‘Command and Control Management’

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by John Carlisle and Joe Carlisle, Mad Management

READ ON THE SHA BLOG:

Command and Control Management:

ABSTRACT: Although the Command and Control style of management is a fairly modern phenomenon, like all ideas, its roots go much further back, to a very dominant model of how to discipline and organise institutions. The philosopher Michael Foucault famously uses 18th Century Utilitarian philosopher Jeremy Bentham’s panopticon as a model for how a modern disciplinary society seeks to at all times to survey, or at least give the possibility of surveillance, its populace. The panopticon is a surveillance structure originally designed by Bentham for prisons but reproducible in any environment. The centre is occupied by a watchman who cannot be seen but who is surrounded in the round by the cells or workplaces of those he surveys. Each in their own compartmentalized sections the watchman, or manager, can see everything the prisoners do. As Foucault describes ‘[t]hey are like so many cages, so many small theatres, in which each actor is alone, perfectly individualized and constantly visible.’

National Health: Who Cares?

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The Great Yorkshire Conversation, Part 3

Saturday 26 September, 2020, 2pm – 5pm on Zoom
REGISTER HERE: https://www.eventbrite.co.uk/e/national-health-who-cares-tickets-111800787164

NATIONAL HEALTH: WHO CARES?

Discussing a comprehensive strategy for restoring our universal health system

Key issues

  • Restoring the whole Health System
  • Driving out Privatisation

The coronavirus pandemic has exposed the failings of a health service hamstrung by damaging government policies and unnecessary austerity. Our conference will provide a platform to explore the power of socialism to deliver the highest quality healthcare to all, free at the point of need, publicly financed.

The way to do this is to address the service as a whole system from the Upstream (Public Health, including Care Homes) to Final Delivery (Primary and Acute Care).

It is axiomatic, therefore, that bolstering public health services has a positive impact on societal inequalities and the vulnerable in our society. This will reduce the demand on primary and acute care and reduce costs while improving quality. The rationale for privatisation will disappear and we will bring services back in-house.

Our main speaker will be Prof. Allyson Pollock (Professor of Public Health, Newcastle University; Hon. President of the SHA). A recent BMJ editorial by Prof. Pollock discusses “COVID-19: Why we need a national health and social care service” (read online).

Conference Outline

  1. Welcome and introduction
  2. Speaker (Prof. Allyson Pollock)
  3. Q&A
  4. Discussion groups
  5. Feedback
  6. Forward to YSHA Conference 2021
REGISTER FOR ‘NATIONAL HEALTH: WHO CARES?’

A Brief History of Folly: the NHS, Integrated Care, and How to Challenge the Changes

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John Carlisle, Chair, YSHA

25 March 2020 (revised 13 May 2020)

The NHS was an Integrated Care institution, until the politicians began to meddle with it. Norman Fowler started the rot when he set aside the Area Health Authorities (AHAs) in 1982, after being Health Secretary for less than a year. The AHAs had been running for eight years and were on the verge of integrating with local government to balance regional demand and supply. The management system was key. Local management teams integrated the hospitals, family medical clinics and community health centres; and decisions were made by consensus.

Fowler’s intervention was a major disruptor, opening the way for the top down, ‘efficiency’-driven fragmented encumbrance that Hunt and Stevens have left us with today.

What was Norman Fowler’s qualification for this key role? Just like Michael Gove’s for education – journalism! How much did he know about how large service organisations work best? Did he visit the Marriott or Taj hotels, famous for their service, or John Lewis, or even another successful health service? No, his opinion was sufficient. He clearly had never heard of Continuous Improvement, a policy used by the finest companies in the world, e.g. Toyota. Toyota has never reorganised in fifty years; but it obliterated General Motors in less than 10 years, with a little help from Honda and Nissan – not on price, but customer satisfaction.

Here we have the nub of the problem: Ministers are put in charge of vital services like the NHS, Transport, Justice, and Probation (the last three all fell under the egregious Chris Grayling) with no understanding of them as systems. Instead they arm themselves with neoliberal ideology, and with command-and-control management style. The extent of their ignorance is only matched by the degree of cognitive dissonance, which means they refuse to acknowledge any evidence that shows their policies are not working.

This is where activists have gone wrong. In the case of the NHS they have presented moving examples of very sick patients in corridors, nurses at the end of their tether, grieving families etc. This approach is not effective in challenging a money-driven government. The empathy in the political world, especially of the Conservatives, seems negatively correlated with the seniority and significance of the post, e.g. Theresa May and Priti Patel at the Home Office, Chris Grayling at Justice and Probation, Jeremy Hunt in health. In summary, those with the thickest skins get the posts requiring the greatest humanity.

What we need to do is point out clearly their failures as ‘executives’ in their jobs and the subsequent waste and increased costs. We need to relate these consequences to their flawed organisational model, i.e. targets, cost-cutting, outsourcing, privatisation, and, most subtly malignant of all, excessive governance and compliance. The YSHA will be directing its efforts to replacing the Tory public sector disaster with a State economy based on Bevan’s In Place of Fear (1952). This will resurrect the model of excellent service the NHS provided before the destructive tampering. It will then be applicable in all public services as they are brought back into the public domain, working hand in hand with a new green economic strategy.

We must be prepared to change everything!

The Economics of a Social Democracy

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John Carlisle, Chair, YSHA

24 April 2020

In Place of Fear, a book of reflections by Aneurin Bevan (published 1952), has often been overlooked for what it really is, i.e. a handbook for running a socialist nation. Most people seem to assume mistakenly that the title refers just to the NHS, whereas the chapter A Free Health Service is just 24 pages in a 203-page book. The rest of the book is a deeply insightful analysis of the post-WWII world and a prescription for Britain’s recovery by instituting socialist practices in the UK.

Bevan’s grasp of the economics of a socialist country was profound. He accepted the reality of a mixed economy, stating that that is what the people in the West would prefer, but nevertheless was clear that the conflicting social forces were poverty, property and democracy: “Among them no rest is possible”. The balancing of these is a dilemma that remains today. The management philosopher Charles Hampden-Turner says dilemmas can only be managed, never resolved. This, Bevan writes, is the responsibility of the legislature, by efficacious state action and judicious collective policies.

In possibly the most important chapters on macroeconomics (chapters 2 and 4) Bevan shows his scorn for British businessmen in times of crisis. He compares them unfavourably with those in the USA: “In Britain the businessman is mobilised. In the States he mobilises.” If the Labour government had not nationalised some key industries then the continuing insufficient investment would have damaged even more an already unproductive industrial sector, e.g. railways and steel. Labour revived them and invested in the infrastructure needed, and production began to rise steeply. For instance, in 1952 steel production had risen by 50% and oil production by 16 million tons more than in 1939. In 1950 Britain stood third out of the Western Europeans in industrial production and first in agricultural production, and had doubled her exports.

All this went on while Britain was broke. The USA had suddenly terminated the Lend-Lease agreement in 1945 that the country had relied on to keep its military and its empire afloat. Keynes had to negotiate a $4billion loan from the USA, but there were conditions: US loans became conditional upon progress towards sterling becoming fully convertible into US dollars, thereby aiding US trade. The $2.7 billion Marshall Plan contribution again largely went to propping up its “world power” role in 1948, and to the housing programme, as opposed to renewing the public infrastructure. The global player funding was a mistake, as Keynes pointed out.  In July 1949 the pound fell from $4.03 to the dollar to $2.80. This, and paying for the Korean War, incurred public spending cuts, including in the NHS, e.g. charging for prescriptions, dental services and spectacles. Nevertheless, the NHS and National Insurance continued to be implemented, as did the social housing programme.

This all took place largely under a Keynesian economic thinking, where demand was the driver, not money supply. This was part of the Post-War Consensus, which accepted some degree of nationalisation, promoted strong trade unions, regulation, high graduated taxes and a generous welfare state. What Bevan was unaware of when his book was first published was that the economic system under which this happened underpinned the socialist thinking that informed the Post-War Consensus.  In other words there was no major political argument against the principles that were a given in the Beveridge Report. Hence, the succeeding Conservative government kept the housing programme going, supported the NHS and did not quibble over institutions like British Rail. What a different world.

The Post-War Consensus was an unconscious paradigm. When I first arrived in Britain from Africa in 1965 people complained about, but accepted, high taxes, moderate wages for managers and workers, the dole, the trade unions’ role and comprehensive schooling, not least because of low unemployment.

If Socialists wish to get back to that world then we need to unpack the economic thinking that is creating the conditions for inequality and low productivity today (and not just in the Conservative Party), and identify and implement those conditions that must prevail to deliver a fairer, more just society. It is very important that we do not make this a discussion between the Left and the Right. This always obscures the debate.

Universal Basic Income (UBI) is a term now familiar to most people thanks to the COVID-19 pandemic; but it is only the tip of an iceberg that is the New Economics, the system that is required today. After all, the Tory party mooted it as part of a strategy to mollify critics of pay inequality. So, what are some of the economic axioms that Socialists need to promote to support Universal Basic Income into reality?

Modern Monetary Theory (MMT) has as one its foundations is the notion that the government is not a currency user, but a currency issuer. It creates money to finance public spending. The austerity regime conceptualised the government as a currency user, financing its spending by taxation, by borrowing (debt issuance) or ‘printing money’. This modus operandi creates constraints to public spending, e.g. spending can’t happen because it requires more taxation, borrowing which may lead to increased interest rates, possible inflation, etc. All of these beliefs have been debunked by the current crisis, where governments have, miraculously, found trillions to fund the losses in commerce and industry and wages.

However, to quote the authority on this topic, Professor Michael Hudson:

After being attacked by monetarists and others for many decades, MMT and the idea that running government budget deficit is stabilizing instead of destabilizing are suddenly gaining applause from the parts of the political spectrum that long opposed MMT: the banking and financial sector, especially the Republicans. But what is applauded is in many ways something quite different than the leading MMT advocates have long supported.

Modern Monetary Theory (MMT) was developed to explain the logic of running government budget deficits to increase demand in the economy’s consumption and capital investment sectors so as to maintain full employment. But the enormous U.S. federal budget deficits from the Obama bank bailout after the 2008 crash through the Trump tax cuts and Coronavirus financial bailout have not pumped money into the economy to finance new direct investment, employment, rising wages and living standards. Instead, government money creation and Quantitative Easing have been directed to the finance, insurance and real estate (FIRE) sectors. The result is a travesty of MMT, not its original aim.

By subsidizing the financial sector and its debt overhead, this policy is deflationary instead of supporting the “real” economy. The effect has been to empower the banking sector, whose product is credit and debt creation that has taken an unproductive and indeed extractive form.

This can clearly be seen by dividing the private sector into two parts: The “real” economy of production and consumption is wrapped in a financial web of debt and rent extraction – real estate rent, monopoly rent and financial debt creation. Recognizing this breakdown is essential to distinguish between positive government deficit spending that helps maintain employment and rising living standards, as compared to “captured” government spending to subsidize the FIRE sector’s extraction and debt deflation leading to chronic austerity.

Naked Capitalism: The Use and Abuse of MMT, Hudson, M. et al April 2020.

The Socialist drive is to ensure that this does not happen as the pandemic eases. Never has “know thy enemy” been more important. The Yorkshire SHA has taken on the task of awakening not just the Left, but every concerned citizen and politician to these dangers from unreformed neoliberal politics. A good starting point is a careful study of chapters 6, 7 and 8 of In Place of Fear: The Transition to Socialism, Social Tensions, and World Leadership. The time to start is now.

General Practice and Primary Care Networks (members’ meeting)

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YSHA meeting 11th May 2019

at Mill Hill Chapel, Leeds

The meeting focused on the themes introduced in talks by Dr Jack Czauderna (Doctors In Unite) and Dr John Puntis (KONP co-chair): 

Jack: General practice cannot to be just a set of tasks carried out in relentlessly driven isolation. It must return to its role as family practice, committed to understanding local communities and the families that live in them, and supporting them in pursuing their own health

John: Primary Care Networks (PCNs) and a Charter for Primary Care

Summary of the practical issues raised:

  • GPs are no longer family doctors, so we miss the notion of community. We need get back to Primary Care Teams. However, we are so used to being in a command and control environment that many GPs will not have the skills needed for a participatory culture. They will need to be helped to design a management system conducive to collaboration and to develop engagement policies and skills.
  • PCNs are an overkill. Structural changes, e.g. compartmentalisation of function and role are not conducive to collaboration. It is not something you can “harness” – a classic top down policy that politicians use to disguise their control pathology. We need to provide a collaborative model that that really works, as opposed to strangling people’s efforts to cooperate.
  • The vision needs to include real shared values embedded in policies, e.g. we will really understand the patients’ needs before applying a solution and will engage the patient and their family/community in the process. Then like the GPs we may need to train the staff in these engagement skills, using a set of behavioural skills that have been shown empirically to work. The vision may also wish to include a profit-sharing policy without profiteering, e.g. ask staff how any surplus could be distributed – externally as well as internally.
  • Only then look at the legal structure the PCN might need, e.g. a Community Interest Company (CIC). 

The meeting had a very engaging and informed discussion on economics and, in particular, Modern Monetary Theory, which could dramatically change the SHA and politicians’ stance on funding.

Setting Stupid Targets for the NHS

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John Carlisle, Chair, YSHA

16 November 2018

Setting Stupid Targets for the NHS
The NHS has been damaged by deluded politicians and their targets strategy.

Labour damaged the NHS by its target policy. The Coalition followed Andy Burnham’s proposal to cut the number of targets, but still set them to “name and shame”, which compounded the catastrophic impact of the Lansley bill. In their marketisation drive they have also continued to set ridiculous incentives for GPs and NHS staff, such as the recent £55 for every dementia diagnosis (a Tory pledge). This latter policy just demonstrates the Tories’ utter lack of trust in people, even in our great NHS, and their lies.

Their perception of people is that we are venal and will only respond to selfish incentives, even the most dedicated professionals. It also demonstrates the ignorance among politicians of all stripes of how organisations really work. The following discussion on the use of targets demonstrates this.


Targets and tick boxes
The previous Conservative government had set targets in the 1990s – for example, guaranteeing a maximum two-year wait for non-emergency surgery and reducing rates of death from specific diseases. But what was different about Labour’s approach to targets in the NHS (and across the public sector more generally) was the volume of targets and the vigour with which they were performance-managed from the centre – via Blair’s Prime Minister’s Delivery Unit (operating according to the principle’s of ‘deliverology’).

The diagram of targets for A&E diagram below says it all.

Targets A&E graph

Figure – Targets set without regard to system capability or the nature of demand

The Labour government set an impossible target for A&E, treating it as though there would be no seasonal variation. Note, from 2005-2010, the failures occurred in the first quarter of the year, i.e. holidays and winter. What a surprise! But still marked up as a failure. This is mad management, setting up the NHS to fail (98%) 40% of the time. This is equivalent to the battle orders of the Somme ensuring maximum casualties by continuing to drive soldiers en masse into the German guns. Like the generals who perpetrated this infamy, the politicians sit well behind the firing lines, refusing to even look at the carnage caused by their policies.

The diagram says: from 2005 to 2010 politicians guaranteed failure in 9 quarters by their obsession with targets and scapegoated so-called failing hospitals!

Having seen the failure to achieve the 98% target the Coalition reset the targets to 95%. This despite the fact that the Tories pledged to scrap targets in 2007, highlighting a series of flaws with present targets, which Lansley himself said “distorted the way the NHS works” (The Guardian, 22 January 2007).

Note that from 2010 to 2015 there would have been a 100% failure rate had the target remained at 98% (the dotted blue line on the diagram). This is the reality. It is also clear evidence that targets DO NOT WORK, i.e. things got worse! This would not have been a failure by the NHS staff! Just a very stupid policy.

For years the NHS had been punished by targets, for which Labour was largely responsible, especially Alan Milburn, who is now the champion of private health (see below). This was tremendously de-motivating and expensive, as it led to rework, readmissions, and lack of beds; all of which cause the nursing staff great stress and strain and wasted millions trying to do the impossible.

Not only did it cause a drop in morale, but it also caused “gaming” – intelligent professionals subverting the system to survive. Professor John Kay in his book Obliquity quotes the example of an eight-minute response target for ambulances which led to the vast majority of emergency calls getting just that, and almost none recorded as longer. The target changed the way the dispatchers allocated vehicles, presumably trumping the prioritisation of patient need.

To his credit, Andy Burnham admitted that the target emphasis was a mistake; but insisted that initially it was the right strategy. It never was. It contravenes every quality improvement principle, beginning with understanding the real performance capability of the A&E system. They clearly never understood the principle, otherwise they would never have set the 98% target, i.e. understand the normal variation occurs, e.g. winter comes every year from November to February. (Note when the targets were missed, the 1st and 4th quarters above). If the politicians had any wisdom then, with the help of the staff, they could have transformed performance without causing anomalies and heartache.

Never set arbitrary targets, and never, ever, compound the error by using targets to punish or reward people.

Any improvements in results are achieved by understanding and changing the system, driven by the staff. Not by targets! The Royal Bolton Hospital in 2006 is a good example. The staff redesigned the entire process, which improved stabilisation and made access into theatre and discharge rates happen more quickly. The four key effects have been:

  • Reduced length of time it takes a patient to get to theatre from A&E by 38 per cent (2.4 days to 1.7 days)
  • Reduced paper work across the process by 42 per cent
  • Reduced total time patients spend in hospital by 32 per cent (34.6 days in 2004/05 to 23.5 days in 2005/06)
  • Significant reduction in mortality by at least one third. In 2004/05 327 patients were admitted with fractured hips and 75 died (22.9%). In the first half of 2005/06 there were 164 admissions of which 24 died (14.6%)
  • Improvement efforts in the NHS usually amount to gains of 3 or 4 per cent at the margins – these are improvements in the range of 30-40%.

But this is ignored by successive governments who insist on the command and control policies led by targets, while ignoring the cries of the NHS employees who were being damaged by the policy. Between 2001 and 2007 there were about 150 press features criticising, with evidence, the impact of targets. Also in the influential Berwick report in 2014, The Science of Improvement, the word “target” is not mentioned once!

Today, in 2018, the performance levels are even worse, for example so-called “bed-blocking”. So much for targets! The only other country that set as much store by targets in the workplace was the USSR, and look what happened to their economy!

© John Carlisle, 2018

The Conservative Government’s Misery Business

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John Carlisle, Chair, YSHA

18 July 2018

The government has for eight years now been successfully building national factories which produces millions of sick, depressed and hopeless people. The recently retired CEO and Chairman, George Osborne and David Cameron, can sit back with great satisfaction at the success of their enterprise: The Austerity Brexit Company.

They have brilliantly cornered the market in misery. The cunning strategy is threefold:

  1. Broaden the customer base by policies that punish those in greatest need and those who have vocations to alleviate suffering, e.g. carers, nurses, doctors, and create anxiety, uncertainty and fear, especially as regards employment, by insisting on a Brexit that is unworkable. The latter is a brilliant marketing ploy, of which Richard Branson himself must be envious.
  2. Enact legislation and policies that supports private enterprise in the public realm (NHS, public transport, etc.) and take money from municipalities to give the Treasury, and social care.
  3. Employ as directors of the great departments of state the “children of Douglas Haig”, who will carry out any neoliberal strategy they have devised, no matter what the cost to the people. In a really fair monarchy Grayling, Duncan Smith and, the recently retired Jeremy Hunt would have been awarded knighthoods for the successful obliteration of the wellbeing of both the employees in these departments and their “customers”.

Jeremy Hunt, who comes from a military background, would doubtless be proud to be associated with Field Marshal Haig on this day, as we commemorate the centenary of the turning of the tide of World War I. To quote B.H. Liddell-Hart, a distinguished military historian who had been wounded on the Western Front, from his diary: He [Haig] was a man of supreme egoism and utter lack of scruple—who, to his overweening ambition, sacrificed hundreds of thousands of men. A man who betrayed even his most devoted assistants as well as the Government which he served. A man who gained his ends by trickery of a kind that was not merely immoral but criminal.

To examine the parallels just look at the nurses, who, like the Tommies in the war, are the backbone of the NHS, and whose ratio to patients is the main determinant of good patient care.

NURSES (with grateful acknowledgement to NHS FOR SALE?)

The NHS is spending almost £1.5bn a year on agency nurses while its own staff are leaving in droves, a new report suggests.

The vast outlay on temp workers would be enough to pay the wages of 66,000 full-time positions for a year, according to the study by The Open University.

The RCN branded the situation dangerous, but ministers said steps were being taken to recruit more nurses. Hunt was warned in mid-2017 of the coming crisis: NHS faces staff crisis as student nurse applications plummet after Tories scrapped their grants (The Mirror: 13th July 2017).

The number applying to be student nurses has dropped from 65,620 to 53,010 – a fall of 12,610 on last year. The fall comes after the Government axed student bursaries for trainee nurses and midwives.

Stressed nurses are leaving the NHS in increasing numbers after 160,000 quit in five years. Long hours and poor pay have been blamed for the numbers leaving increasing by a fifth.

An unprecedented NHS staffing crisis has left at least 40,000 unfilled nursing posts in England alone and wards having to close due to dangerous understaffing. Data released by Government shows 33,530 quit the profession in the year up to September 2017.

This is a 17% increase on the 28,547 who quit in 2012/13 after year-on-year increases for the last four years. In total 159,134 nurses have quit the NHS in the last five years.

The number of nurses and health visitors across the NHS in England has dropped by over 400 people. Sector leaders feel this decline reflects how frontline nursing has become an “easy target for cuts”.

At a time when the government is actively trying to boost workforce numbers to tackle high rates of vacancies across the country, the latest figures from NHS Digital show that the opposite has been happening. Since 2016, the nursing and health visitor workforce has shrunk to 284,000 FTE, a drop of 435 people.

There was also a decrease of 0.2% across the nursing workforce within GP practices, with 27 less staff working in the NHS now than in 2016

Janet Davies, chief executive and general secretary of the Royal College of Nursing, argued the latest statistics are a worrying sign that the number of nurses continues to slide – and they have also come just a day after a major survey revealed public satisfaction with the NHS is dwindling due to staffing worries. This must be a major achievement for the Sickness Business. Well done!

Almost two thirds of healthcare assistants (HCAs) are performing roles usually undertaken by nurses, such as giving patients drugs and dressing their wounds, in the latest illustration of the NHS’s staffing crisis. The apparently growing trend of assistants acting as “nurse substitutes” has sparked concern that patients may receive inferior or potentially unsafe care because they do not have the same skills.

Of the 376,000 assistants in the NHS in England, 74% are taking on extra tasks, according to findings by the union Unison.

This is the equivalent of Haig’s attrition rate exactly 100 years ago. In Churchill’s chilling phrase, “driving to the shambles by stern laws the remaining manhood of the nation. Lads of 18 and 19, elderly men up to 45, the last surviving brother, the only son of his mother (and she a widow), the father, the sole support of the family, the weak, the consumptive, the thrice wounded—all must now prepare themselves for the scythe.”

We have had our warning for years. Now let us turn on the government and turn the tide of their war against the public sector.