In the often heated debate about the future of the NHS, there is one thing that politicians seem to agree on: both sides are happy to use the slogan "more resources to the frontline". The slogan is not just naive, it damages the service.
The slogan effectively captures the public mood. When a UKIP politician on BBC Question Time claimed that the NHS has two managers for every nurse, he was overestimating the manager count by a factor larger than 20 (see useful analysis of the real numbers here and here).
The slogan reinforces beliefs about the NHS that are simplistic, naive and probably incorrect. But the slogan is so attractive almost nobody looks beyond it.
This wouldn't be a problem if the people running the system didn't share the belief. But the slogan was written into the health bill. Despite the whole thrust of the bill being to free up local NHS organisations from central control to help them decide how to run the system, a centrally imposed target on how much could be spent on management has been built in. This target was derived from the idea that we should move more resources to the frontline, even though the best evidence available at the time suggested the system was undermanaged before the changes.
The second reason the slogan is so dangerous is that it affects how well the services run, damaging their quality and productivity. The slogan discourages us from thinking of a hospital as a system. Instead, people casually accept that all that matters is how many doctors or nurses there are.
It never seems to occur to people that a hospital is a complicated system of interacting people and components that requires a lot of coordination to function at all. There is no point having a doctor in the operating theatre if the anaesthetist hasn't turned up, the theatre hasn't been cleaned, the hospital has run out of AB-ve blood and there is no bed available to receive the patient when the operation is over. The slogan just diverts thought from those complexities, dissuading us from asking how many supporting people we need to enable surgeons to do their work well.
A recent estimate from one doctor suggested that perhaps three hours a day are consumed in paperwork. We might have more staff on the frontline, but we are not spending it in front of patients; instead, we are wasting medical time doing badly designed administrative tasks that should mostly have been automated and computerised. More resources to the frontline is leading to less frontline time with patients.
If we lived in a world where our attention were not distracted by a beguiling political slogan, we might ask more intelligent questions about how the NHS works. A hospital is a complex machine where all the parts must work in harmony. It needs a lot of cogs other than doctors and nurses to function and sometimes it doesn't work well because there isn't enough support of the frontline. Sometimes, investing in better systems and investing in more support staff (and managers) is the way to improve the effectiveness of doctors and nurses. Maybe, for example, better organised A&Es are more pleasant places to work and therefore find it easier to recruit the doctors they need to function well (but this might mean they need to invest in managers or systems first). This isn't just speculation; we have strong evidence that good management dramatically improves the quality and cost effectiveness of what doctors and nurses do.
A more nuanced view of how the NHS actually works might give managers a better sense of their role. They should be making sure the systems and processes make it as easy as possible for the frontline staff to do their work. They should be supporting the front line. We might even choose to invest in more managers or more computers or more support staff because that is the best way to make the whole system work better. But we won't, because we are all befuddled by the slogan: "more resources to the front line".
Dr Stephen Black is a health management expert at PA Consulting Group