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Are you ready to give up control?

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As the government’s dispute with junior doctors over their new contracts drags on, there seems to be something peculiarly British about the dispute. With the NHS at the centre of the dispute, its centrality in British society is re-affirmed.

The UK newspaper The Guardian has recently featured the NHS and one of its headlines sums up the unusual status of the NHS in the  British psyche; when it described the organisation as being “almost like a religion”. Another example of its uniqueness was illustrated in the much-praised opening ceremony of the 2012 Olympics. Where in the world but the UK could the health service have featured so centrally – where in the world but the UK would these references have made sense?

It might seem curious then, when considering its high status in the UK, that a dispute should have reached the stage in which one party is proposing to impose a new contract on the other.

Possibly this is a symptom of problem that is more universal then the UK’s NHS, the friction between centralisation and de-centralisation.  Anuerin Bevan, often considered the father of the NHS, has been quoted (perhaps apocryphally) as saying that “when a bed pan is dropped in Tredegar, it should be heard in the Palace of Westminster”.  This metaphor undoubtedly most aptly illustrates the centralised nature of the NHS.

It is interesting, I think, that the political importance of health provision is a far less contentious or significant issue in the rest of Europe where de-centralisation is more normal and therefore where local problems can be solved at the local level – from bed pan clumsiness to employment contracts.

Centralisation and the level of de-centralisation, in business and in government, is an ever-present challenge. It is maybe one of those issues, like economics, that can be difficult to transfer from the micro to the macro. Many of us in positions of responsibility learn the advantages of delegation. We also learn that for delegation to be successful, it must be accompanied with trusting our subordinates with responsibility and accepting that they may make mistakes.

But does that lesson transfer to the macro-scale? At the micro-level, management, fundamentally, is about the allocation of resources – people, material and time.  But at the macro-level, politics is about the allocation of power, often a much more difficult resource to surrender.

It might be that a useful parallel can be drawn from the military approach to the allocation of power. In the military, command and control is clearly defined and the level to which it is allocated is laid down in orders.

However, even the military approach differs distinctly between the army and the air force. The army uses the philosophy of “mission command” in which subordinate commanders take the commander’s intent and, with allocated resources and set constraints, determine how to execute the mission. In the air force the principle of “centralised command – decentralised execution” is favoured.  All missions are centrally ordered through an air tasking order which is then transmitted to squadrons for execution.

The difference is that army subordinate commanders are encouraged to execute their own plan; whereas in the Air Force orders cannot be varied without reference to the centralized command.  These different philosophical approaches, which can cause tension between the air and land environments, are prompted by a combination of the scarcity of air resources and the ability of air assets to deliver affect across the whole of the battlespace.

How then can these approaches be transferred to the UK health service?  Is it time for a less-centralised approach?  For central government, this will mean a large-scale relinquishment of power but it would have the political benefit of placing responsibility at a lower level.

Without drawing too close parallels between military operations and surgical ones, it is perhaps time for the government to exercise mission command with the NHS?

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