What makes a good boss?

I was pleased the Prime Minister tackled the difficult issue of nursing and nurse leadership yesterday in his speech. Many of the problems I see in the public sector stem from poor management, just as companies which go bust are often badly led.

There are big differences between being a senior manager in the public and private sectors. In the private sector the danger is the boss has too much power. You have the power to hire and fire, to reward and to penalise. Your approval is sought by the ambitious, and your disapproval can cause angst and worry for your staff. In a private sector company the problem for the boss is to get honest advice from employees. The boss has to beware. A throw away remark or an ill formed thought can become a mantra or a command which people take too seriously. The danger is rash action based on the boss’s poor understanding or unchecked prejudice.

In the public sector the Minister has no power to hire and fire, to set salaries or award bonuses. There is plenty of honest – and some self serving or badly informed- advice available. A clear Ministerial decision or instruction can be treated as an invitation to a seminar by civil servants. It might become a challenge to them to see how they can rally forces against it. Ministers need to learn how to get the system to do as they wish, as it is not easy. The danger is nothing new or better ever happens. The forces of inertia can be very great. It is especially difficult for a Minister who wishes to do more with less, as the whole culture is in favour of spending more as a signal of success.

Nursing, as the Prime Minsiter observed, should be about caring for patients. Record keeping is important. A good hospital needs to be meticulous in recording drugs needed and treatments administered to avoid errors and to check on results. This need not get in the way of patient contact. Indeed, the records should mainly stem from nurse and doctor contact with the patient, and can be mainly carried out at the same time as the conversation with the patient. The drug taking needs to be recorded at the bedside when it is administered. The patient’s condition needs to be recorded along with their feedback when the nurse or doctor calls.

Good leaders or managers know when to listen, when to seek advice, when to consider, and when to decide. They decide based on good evidence, and carry through their chosen course. They need to explain it to staff and all affected by it. They need to carry as many as possible with them, but at times they may need to make a decision which does not meet with the approval of some involved. In such cases it is even more important to be right, when you need to draw on superior experience and knowledge to make it worthwhile going against the viewpoint of some of the team and those affected.

Nurses above all have to carry the patient with them, and must regard the patient as the most important person and the ultimate decision taker. Many patients will trust their medical advisers to do what is best. Others need explanations and need to be persuaded to consent to the interventions thought helpful. All this requires more time with patients. If the Prime Minsister achieves anything from his speech , it is important he achieves this simple thing. Nurses need to spend more time with their patients. The “paperwork” as it is called in a rather old fashioned way has to stem from the work done at the bedside, and has to to be fitted into the relationship with the patient.


  1. Ian
    January 7, 2012

    It would be good to subject the NHS to the high standards of the private health sector. We would see fewer patients being bumped off that way (Gosport being only the most notorious example). The GMC’s workings should also be made more transparent to avoid cover-ups, and less subject to political interference – striking off doctors for their views on MMR is not on.

    And as the Tories don’t stand a cat’s hope in hell of gaining seats in Scotland (hence the desperate attempts at recruiting supporters in Northern Ireland), the abolition of the Barnett formula to give English people equality in health rights would increase Tory representation at the next election. If Salmond doesn’t like this he can always sell off some shale gas rights.

    1. uanime5
      January 7, 2012

      The private sector doesn’t have high standards and for many private hospitals their solution to any complications is let the NHS handle it.

      1. libertarian
        January 8, 2012

        Do you have any evidence for this ?

        1. alan jutson
          January 9, 2012


          The Private clinics have not exactly covered themselves in glory over the breast implant scare in the last few weeks, if the press is to be believed.

          Why should the NHS have to pick up the tab for anything else other than the few reconstruction jobs that they were responsible for.

          Aware its not probably as simple as it sounds to resolve, but they chose to sell and install the goods which are under question, which now turns out were probably not fit for purpose in the first place.

          How they became approved by EU standards, if that is what they were, may now perhaps become an issue.

      2. Ian
        January 8, 2012

        Take MRSA. When NHS hospitals were continuously being exposed for this, very few private sector hospitals hit the headlines. Whenever they did of course Labour newspapers made a meal of it.

        Filthy nurses and wards are an irrelevance to an unaccountable stalinist monolith, but private hospitals have customers to worry about – and shareholders too.

        We should have been given state health insurance after the war, so that patients could have chosen between municipal and private hospitals. But all Bevan wanted was an army of payroll-voting clerks – the NHS.

        No doubt like today’s hypocritical Labour MPs and hacks he took out private insurance for himself though.

  2. StevenL
    January 7, 2012

    “[Good managers] need to carry as many as possible with them

    And they do this my making a ‘no compulsory redundancies’ policy #1 priority and never sacking anyone.

    Nurses above all have to …

    … pay a mortgage on £160k average house price?

    That’s reality and it’s a reality the tories support with ZIRP and QE.

    1. Electro-Kevin
      January 7, 2012

      It’s not just mortgages – it’s the cost of renting too.

      Even in areas of high unemployment housing costs are distorted by excessive government payments to BTL landlords who provide welfare housing.

      This has caused house prices to rise excessively in parts of London too. It makes it really hard for people with jobs. Even with good pay.

  3. Paul Danon
    January 7, 2012

    Ministers don’t need to learn how to use the system. They need to be able to hire and fire civil servants and to get their policies implemented without obstruction.

  4. Kevin Ronald Lohse
    January 7, 2012

    Dear John. The best description of nursing I’ve come across is, “Doing for the patients what the patients can no longer do for themselves.” The duty of care is quite clearly laid down in that description and is doubly pertinent when considering care for the infirm elderly. One would expect the nurse in charge of a ward to spend much of their time supervising the care of patients. In fact it is not unusual for the nurse in charge to spend over 60% of their time in management meetings and other bureaucratic processes that have little or nothing to do directly with the well-being of the invalids in the Ward. This bureaucratic blanket, a direct legacy of Labour’s use of the NHS to provide a job creation scheme rather than of improving the health of the Nation, drives dedicated doctors and nurses to distraction, and is the prime de-motivator in the NHS. We know that wards are closing, but you should be in a position to find out whether admin staff are being commensurately cut. I suspect that, as the bureaucratic hand wields the axe, the percentage of admin staff to front-line nursing staff is increasing. Overweening bureaucratic processes within the NHS are what our health ministers should be attempting to tackle. I suggest that clearing away the bureaucratic undergrowth would allow the frontline nursing staff to concentrate more on the patient.

    1. uanime5
      January 7, 2012

      You do realise that admin staff do the paperwork so doctors and nurses can spend more time caring for the patients.

  5. Mike Stallard
    January 7, 2012

    Yesterday, after an excellent and most helpful visit to my GP, who apologised abjectly for keeping his patients waiting for 30 minutes (he had an emergency and I caught sight of two people weeping in the hallway), I went to a hospital and saw a Consultant.

    It was just a small country hospital. I was seen ten minutes early and the nurses on both occasions were smart, polite (I was called “Sir” by one of them!) and businesslike. They made sure that everything was done correctly – even when it was difficult (my blood pressure had to be taken twice).

    The Specialist was outstanding. He gave me a very thorough examination, seeing the problem like a puzzle rather than as a chore, and then set out two perfectly understandable possibilities for treatment. I chose one and he then humbly explained, admitting as he did so that this was his special interest and that he was writing a paper on the subject himself at the moment, that he could not really understand the problem himself, but that if it got worse, I should come back immediately to see him.

    I left contented and convinced. The GP described him as a “diamond in a muddy pond”.

    So I record this to show that things are not always as bad as the papers delight in saying. Leadership all round, actually. And a determination to face up to illness and not to “go with the flow”.

    1. lifelogic
      January 7, 2012

      I agree there are certainly a huge number of hard working and efficient staff in the NHS. It is the system, structures, charging systems, resource allocation and the organisation that so often fails both patients and the many good staff.

  6. lifelogic
    January 7, 2012

    Alas even in the private sector you do not actually have the power to hire and fire. The staff are often well aware of this too. There is a risk of huge legal claims, made on an absurd heads you lose, tails you lose anyway basis. You cannot even retire people at any age thank to Cameron’s new rules. A good boss, in the private sector, at the moment, is one with the ability and talent to find the money to pay the wages each month and persuade the banks or others to invest in the tools needed to do the job efficiently.

    In the private sector a good boss is one who actually gets the organisation to do something useful. Something that the public actually wants or better one who just closes their department down. So much of the public sector does nothing of any real use to anyone or even just causes positive harm. Its main activity is the licencing, regulating, inconveniencing and taxing of people & business and the distribution of money from the responsible to the feckless – after taking a large cut themselves of course to cover there wages and pension.

    1. lifelogic
      January 7, 2012

      It is reported, surprise, surprise, that Justine Greening will give the green light to HS2. Clearly no shortage of money to be tipped down pointless drains in the state sector. How many real jobs in the private sector will this pointless project destroy I wonder? Certainly far more than it creates, perhaps by a factor of three or similar I would estimate. This is one project that could usefully be closed down, as soon as possible, by a good manager/minister – together with the green deal nonsense and the equalities & human right commission and many more.

      It is also reported that Labour is complaining that the BBC is too pro-coalition in its coverage. Well since the coalition policies are basically socialist, pro EU, big government, tax and waste & BBC to the core (and therefore very similar to Labour’s) what did they expect and what do they actually want?

      Where is the sensible opposition to these policies from people calling for smaller and better government in the media? Only seen on a few web sites like this one alas.

      Reply: I agree that the case for government doing less and spending less is rarely put and remains unpopular or outside the realm of the possible on much mainstream media.
      The battle of HS2 is not over even if as briefed the government confirms it again next week. The forces against will I am sure battle it all the way to the first contract. Remember the announcement is likely to say no work starts on the ground on this project before 2015, the latest date for another election.

      1. Bazman
        January 7, 2012

        It’s strange how many advanced countries have many miles of ‘pointless’ high speed rail and we have next to none. I wonder if they know how ‘pointless’ it all is? Japan have been squandering money for years on this and the Germans and French railways?
        Maybe a 18 lane motorway from South Wales to London is the answer?

        In Japan most people live on the coastal strip where there is flat land for rail routes serving millions of people. The geography makes it much easier there.

        1. lifelogic
          January 7, 2012

          Trains are indeed often pointless that is why they need such a huge subsidy. They certainly has not made Japan boom economically over the past decades.

          Trains rarely make sense in a small country such as the UK other than for some crowded city commuting and a few intercity routes. People usually need transport at either end anyway. So, door to door, driving is usually cheaper, faster, greener and more convenient.

          Improvements and simplification of rail ticketing systems would save far more time than this absurd vast expense on HS2

          Trains when all said and done are just large vehicles but restricted to set routes and run mainly for the benefit of the staff and even partly under the control of the unions. Cars, bikes, coaches and planes are usually better, more efficient, convenient and far more flexible in most circumstances.

        2. Mike Stallard
          January 7, 2012

          I so agree with this statement – I live in the East and cannot be accused of NIMBYism.

        3. StevenL
          January 8, 2012

          Well exactly. All these nations that have similar living standards and GDP per capita have it and we’ve managed to keep up without it. So why do we need it?

          I find just under 3 hours on an old 125 diesel train perfectly a perfectly acceptable way to get from Newcastle to bang in the centre of London myself.

          I’ve only ever done London to Birmingham a couple of times to go watch the test match. The service was perfectly acceptable. Sure, I’d prefer it if it was cheaper, but then I’d prefer it if the test match ticket and the beer at Edgbaston was cheaper too. That’s life really.

          Now a dual carriageway running from Newcastle to Edinburgh, that might make sense.

      2. ian wragg
        January 7, 2012

        I’m interested that the letter in the Telegraph was signed by the chairman of Siemens. Whats the betting they “win” the contract to supply the rolling stock and power control equipment.
        Probably half the jobs and 70% 0f the cash will go overseas, not helping the Uk one iota.

        1. Norman Dee
          January 7, 2012

          Don’t write off Hitachi for the Rolling Stock, I haven’t heard any complaints about the Arrow train on the Folkstone run yet so they will have a proven system already running and they are promising to build in Europe. I say “build” how much of it that will actually be assembly we don’t know.

        2. A different Simon
          January 8, 2012

          The EU clearly has it’s preferred suppliers list and the others just won’t get a look in .

          I wonder whether this time a civil servant will have the decency to pull a director of any British company aside and indicate that they are wasting their time before they spend precious money preparing a tender ?

          Perhaps British owned/based manufacturers have read between the lines following the Bombardier fiasco and will just let Siemens have it unopposed ?

      3. Atlas
        January 7, 2012


        Your words are an encouragement. As somebody who has no axe to grind on the H2S decision in terms of its proposed route, I still think it is a waste of scarce resources. Existing lines could be re-vamped at far lower cost.

        I suspect that if you strip back the facade you will find an EU travel ‘harmonisation’ reason for it. Is it that some Civil Servant has a bee in his bonnet about this – or has he invested so much time and effort in the murky ways of the EU, that its abandonment would be too much loss of face for him (and his Knighthood)?

        When I was employed I used to get cross about how poor bosses could wreck firms and so bring misery to thousands of employees when the firms went bust; especially when these same bosses walked off with golden handshakes and secure pension pots.

        1. Martyn
          January 7, 2012

          To my mind it is rather more than a suspicion, because HS2 appears to be on the EU ‘TEN-T’ project, which in short says:

          “In order to establish a single, multimodal network that integrates land, sea and air transport networks throughout theUnion, the European policymakers decided to establish the trans-European transport network, allowing goods and people to circulate quickly and easily between Member States and assuring international connections.

          The cost of EU infrastructure development to match the demand for transport has been estimated at over € 1.5 trillion for 2010-2030. The completion of the TEN-T network requires about € 550 billion until 2020 out of which some € 215 billion can be referred to the removal of the main bottlenecks.

          A key issue for the future in relation to the implementation of the TEN-T policy is to rationalise the allocation of grants and to link it to the projects’ European added value so as to ensure the best value for EU money. In this context, the Trans-European Transport Network Executive Agency (TEN-T EA) was created in 2006 to implement and manage the TEN-T programme on behalf of the European Commission”.

          Google TEN-T and you will see what I mean.

        2. Mike Stallard
          January 7, 2012

          “I suspect that if you strip back the facade you will find an EU travel ‘harmonisation’ reason for it.”


          OK so it was 2005 – but the current commissioner has said that he is all in favour too.

      4. Antisthenes
        January 7, 2012

        I do not believe that we should be too quick to oppose infrastructure projects. Before we do we should know all the factors in favour and weigh them with the factors against then make a decision. This does not appear to be what is happening certainly the NIMBY’s and green’s are opposed but they are narrow interest groups so their opinions must be heavily discounted. The deciding factor has to be that which is in the best interest of society as a whole. Infrastructure is one of the few areas that I believe is for government to have the major responsibility for which if correctly planned and implemented can have untold benefits.

      5. electro-kevin
        January 7, 2012


        What a waste

        The country is crying out for more carriages on peak services, longer platforms in some places, a better (simpler) fare structure and cheaper ticket prices.

        Just think what this HS2 money could do.

        We also need to get tough on metal thefts. This country is a soft touch and our very infrastructure is being spirited away to global markets from under our noses.

        No-one needs to go to war with Britain anymore – they just watch and wait to pick at our bones as we collapse under the weight of our own moral flabbiness.

    2. lifelogic
      January 7, 2012

      In the larger private sector companies (where the bosses are often not main shareholders) directors can sometimes have too much power relative to shareholders. Here often directors can drive companies into the ground while paying themselves huge sums, in wages, bonus, pay offs and pensions, and shareholders have, in practice, far too weak powers (and information) to do much about it.

      1. javelin
        January 9, 2012

        As part of the new Government rules I would say that shareholders should always have the option to vote for directors payrises to be equal to a 3 year rolling average growth in share price / earnings. They can table their own pay rise in addition but they would need to justify it to the shareholders. As far as I can remember the FTSE hasn’t risen in years so there is a lot of soul searching to be done by directors.

  7. Antisthenes
    January 7, 2012

    The NHS is dysfunctional and not fit for purpose and always will be until a new formula of provision and funding of health care is put in place. There are other examples throughout the world of health care systems that are infinitely better than the NHS. You do not have to look far to find in my experience one of the best and that is France. To give you an example of how superior I have found it as I had a medical problem that began in 1986 I was under the NHS until 2004 in which time the NHS failed to diagnose or cure the problem even though I had seen numerous doctors and specialists. In 2004 I moved to France and was treated under their health care service. Within a year the local French GP had identified and cured my problem a very telling experience. My story is not an isolated one having met many ex-pats who have told me similar stories. The point being that the French system allows for an environment that ensures the best attention and care for the patient where as the NHS environment is not patient orientated at all. The French system differs from the NHS without going into too much detail in that most of the provision from the GP to the hospital is provided by the private sector. There are state owned facilities but the patient may choose which to use. Medical records are held by the patient and not the doctor. There is a great deal of separation between functions GP’s do not have any nurses in their practice they have their own facility within the community and compete for patient business. Within communities their are competing laboratories that patients go for things like blood test where it is normal to have a test on one day and the test results the following one sent to the patient not the doctor. Funding is by the state paying C70% and the patient paying C30% usually by having a top up medical insurance but it is not compulsory. For the very poor the state will pay some or all of the cost of the top up medical insurance. The French system is not perfect but is worth emulating and improving on where improvement is possible.

  8. outsider
    January 7, 2012

    Having had to consider your headline question professionally for many years, I can confirm only that it is a very difficult one.
    One conclusion is that our Anglo-Saxon culture tends to create all-powerful,all-responsible boss jobs and then be shocked and surprised that there is a shortage of supermen and superwomen to fill them.
    Another is that simple leadership skills (natural or taught) and experience are both keys to success. In politics, we suffer from catapulting people such as Messrs Blair and Cameron into high office without any experience of running things. The idea that aspiring politicians should cut their teeth as elected mayors or equivalent seems a good one, since few politicians now have experience of running businesses, trade unions or institutions.
    The odd thing about Mr Cameron’s nursing initiative is that he has had to take it rather than Mr Lansley. This would not have been necessary in, for instance, education. There is a big contrast between these two reform areas. Mr Lansley has lots of insider experience and has had no difficulty getting civil servants to do what he wants; but he has failed to inspire either the professionals or the public. Mr Gove has carried most parents and unprejudiced teachers with him but lacks the experience of office to command his civil servants.

  9. Martin
    January 7, 2012

    I hate to disagree but I would have rather the Secretary of Health had run with this.

    If it then goes wrong it is the Secreatry of State who walks the plank. If the Prime Minister make the announcements etc and it goes wrong then who walks the plank/takes the flak?

    In a company if a Director makes a pigs ear of something hopefully there is a CEO or Chairman to who will reprimand/demote/fire him/her (often isn’t the case and the adminsitrators get called in a few years later).

    Reply: The PM has consulted and discussed it with the Secretary of State, who is happy for him to give it the higher profile a PM announcement generates.

    1. Bazman
      January 7, 2012

      How can the failure or success of one man be justified as punishment enough for any problems caused to the population? A reply is expected from the fantasists. Ram it.

  10. Pete the Bike
    January 7, 2012

    All good points. At present the NHS is run almost entirely at the convenience and for the benefit of it’s staff. No private company, unless a state protected monopoly, could exist for long providing such appalling service.

    However no matter what politicians say this will not change unless the monolith is broken into smaller and far more responsive units. Sadly there are so many people that are conditioned to react with horror to any suggestion that the NHS should be altered that it will not happen. The dinosaur will carry on devouring resources, getting more worse by the month whilst anybody with the cash and intelligence will go private either here, expensively, or abroad for much less. I note that a certain private hospital in the far east will fly you there, accommodate you in 5 star equivalent surroundings, and do your operation for less than you’ll pay here for private “out patient” treatment.

    Best if we just accept that politicians will waffle, taxes go up, services get worse and the country will continue to decline as history takes it’s course.

  11. Rebecca Hanson
    January 7, 2012

    So what do we do if we have a minister who is following a massive program of reform which is not at all grounded in evidence but instead runs contradictory to all the established evidence and ignores the key underpinning structures of the economics and politics of his area of responsibility?

    What do we do if the minister systematically labels and spins each professional expert as being a self interested, ignorant mandarin?

    What do if we know there is no way the minister’s reforms will happen because they are exceptionally economically inefficient in a way he does not understand but has been understood by the academic experts for a long time?

    What do we do if we understand the minister’s intent and know that the way to deliver it is through reform in areas which he is not addressing because he is focusing on reform which will just make things worse?

    “In the public sector the Minister has no power to hire and fire, to set salaries or award bonuses.” except in education where the people with ability have been cleared out and replaced with exceptionally inexperienced people who believe what Michael Gove is telling them and Cummings ships money wherever he likes.
    References to justify this comment are here: http://www.linkedin.com/groups/TOP-TRUMPS-State-Education-in-126310.S.69072770?qid=fe6a43d6-e32c-468d-8176-16656d5c8693&trk=group_items_see_more-0-b-ttl
    and all over the press – search for newspaper articles about people leaving the DFE.

    The Minister should be entitled to pursue his reform if he hasd argued the case for it in an election and in the Commons, and if it legal.The civil service task is to make the best job of implementing it.

    1. Rebecca Hanson
      January 7, 2012

      That last comment was a reply from John to me.

      I think the civil service have made an incredibly good job of implementing it given the reality of the economics of education John. Lots and lots of schools have been strong-armed into becoming academies without consultation (because those which are properly consulting won’t do it despite the financial threats: http://www.timesandstar.co.uk/cockermouth-school-morally-we-could-not-become-an-academy-1.841889).

      Democratic consultation has been shut down – with all the representative bodies such as WEF, ACME and the like being systematically ignored so the realities from the ground are not heard. Discussion in cyberspace is stitched up, with major forums being managed so that posters like me who coherently criticise Gove’s policy are harassed, banned (see for example the discussion here: http://www.localschoolsnetwork.org.uk/2011/11/academy-conversions-slowing-down/) and their comments systematically deleted. Where I post on forums where the moderation is not managed systematic lies are posted to skew the discussion (see my comments here about this issue: http://www.localschoolsnetwork.org.uk/2012/01/the-madness-of-small-primary-schools-becoming-academies/) and individuals who comment are systematically harassed with lies being sent to their employers and professional bodies to discredit them as I have been (documents available).

      Is there any point at at which it should be recognised that civil servants cannot actually deliver something which will cost vast amounts of money the minister will not admit and which will not deliver the benefits the minister claims? Or will we just continue for the full 5 years with a tide of people being appointed to do a job they don’t understand but are convincingly told is coherent and possible and then sacked when they fail to deliver and ridiculous fantasy? Another 3 years of money being poured down the drain and the real issues not being addressed?

      You are interested in how we resolve bubbles of hubris John – they are at the heart of the financial crisis and we have precisely the same kind of bubble going on in education. You ask why no-one in authority listened to the people who explained what was happening in the run up to the financial crisis and I ask why no-one listening to me.

      Big questions I know. I don’t expect solutions. I’m just grateful you run a blog where intelligent free speech is allowed. My thanks also to the managers of the Local Schools Networks and the variety of groups on linkedin.com where free speech is now also being supported.

    2. Max Dunbar
      January 7, 2012

      Can you please condense and make readable.

      1. Rebecca Hanson
        January 8, 2012


        Where academy status is being properly consulted, school are finding it doesn’t provide the promised freedoms and are deciding not to accept it.

        However Gove is determined to take them out of local authority control and put them directly under his own control so that they will ‘be more free’.

        It seems that forcing schools to become academies because they are placed in on notice to improve or in special measures is actually illegal, so one of the civil servant’s jobs will be to subvert the law.

        Given the vast pressures which are being placed on these schools already, what more are civil servants supposed to do to deliver Gove’s dream? Fun job – to subvert democracy to create an outcome which is counter to the minister’s stated objectives and to find ways to subvert the law and bully schools. I would leave as, it seems, most people with any credibility, ability or self respect have.

    3. libertarian
      January 7, 2012

      So what do we do if we have a minister who is following a massive program of reform which is not at all grounded in evidence but instead runs contradictory to all the established evidence and ignores the key underpinning structures of the economics and politics of his area of responsibility?

      I know Rebecca you are talking about Tony Blair, Gordon Brown and John Prescott in the last administration and Chris Hunhe, Vince Cable and Ken Clarke in this one aren’t you?

      Totally agree

      1. Rebecca Hanson
        January 8, 2012

        The week before the Iraq war I visited my MP and gained his personal categorical assurance that he would not vote for war without a second UN resolution.

        He voted for the war.

        This double atrocity of the war and the lie taught me to be more aware of insane policy which has developed a life of its own which our politicians don’t seem to be able to stop.

        Like Michael Gove’s policy re: giving schools more freedom.

        When Michael Gove took power there were two big bottle necks to schools and teachers having appropriate professional freedom. One was that Ofsted needed to be reformed to comply with the post Hampton review law to which it became obliged in late 1999 which protected organisations from inappropriate political and regulator intervention and provides for best practice in inspection and regulation. Instead of doing this he has given Ofsted much greater inappropriate powers.

        The other was the addressing of the barriers to good professional practice created by high stakes narrow assessment, in particular by SATS. Technology and the extent of the web now makes this challenge easily resolvable with intelligent policy in ways which were not possible 3 years ago. But Michael Gove has no interest in that.

        Instead he is obsessed with forcing schools to dump what is in most cases efficient, effective and democratically accountable LA co-ordination and to be accountable directly to him, creating only chaos as pressure groups dominate, not proper accountable freedom freedom for the intelligent and moderate majority.

        1. Rebecca Hanson
          January 8, 2012

          For more specific details regarding the reforms needed to Ofsted see the relevant posts on my education blog from August and September:

          For more specific details regarding the reforms needed to assessment see posts 21-26 of this discussion:

  12. figurewizard
    January 7, 2012

    In the public sector the boss has too much power too. Not the director say of a large NHS trust and not the minister he reports to but ultimately the Prime Minister and his advisors. We saw this during the Labour government when in order to balance building up treasure in heaven in order to bolster their appeal to the voters, dozens of new hospitals were developed using the off balance sheet device of PFI.

    The directors of the trusts concerned were then faced with the prospect of losing their jobs if they would not go along with saddling themselves with servicing debt and interest repayments for these, which in many cases were clearly going to far outstrip their future operating cash flow. This is the exact opposite of what would be the case in the private sector.

    The inevitable result is that many trusts are now facing a financial situation which would have put most businesses into the hands of the receivers by now. By all means ring fence NHS spending but please do not ring fence its structure, management and use of resources.

  13. BrianSJ
    January 7, 2012

    Ministers should not fall for the trap that they are ‘in charge’ of a department for the reasons you state. They are customer representatives. Preferably with the ability to turn off money or move it elsewhere quickly.

  14. Matt
    January 7, 2012

    I tend to think that there is a clear distinction between leaders and managers. Surely ministers are all about leading and having a good team of managers to lead. Not understanding this distinction tends to result in people who should be leading managing and those who are trying to manage doing so with no clear guidance. The latter scenario is common in all organisations whether public or private and non conducive to improving efficiency or productivity.

  15. john w
    January 7, 2012

    John,my local newspaper says that thelocal NHS is spending over £7million a year on agency cover.It also mentions a local care charity have taken their mini buses off the road because of the new EU regulations.They mentioned that it costs £4000 to fit the filter kit that makes older mini buses legal.I feel very protective towards disabled people when they are going to get kicked in the teeth.

  16. backofanenvelope
    January 7, 2012

    A couple of years ago I broke my shoulder. I have no complaints about the care I received; all excellent. But I do have an observation on paperwork in the NHS. First stop – Minor Accident Unit. Copious handwritten notes taken. Next, the ambulance. Once again, copious handwritten notes, although the paramedic had a laptop. Arrive in the Emergency Unit. Copious handwritten notes. Parked, awaiting attention. Doctor arrives, takes copious handwritten notes. How difficult would it be to automate all this note-taking? On the other hand, the X-rays from the MAU were available all over the General Hospital.

    Some has commented on French hospitals. A friend of mine had her baby in one. Excellent treatment all round – but cold and soulless. She speaks excellent French.

    1. Antisthenes
      January 7, 2012

      Yes to a Brit the French will often come across as cold and soulless that is because they have not yet completely abandoned the concept of personal responsibility and self-reliance and only will do for you with good grace that which you are not able to do for yourself. If a Brit expects hand, foot and finger service in France then the Brit is going to be sadly disappointed. However what they will get is an efficient, comfortable and first class medical care.

  17. lojolondon
    January 7, 2012

    John, what the NHS needs is a flat structure, with no hangers on. Like all the trusts and NICE and all the admin that goes with being politically correct and respect for ‘uman rights etc.
    There should be 10 ‘reportees’ per manager. So a first level manager (eg. Staff Nurse) will have a team of 10, a second level manager should have 1,00 people in his team and a third level manager will have 1,000. This will be a flat structure, with great communication, no more than three links top to bottom in almost every hospital.

    Extend this so a ‘Trust’ will have 10 hospitals, and 10 ‘Trusts’ will form the NHS.

    This will cut the budget in half, with NO reduction in front line activity, better communication and improved responsiveness.


    1. Bazman
      January 7, 2012

      The wold is full of ‘hangers on’.

  18. lojolondon
    January 7, 2012

    On a totally unrelated issue, John, I know you are against it, but wanted to say HS2 is a white elephant. Labour’s was the dome, costing £1Bn. This will cost £32Bn and we all know it will be finished late and double the budget. No normal people will be able to use this blot on the landscape, like the Heathrow Express, only government and private employees will afford the tickets.

    The worst is that it is apparently being built only because of an EU agreement to ensure high-speed rail to main arteries of the country. I think there should be some honesty about this, especially because the EU will NOT be paying for it and the major beneficiary seems to be the German and Austrian companies that build the equipment to install the line.

    Reply: I do not think it offers value for money. Remember no work starts on the ground before 2015. I expect lots more arguments about it before then.

    1. alan jutson
      January 7, 2012

      Reply to reply

      I only hope no contracts are signed before 2015 either, or if they are, the government gets someone who has extensive commercial experience to write and agree them, with no cost overruns allowed, penalty clauses for lack of performance and compltion dates. etc etc..

      We do not want the fiasco of not being able to cancel them at a later stage because it would cost less to build, than cancel.

      Examle: Think aircraft carriers fiasco.

    2. Mark
      January 7, 2012

      It is important to ensure that no contracts are signed until building is about to commence, or at least that any that are signed offer minimal cancellation penalties.

      Also, contingency provisions need strong policing. I’d like to see negotiators given a mandate to recommend cancellation if they aren’t able to secure good enough terms. Even then, there is a severe risk that things will end up much like the Chunnel if it proceeds – half built when the money runs out, and utterly failing to meet traffic and revenue forecasts.

  19. Matt
    January 7, 2012

    Not sure that the PM’s involvement is enough to change things. Maybe a radical change is needed.

    A few weeks ago I went in to a visit cousin – ward with a lot of turnover – knee joint replacements.

    A new hospital last 10 years – “look on the floor” my cousin said. Under the bed it was in a poor state, lots of fluff, a couple of paper cups and a set of headphones. The mess was there for the few days that he was in.

    He picked up an infection – was it related to the overall standards? No idea, but it doesn’t fill you with confidence.

  20. Richard1
    January 7, 2012

    More honesty is needed. Its not about too much form filling or that nurses dont have clearly laid out duties of care. The problem is they are employees of a monopoly & as always in monopolies the NHS is run too much in the interest of its employees rather than its patients, with over-powerful unions. If people cant get fired for doing their work badly & dont get paid more then mediocre colleagues for doing work well, & if there is no choice for the patient nor competition amongst providers, we will always have shocking instances of poor care. The challenge is to find a mechanism whereby nurses – like workers in a customer-facing private company such as a retailer – need to provide good care without being specifically ordered to, or they lose their jobs. Where they can be paid more and promoted at the discretion of managers if they do well. Where there is real choice for patients, and competition amongst providers. How can we do this, which will lead to so much better healthcare, without accusations of ‘privatising the NHS’? A prize needs to be offered for the answer.

  21. alan jutson
    January 7, 2012

    Most people do not recognise that they have a good boss until they have worked for a bad one.
    It also applies the other way round as well, if you have never worked for a good boss, you think all bosses are like the one you have.

    Same applies to Companies.

    Good management is structured in some way (to suit the business) everyone should know what they are required to do, be trained in the system employed, and know that controlled use of some initiative is welcome when perhaps the situation demands it.

    Staff shoud be treated like adults and a structue should be in place where ideas, and yes complaints can easily be aired without fear.
    Staff should feel that advancement/salary/bonus within the Company is possible if they show consistant above average performance.

    It goes without saying that working conditions should be acceptable, and a sensible but firm attitude should be taken with regard to sickness, holidays, days absent and time off (unpaid or otherwise) for close family illness.

    Above all the Company mantra for all employees (Directors, Management and Staff) should always be, we only have a job because our customers choose to pay us for our services and goods, rather than use someone else.

  22. FG
    January 7, 2012

    I’d stick to politics if I were you or speak to David Nunn FRCS (his resignation letter makes interesting reading.

    You clearly know nothing about how a healthcare system operates at the coal face.
    Until adequate frontline staffing levels are achieved on most wards then the average punter takes their chances -isn’t this part of the eventual plan for privatisation ?

    Hourly ward rounds by Nurses – how we laughed.

  23. MajorFrustration
    January 7, 2012

    Some years ago whilst sailing to the Med we had to divert to Roscoff when a crew member fell against the wheeel and appeared to be coughing blood. On arrival at Roscoff we were met at the slip by and ambulance and after less than an hour and a half the crew member was back on board – after paying about 10Frs for an xray which showed only minor bruising. In the NHS one gets the impression that after an hour and a half in A&E you might be lucky to have your name taken.

  24. Iain Gill
    January 7, 2012

    What you say about nurses is “motherhood and applepie”
    What you say “must regard the patient as the most important person and the ultimate decision taker” should go for all health providers.
    The problem with the NHS is that the only control loops to bring change, innovation, improvements, to shut down the worst units and expand or replicate the best, and so on only comes from
    1 Top down command and control, as per Mr Cameron’s statements “you must visit every patient every hour” etc., and much like rice production in Mao’s China this way of running a big enterprise has been shown time and time again to be a failure. Indeed top down political control and decision making far removed from the patients is the VERY REASON why nursing is messed up in this country alongside much else in the NHS.
    2 Complaints system. Doesn’t work, people see it doesn’t work and have become disengaged. Nothing ever changes.
    3 Tweaking metrics and performance targets. Doesn’t work. Decrease the target for length of time waiting in A & E and folk just get held in the ambulance or moved straight into a holding area and so on. Mostly the current rewards and incentives in the system reward managers who make the patients wait for a long time, wait for them to die, move out of your area, or give up and go private and you have reduced your workload.
    4 Controlling spending by rationing and hidden rationing, waits, hidden waits, management playing the system and kicking people off waiting lists fraudulently with no come back on them even in the most extreme cases.
    All in all the biggest problem is the patients have no say, no buying power, no ability to take their business elsewhere. This needs to change. This does not mean we abandon the weak or the poor, quite the reverse we need to empower them to take their business elsewhere when one health provider is letting them down.
    It needs competitive pressure on individual health provider units, it needs real patient control of health spend so that they can walk out when they are subjected to dirt, waits, rudeness, obvious poor care and so on – and take their business elsewhere and the money following the patient. That is the best feedback loop of all, it doesn’t need a lot of high level strategizing or control just empower the patients.
    Move the NHS to being a state backed health insurance provider, change it so that patients are guaranteed cover for various conditions and treatment is not on the whim of the managers, and make all the health providers properly competitive. Learn from the best of the rest of the world.

  25. zorro
    January 7, 2012

    What makes a good boss…..?

    Leadership skills rather than management ones if we are talking CEO level…… The ability to effectively communicate your agency/company’s core purpose/aims and inspire managers to achieve those aims.

    The less effective leaders I have seen lack the energy and vigour to achieve this aim. In the public sector, they are unable to innovate or simplify structures to deliver services or control security effectively. Often they lack relevant knowledge of their fields or ‘credibility’ with this tendency to parachute leaders/senior managers who have supposedly delivered wonderfully in the past but whose record does not stand up to scrutiny.

    Good leaders look at organisations, their history, and issues through their own eyes but also consult practitioners and listen to them rather than inexperienced senior managers. They also have the inner strength to change. This is not change for change’s sake, or to achieve some PC target, but rather to clearly concentrate minds on what an agency is there to do. This often requires stopping projects and refocusing existing ones to clearer aims. It never ceases to amaze how ‘projects’ develop lives of their own and go wandering off course and take far too long to achieve their aims.

    I know that this is all apple pie, but it is really simple things like the right leadership which turns companies around and the ability to inspire people to achieve by motivating them to do their job rather than meeting an artificial ‘target’. I think that this can be relevant to nursing – patient focused rather target focused.


  26. john w
    January 7, 2012

    John, i noticed plenty of comments about the railways.£80million has been spent by network rail on tunnel digging machines.Perhaps they could dig a nice big hole to bury all the debt and bills in.It would be nice to avoid paying other peoples bills.

  27. BobE
    January 8, 2012

    Hs2 does not start near London nor end near Birmingham! How insane is that?

  28. Jon
    January 8, 2012

    This is a general trend I’ve seen happen from the private sector point of view.

    Why should a boss get up out of his chair to “walk the floor” if he can get the workforce filling out spreadsheets and email it.

    Then it develops a stage further, employ some recent uni grads who know spreadsheets and ask them to to that job of deciding for him.

    Soon you have a boss with no idea what is really going on but can present to shareholders a load of b@ll@cks.

    Its not those on the shop floor to do the managers job for them what ever industry that maybe. A spreadsheet has its place but for too many managers thats all they look at and are ignorant of what can be going on.

  29. forthurst
    January 8, 2012

    Where will it end? Now it’s the PM’s job to define to nurses how to perform their roles. The state controls half our resources, so half of what we spend our money on is subject to micromanagement from Whitehall, without of course avoiding those meddlesome nostrums emanating from Brussels.

    I do not think the PM is qualified to tell doctors and nurses how to do their jobs. He has not spent seven years studying medicine.
    I would rather that the running of our hospitals and schools was none of the PM’s business. Furthermore, those institutions that have not afforded themselves of the PM’s wisdom appear to be better run than those that do.

    MPs are legislators. If they are Labour or LibDem, they attempt to legislate in order to sabotage our country. If they are Conservative they pretend not to. Whatever, it is not the function of MPs to tell people how to do their jobs or certainly not until they are doing their own properly which means acting in the national interest rather than for their own personal or sectional gain and not making things worse by design or through pure idiocy.

    MPs should try to understand how most of what they have done is bad for the country; how they have organised education, immigration, healthcare, incentives to positive action.

    The PM should facilitate those who wish to provide good healthcare as a vocation. That means that those given the resources are not spivs motivated by avarice but those who are qualified and desirous to treat the sick. Insofar as the system does not work at present in part or in whole, it is a consequence not of the incompetance of the best practioners but of those in Whithall who have created the system, a system which deliberately fails to ensure that those practising healthcare in this country are either liguistically or technically qualified to practice safely and effectively, a system that puts people less qualified than the PM in charge of running hospitals, and prevents those who know what needs to be done to effect it.

    Leadership is about leading from the front, but it is also about leading by example, mentoring in order to pass on skills and best practices. The attempts by Whitehall, a leaderless behemoth, to replace leadership in the field with reams of tripe deluging from their remote ivory towers does not work and will never work.

    Reply It is MPs’ jobs – as government Ministers – to supervise large public services which are not in the private sector and not subject to competitive pressures. It is other MPs’ tasks to support, to question Ministerial performance, or in extreme conditions to secure the sacking of the Minister. Large monopoly public services do not run themselves, and cannot be de-politicised as the public sometimes says it wants. In the end the b uck stops with the government, and the government has to raise the taxes fo pay the bills. The public by a large majority wants a public sector financed NHS, so there have to be Health Ministers and a PM concerned about the way the place is run.

    1. forthurst
      January 8, 2012

      I was trying to draw a distinction between politicians acting as facilitators through legislation, and acting as micro-managers of technical functions for which they have no qualifications. I obviously failed.

      It is facile in the extreme for someone with no medical qualifications (the PM) to determine the missing link in our system is the failure of nurses to perform hourly ward rounds. Patients are starving or dying of thirst because no record is kept of their calorific or fluid intakes as unskilled orderlies supply sustenance and then remove it untouched.

      It is time for nursing staff to take full responsibility for their patients wellbeing and doctors to take full responsibility for their patients’ treatments. It is time for those without relevant qualifications to be booted out of the way and hierarchies of qualifed staff, based on skill levels, created that ensure patients get effective treatment.

      Just because politicians hold the purse strings does not mean they know best. There is nothing worse than knowing how to do a job and then being told to do it in some other arbitrary way which makes it harder to deliver the desire service. It happens in the private sector, I know, but it seems far too much the norm in the public sector.

  30. Sue Doughty
    January 8, 2012

    As a patient I have to say that good nurses are as few and far between as good shop assistants. They do tend to hide away and they do harbour prejudices, (behave against the rules-ed), though some are marvellous all aspire to be working outside the NHS

  31. Caterpillar
    January 8, 2012

    There is a growing research body on the ‘intrinsic motivation crowding out hypothesis’ and evidence for its presence in both the NHS and public HE in the UK.

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