Every private business, every public organisation, every charity or community group or whatever needs to have effective management who can steer the organisation in the direction that it needs to go. A manager in the private sector needs to act in order to maximise profit and customer satisfaction, a public sector manager needs to ensure that the service they are providing is provided at efficient cost and in a timely manner. A charity manager needs to ensure that the charity’s aims are met and that the charity is complying with all relevant laws and even a small community group needs managers who will act in the interests of the organisation and the community that it serves.

Management is vitally important and good management is the difference between a company failing or prospering or a public sector achieving or not achieving its goals and a charity being run effectively and honestly or not. A good manager with sufficient powers to act in a way to improve an entity whether that be public or private is an asset. They can make a good organisation great and a bad organisation much better than it was.

As I said good management is important which is why it’s right to ask why is the NHS managed in a similar way to how Post Office Telephones was in the 1970’s? Managers in the NHS cannot easily hire good staff or fire bad ones and this is just like Post Office Telephones in the seventies where bad staff could not be sacked because such sackings would be blocked by very powerful Trade Unions. Managers in Post Office Telephones were, apart from specialists in research areas, also not in a position to engage in innovation either as they had little in the way of power to do so.

Managers need to be able to manage and have the necessary powers to manage and there’s a story in the Spectator that shows that managers can’t manage as they should.

This article, by Druin Burch, which I was gratifyingly alerted to by Jon MC over at Harry’s Place (link below) is by a doctor who became an NHS manager. It’s a fascinating window into the culture of NHS managers who are sadly not given enough actual powers to be able to properly manage.

Druin Bruch said:

NHS managers can, with effort, recruit to new posts. But dismissing people for ordinary poor performance is practically unheard of: it takes the most outrageous incompetence. The normal incentives by which businesses operate – paying people more when they perform well, getting rid of them when they don’t – are non-existent. Lacking the levers for change, managers are left with two options. They can accept that they’re helpless, or they can lie.

“Here’s how I do it,” said a grey-haired doctor to me, encouragingly. He’d had a career in senior hospital management and wanted me to do the same. He was excellent, with full insight into the limitations of his power. There had happened to be a surge of admissions 48 hours before. “I’ll walk round the Emergency Department today,” he explained, “and I’ll hug people and tell them they’re doing a good job and I’m going to help create space by pushing discharges. I know the average length of stay is 72 hours, so within the next day everything will improve and people will think I’ve helped.”

What a terrible situation. A manager who can only hire with great effort and who can only dismiss people who are outrageously incompetent or even dangerous. Maybe this inability of managers to be able to weed out wrong’uns from the NHS is why the NHS has so many incompetent or utterly useless staff?

Druin Bruch added:

Management, actual management, is both important and hard. To make an institution run better can be deeply satisfying; to do it in healthcare has the added pleasure of seeing directly that you’ve improved lives, and not just the bottom line. But give people management roles in a setting where they can’t manage reality, and you should not be surprised when they shift to managing reputations and illusions. Put people in dishonest situations and you breed dishonesty.

In most of the NHS, the relationship between doing better work and being better rewarded is entirely absent. Incentives are often misaligned, frequently perverse.

What an awful way of managing a healthcare system. It’s almost Soviet in its operation. The management cannot change the reality of healthcare delivery by for example sacking the incompetent or arrogant staff, such as the one who killed my mother with wrong medication, they cannot hire decent people and they have no levers they can work to make things better. They can’t even incentivise staff to do better work. All they can do is bullshit and manage reputations instead of properly managing healthcare.

It’s a terrible way of managing in a system that is increasingly terrible for the customers who use the NHS. Britain deserves

Links

Spectator article on NHS management

https://spectator.com/article/lucy-letby-and-the-truth-about-nhs-managers/?edition=us

The Harry’s Place thread where Jon MC and his entertaining and often very thoughtful posts can be found.

https://hurryupharry.net/2026/08/31/september-hangout-2/