The Secretary of State’s Desk

Woman businesswoman under stress missing her deadlines


“The rational response of an appointed NHS CEO is not necessarily to improve the long-term performance of the hospital, but instead to minimize the amount of bad news that ends up on the Secretary of State’s desk.”



This is just one conclusion to academic research,  ‘The Impact of CEOs in the Public Sector: Evidence from the English NHS‘ published by the Harvard Business School.

The paper, available here, authored by leading academics Dr Katharina Janke
(Lancaster University), Prof. Carol Propper (Imperial College & University of Bristol) and Prof. Raffaella Sadun (Harvard Business School) is supported by detailed, statistical analysis, which mere mortals would not pretend to understand.

The conclusions are enlightening and should be essential reading for the Secretary of State for Health & Social Care, his Junior Ministers and officials, along with the Boards of NHS Improvement and the Care Quality Commission.  Essentially:

“We find little evidence of CEOs being systematically able to change the performance of these organizations. We also do not find evidence that a change in CEO brings about an improvement (or even just a change) in performance.”

The paper proffers two possible explanations [abbreviated and paraphrased]:

“Lack of CEO effects is consistent with top managers chasing political goals, not policies that might improve hospital performance. The rational response of an appointed CEO is not always to improve long-term performance, but to minimize the bad news landing on the Secretary of State’s desk: this may explain why there is a CEO effect in remuneration, unassociated with observed performance, but with receiving public honours. The political nature of the NHS may lead to negative sorting (reluctance of high performers to seek CEO appointments). 

“Hospitals are large complex organizations, in which highly trained (and hard to monitor) individuals run separate, interconnected production processes. Top Management may find it difficult to engage in co-ordination and getting a large number of actors, who traditionally have not worked together, to work co-operatively. A possible interpretation of our finding is that the organizational inertia of a large hospital is often too strong for a CEO to impact performance.”

These conclusions are remarkably similar to expert (unscientific) analysis of Southern Health’s recent reply to a letter from Suella Braverman MP to the Secretary of State. A press release and Southern Health’s response are available here→.

The expert analysis is here→.  The similarities with the conclusions of the Harvard Business School paper are clear. For example [abbreviated and paraphrased]:

“I am also mindful that there is a political and PR exercise at play here.

“[Directors] have forgotten that the letter was addressed to the SoS. They address the points made as though it were directed to them as criticism and write what I feel is a very defensive letter. A better approach would have been to build on what was said and commit to what they could do with £5m to invest in the areas identified, or indeed suggest where the outcome could be improved by investing it differently. They simply don’t see this opportunity; they see this as a threat to their position and authority. Clear arrogance on their part I would suggest in that they know best. 

“They are dismissive about the points on GP training and the deployment of Medical Examiners essentially saying its someone else’s job to deal with those. Everyone is aware these are not Trust specific issues, indeed the work requires all parties to play their part and work as a team. Saying it’s for someone else to do is very much old school “pass the parcel” mentality which indicates there is much more to do to change the culture.

“Overall, the response doesn’t say a lot. It’s all aspirational. Very little is tangible in terms of specific results that can be expected to be seen by a specific time. 

“The first two pages of the [Trust’s]  reply are all spin and waffle. It tells us very little about what the customer can expect by way of improvements. It tells us there’s a new board, a focus on training staff in a QI methodology, a focus on improving patient and carer engagement, a new organisation structure and an improved culture. No detail as to what this will mean to the customer.  

Regarding the second explanation, we know Southern Health is a large complex organization, in which hard to monitor individuals who run separate, interconnected production processes. It is difficult to engage in co-ordination and getting a large number of staff , who traditionally did not work together, to work co-operatively. As we have said before, transforming an NHS Trust is more difficult than turning around an ocean liner.

When will the Secretary of State’s desk look like that of Russian Tsar Nicholas II in his office in Livadia Palace, Crimea – 4 family photo’s, 6 sheets of paper and a large tome?

figure of tsar Nicholas II in Livadia Palace



1 thought on “The Secretary of State’s Desk

  1. Pingback: Planning to Fail | Campaign for Reform At Southern Health

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