Mid Staffs shows everything that’s rotten in the house of management

4^th March 2013

ResPublica Fellow Simon Caulkin writes for the Guardian's Comment is Free

The Mid Staffs NHS scandal will not go away. The collapse of the hospital trust into administration and the subsequent resignation of two board members ensures that the wound will continue to bleed, ratcheting up the pressure on the embattled NHS chief executive Sir David Nicholson. Investigation of suspicious death rates at a number of other hospitals just increases the sense of foreboding.

One reason that scandals like these both run on and recur is that we persist in thinking of them as exceptional; one-offs caused by a few incompetents or rotten apples in an otherwise wholesome barrel. But they’re not. The terrible outcomes at Mid Staffs were the logical consequence of a disastrously flawed management system that systematically forces people to face in the wrong direction, counts the wrong things, and focuses management attention on the wrong part of the job.

This is “deliverology”, as unappealing in practice as in print, otherwise “targets and terror” – the direct public-sector counterpart of the ideologically-driven, shareholder-first management model that in the private sector gave us Enron, then sub-prime, Lehman Bros, and seemingly innumerable banking scandals in their wake. Unconsciously emphasising how closely the two are related, David Cameron’s big idea for preventing more Mid Staffs was performance-related pay for clinical staff – the very thing that in the financial sector brought the global banking system to the brink of collapse.

Just like these private-sector exemplars, Mid Staffs demonstrates everything that’s rotten in the house of management, from bottom to top. At individual level, targets cause people to face managers and regulators rather than patients; and the tighter the performance management, the more essential elements not subject to targets, such as care and compassion, are squeezed out. Hence the grotesque absurdity of targets for compassion in hospitals or making lessons engaging in schools.

Targets always result in gaming. When it does, the knee-jerk reaction on the part of everyone from politicians to top managers is to tighten supervision to identify and root out offenders. Unfortunately, performance management has a poor record – partly because in overall performance individuals are far less important than the system in which they operate; but also because it is self-defeating, driving a vicious circle in which tight supervision and monitoring lead to demoralisation, disengagement and worse performance, apparently justifying a further turn of the supervisory screw.

The process is graphically described in a recent research report for the Scottish TUC, with the self-explanatory title of Performance Management and the New Workplace Tyranny. Originally presented as an enlightened expression of shared interest, like many other things in management (lean working, human resource management), performance management has morphed into its dark opposite, synonymous “not with developmental HRM and agreed objectives but with a claustrophobically monitored experience of top-down target driven work”.

Applied to individuals such tactics lead directly to Mid Staffs, a system which reshaped people into target-chasers who couldn’t afford to care. At the level of the supply chain the same kind of fierce control gives us a different form of butchery. Scaling up the performance-management tyranny, the big supermarket chains treat meat suppliers as adversaries, writing short-term term contracts, playing one off against the other and driving prices way below the point where something had to give. The immediate result was horseburgers. But behind the scenes is a much bigger, very British tragedy: a meat industry that is in long-term crisis and decline, wholly unable to defend itself against less cannibalistic European counterparts.

Few these days would want to be treated with the mixture of superstition, ideological prejudice and pseudo-science that constituted medical knowledge in the Middle Ages. But that’s hardly an exaggeration of the state of management today. It is management not medicine that has put our institutions in intensive care, and until we decide to do it better unfortunately that’s where they will remain.

The Guardian Article

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