benchmarks versus comparable health systems are any guide, the NHS is a spectacular outlier in investment and management. 

The NHS is very undermanaged

When the Lansley Reforms were in draft form and proposed severe cuts in management numbers there were several analyses that criticized this goal. The King's Fund concluded as part of its commission on leadership and management that:

"If anything, our analysis seems to suggest that the NHS, particularly given the complexity of health care, is under–rather than over–managed."

And this was before the drastic cuts in the Lansley reforms were implemented (see the staffing chart above for their immediate impact). A more recent analysis (in a report by Ian Kirkpatrick and Becky Malby for the NHS Confederation) said:

"...it is hard to argue that the NHS is ‘overmanaged’. At approximately 2 per cent, managers are a very small proportion of the NHS workforce. By comparison, ‘managers, directors and senior officials’ in the UK as a whole make up 9.5 percent of the workforce." 

And, in another report in the series they argued this: 

"We found that even a small increase in the proportion of managers employed (from 2 to 3 per cent of the workforce in an average acute trust) had a marked impact.

Up to a certain point, larger management functions in trusts were associated with higher patient satisfaction scores, a 5 per cent rise in hospital efficiency and a 15 per cent reduction in infection rates. Further tests revealed that it was primarily higher levels of managers employed that drove these improvements and not the other way round."

Both NHS management numbers and total administration costs are far below international norms and have fallen sharply since 2010. Given the clear evidence from Kirkpatrick's work that more managers make hospitals function more effectively, cutting management looks like a bad error. Adding more managers has a lot of leverage over the performance of all the other staff but the NHS has chosen to cut their numbers instead.

Both manager numbers and total administrative costs are far more out of line with international norms than the number of doctors, nurses or beds. Although good comparable metrics are hard to find, the IFS claimed this in 2018:

The OECD has compiled data on administrative costs of different health care systems at the ‘macro’ level – which captures the amount spent on planning, funding and monitoring care, but not administrative costs within individual hospitals. 

They found that the NHS spends relatively little on overseeing and planning care, relative to other comparable systems. In 2014, the UK, Portugal and Ireland all devoted 1.5% or less of their government or compulsory health care expenditure to administration. This compares with an average of 3.1%, with 4.1% in France, and 7.9% in the United States.

Investment in innovation and capital is grotesquely low 

Another area where the NHS is an outlier is spending on capital and innovation. In fact it is an extreme outlier.

This is somewhat ironic given Rishi Sunak's recent spring statement where he diagnosed a major problem for the UK economic productivity as being largely caused by a lack of investment in innovation and capital. As he argued:

"Over the last fifty years, innovation drove around half the UK’s productivity growth.

…our lower rate of innovation explains almost all our productivity gap with the United States.

Right now, we know that the amount businesses spend on R&D as a percentage of GDP is less than half the OECD average.

…

Weak private sector investment is a longstanding cause of our productivity gap internationally:

Capital investment by UK businesses is considerably lower than the OECD average of 14%.

And it accounts for fully half our productivity gap with France and Germany."

The NHS is the largest part of the UK economy controlled by the government. So exactly how has the government sought to control its spending on the key factors that determine productivity in the rest of the economy? 

It won't surprise you to know that it is the opposite of the Sunak recipe for productivity in the private sector.

The Health Foundation did a (little read) briefing on this in 2019. It starts by pointing out the obvious:

"Capital spending is a critical input in health care, with new technology able to transform services and improve workforce productivity. 

The DHSC has proposed a more technology–and data–driven NHS. New technology and IT could improve patient services and increase productivity, but both currently make up a small proportion of capital spending."

So the DHSC has an ambition to exploit technology and IT (which needs investment). But the Health Foundation analysis of 20 years of NHS capital spending compared to peer health systems looks like this:

Only during the late Blair/Brown years did NHS capital spending come close to international norms and it is often the lowest or next to lowest in the whole dataset. The Health Foundation  argue:

"For the UK to move up to the average for OECD countries, capital spending would have to almost double as a share of total health spending"

The National Audit Office also reviewed capital spending in the NHS in 2020 and some of their analysis tells an even more sorry tale. 

They start by pointing out part of the current situation with buildings and other capital assets:

Parts of the NHS estate do not meet the demands of a modern health service. NHS hospitals include Victorian-era buildings, and 14% of the NHS estate predates the formation of the NHS (1948). 

…

The growth in backlog maintenance indicates that there is an increased risk of harm to patients … the backlog of maintenance work to restore buildings to an appropriate standard was around £6.5 billion … High-risk backlog maintenance currently stands at £1.1 billion, and grew by 139% between 2014-15 and 2018-19, indicating an increased risk of harm to patients.

It isn't just the lack of modern IT and diagnostic equipment that holds back the NHS. It needs more modern buildings to do a good job but frequently doesn't have them.  Worse, in some cases, maintenance problems in the existing buildings are so bad they risk immediate harm to patients.

Given this already disturbing background it might be a surprise when they point out that in many years of the last decade the already inadequate capital allocation to the NHS was underspent:

"Between 2010-11 and 2012-13, there was an average underspend of £677 million (12%) against the capital spending limit. In 2017-18, £360 million (6%) was unspent."

And their story gets worse:

"Since 2014-15 the Department has transferred £4.3 billion from capital to revenue spending"

So not only does the NHS start with an inadequate budget, which it underspends, it is then encouraged to pilfer the capital budget to cover operating costs. The reason this has been encouraged is because it is a convenient short term way to cover up operating deficits. These are embarrassing. And, obviously, avoiding embarrassment is more important than the roof of an operating theater falling in. Better still, while operating deficits are visible every year, most of the catastrophes from the maintenance backlog will appear slowly over a decade.

It might seem strange that the inadequate capital budget should ever be underspent. But the NAO explain that too by pointing out that the paperwork and bureaucracy of applying for capital is so baroque that many hospitals can't even get their cases for urgent maintenance past the system. And, even if they do, they might lose the allocation if they can't spend the money in-year as next year's allocation may be arbitrarily different. Short term changes to the budget every year make long term planning of capital spending impossible.

The buildings are inadequate for modern healthcare activities. There is a huge and rising backlog of maintenance to keep the show on the road that is limiting the capacity of the system to do more work. The system frequently steals from capital to employ more staff who will have to work in an environment where their work will be harder and less productive. The NHS is close to bottom on international rankings of the amount of high-tech equipment it needs to do the diagnostics necessary to tackle long elective queues. And there is little budget for investing in better IT to enable front line staff to work faster and more productively without the burden of coping with decade-old kit.

It is lucky that investing in capital or innovation doesn't matter for productivity. Oh, wait, that's exactly what the chancellor blamed for low productivity.

As an ironic coda to this section the following story appeared in the HSJ the day after his spring statement:

"Tech spend under pressure as NHSE told to ‘cut core funding’"

It hasn't taken long for the promises in the last spending review to invest more capital in the NHS to hit the buffers of old Treasury munchkin habits.

The government's goals for an improved, more productive NHS are directly undermined by its choices about how to allocate resources.

There are several important messages here.

Problem 1: the government itself has correctly argued that spending on capital and innovation are vital for driving up productivity. So much so that they are increasing the incentives to encourage more such spending in the private sector. But, when they control the budget, they do exactly the opposite. And, at the same time, continue to demand even higher productivity gains from the NHS. Whipping a dead horse doesn't cover it. It is more like whipping the reliquary containing the ashes of the horse cremated a decade ago after being euthanized for breaking a leg.

The second huge problem here is the lack of attention this analysis has had among commentators and the media. The news is full of stories about how the NHS is struggling because it has 10 or 20% fewer doctors than comparable systems. Lobbyists for nurses and doctors demand higher levels of staffing to fix the overwork, the current catastrophic waiting lists and A&E delays. But there is little mention of the fact that the NHS has perhaps half the capital employed per worker than almost any other health system. The NHS is a far more extreme outlier on this than it is on staffing. And the day to day work the front line staff have to do is much harder and less productive as a result.

The third problem is management. NHS management does make the news more often than capital spending, but almost always to disparage it. Stories often argue that we could cut management even further to put more resources to the front line. These stories usually fail to note that NHS management has already been sharply cut by the Lansley reforms and is currently another major outlier in comparisons between the NHS and other systems (I made the case about managers and their importance in the NHS here). Nor do they mention that very clear work shows that more managers make productivity and medical quality better. 

In short, there is a fundamental mismatch between the government goal for a more productive NHS and the way it provides the tools to the NHS to achieve that productivity. The government and NHSE are like an army who recognises the need for bullets but forgot to allocate a budget for the guns required to fire them. 

The perpetual failure to invest enough in capital, innovation or management is a far bigger problem for the NHS than any shortage of staff. It is about time the commentariat, the media and the government realized this. We won't fix the NHS until they do.

 

Andrew Lansley would have lost the Battle of Britain

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.