Ben was CEO of Nene CCG for 8 yrs. He was a Director of an acute trust and has run national improvement programmes. He is a founding director and Principal Consultant of Ockham Healthcare, which he describes as ‘a platform for change’.

Increasingly centralised control is hampering the NHS and may yet destroy it completely

The NHS needs to take lessons in the art of war. It's the High Command not the front line troops that are orchestrating the debacle.

Sometimes great organisations are shocked to find that the world has stealthily passed it by. For some, like Blockbusters or Borders Books, it is too late, but for others it means rapid and radical change. We wait to see if the NHS, currently feeling every one of its 67 years, is one of the later or will succumb and join the long list of historic failures.

What happened to the Joint Special Operations Command in Iraq and then in Afghanistan between 2003 and 2009 is told by General Stanley McChrystal, in his highly readable book, ‘Team of Teams’. McChrystal tells of how the well-drilled, highly disciplined military muscle of the west that he had been appointed to lead was, undeniably, getting beaten by the seemingly shambolic forces of Al Qaeda. The internet had changed everything, and it meant that speed of decision-making was king. The military had to change or else the war was going to be lost.

Key to the change was understanding what McChrystal terms the ‘Perry Principle’, which says that that which you see you will attempt to control. He illustrates it by comparing the freedom the (relatively small) US Navy was given in the 19th century in its dealings with China, compared with the army that was operating on US soil at the same time. The difference was primarily one of visibility. The telegram had enabled decision making by the General of the army to be checked, challenged and even changed by the White House, whilst there was no means of immediate contact with the navy, making any real time control impossible. The Perry Principle means that the more visible something is, the more those who see it will attempt to control it.

In practice this led the modern day army into slow and bureaucratic processes for decision making. Decisions had to be checked and signed off at increasingly high levels. The delays this caused enabled Al Qaeda to react faster to events and to gain the upper hand. General McChrystal gave his command authority to make decisions that he remained fully accountable for, without needing to check them or sign them off. He made sure his teams knew the big picture, were clear on what they were trying to achieve, and had access to as much information as it was possible to give them, so that they could make high quality, rapid, in the moment decisions.

Under General McChrystal’s leadership the allied forces were able to gain the upper hand over Al Qaeda. He understood that the Perry Principle needed to be challenged, that it was not true that senior individuals, often hundreds of miles away from the battlefield knew better what to do than those on the ground. The increase in visibility brought about by the internet meant the desire to control centrally, to be seen to be doing something, had to be resisted to enable real time, empowered decision making by those on the ground.

The NHS, it seems, has not yet had its moment of realisation. Instead the Perry Principle is in full effect, with the desire for more and more centralised control being fed by requests for more and more information from the front line. Organisations spend phenomenal amounts of time preparing briefings for regulators, who in turn are briefing their bosses and so on and so on right up to the Secretary of State for Health. So we end up with remote, delayed decisions, that slowly but surely are squeezing the life out of the NHS. More than one million people started work in the NHS, nearly all of them inspired by hope and the desire to do good. But we have created an NHS that crushes that hope, that fails to inspire, and that no longer empowers.    

If the deep-rooted, deeply conservative, American military hierarchy can change, then so can the NHS. But it needs its own General McChrystal to understand the impact that the Perry Principle is having and unless that individual (or tactical team) steps forward soon it is difficult to see a future for our much loved and much admired national health service.





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