Fifty Shades of Command and Control

In these challenging times it’s always good when you come across a story that makes you smile. Better still, if it makes you laugh out loud! Here’s one I found amusing and whilst it’s not quite Seven Years in Tibet, the story of Prickles, who spent seven years in Tasmania, isolated and alone, is still a heart-warming story. Her picture is just fantastic, and the story has a happy ending too! I was also compelled to smile on reading the story of the un-named cleaner at Newmarket Library in Suffolk who after deep-cleaning the books and shelves, replaced all the books in size order rather than alphabetically and regardless of genre. Rather generously and perhaps in recognition of the times we are living in, James Powell, of Suffolk Libraries saw the funny side too. Describing it as an honest mistake, he noted that while it might take some time to sort out, time was one of the things they had in abundance.

And last week I heard a different kind of story, and it wasn’t the story as such that made me smile, but the way the story was told. The wonderfully candid and passionate Dr Dame Barbara Hakin, resplendent in her trademark pearls, was a guest speaker on a webinar I was part of last week. Chatham House rules applied, so I’m not going to share the detail of what was discussed. However, she had been invited to speak about how the NHS might be operationalised during a pandemic. She was well qualified to do so, having once been the Deputy Chief Executive of NHS England and responsible for commissioning and the operational planning for emergency situations. Her focus was an exploration of the concept of ‘command and control’ management approaches during an emergency situation. She had plenty of experience of dealing with such instances.

However, unlike other national emergencies, we don’t know how long the current Covid 19 ‘emergency’ situation will last. Learning from other previous pandemics, for example the Spanish Flu and SARs, we can predict it’s unlikely for there to be just one pandemic peak, after which life will return to normal. Almost certainly there will be a further wave (or two) of Covid 19 infections. And sadly, there are likely to be additional deaths to come as a consequence of folk not seeking help at the moment for other conditions for fear of becoming infected. Most commentators suggest that the development of a vaccine is probably the only way to guard against the longer term health impact of the pandemic. Without a vaccine, managing Covid 19 in the future will be difficult, but at least it shoudn't involve drinking a glass of Dettol every night as prescribed by Dr Trump.

Dame Barbara provided a fascinating insight into the largely hidden political machinations and the sometimes challenging relationships between politicians and experts. She made the point that essentially, command and control management should only be used in emergency situations, as there are better and more effective ways of managing complex organisations such as NHS hospitals and community services. Indeed, command and control management has long been rejected by many successful organisations. Its origins can be traced back to the work of Frederick Winslow Taylor. He was the son of a Quaker family, whose parents believed that children should be seen and not heard.

Right from being a young man, Taylor was constantly (some have said compulsively) measuring, counting and studying in the belief that he could come up with ways to make things more effective. It was something he very successfully took into his adulthood, first as a mechanical engineer, where he made a great deal of money, and then most famously through publishing his book, The Principles of Scientific Management. This was published in 1911, and is still regarded as one of the most influential management books of the twentieth century. However, his mantra of ‘follow the science’ eventually fell out of favour, as the work of other management writers (Mayo, McGregor, Herzberg, Peters, Mintzberg) began to challenge the intellectual underpinnings to Taylor’s work. As a group, they could loosely be described as belonging to the social science school of thinking. They were primarily interested in a more humanistic approach to motivation and the psychology of work. This is a different type of science to that which Taylor advocated. And apart from a brief renaissance in the middle 1970s, organisational management has largely seen flatter hierarchical structures, with greater emphasis being placed on developing healthy organisational cultures and an empowered workforce. That is, until a pandemic comes along. Then command and control methodologies once again come to the fore.

Has this approach delivered? Well I don’t do politics on this blog, and I’m sure in the fullness of time a Royal Commission will determine how successful the centralised command and control approach has been. But there are some clear wins: the NHS 111 service, which I’m sure Dame Barbara might recall, was intensely disliked when she launched it, has throughout this pandemic been almost universally welcomed as an effective service; compelling primary care to use video consultations; maintaining the lockdown and social distancing measures are other examples of centralised approaches that have resulted in a positive impact.

However, whilst command and control management shouldn’t negate local decision making, it is at a local level where some of the negative impact of the effectiveness of this approach on services can be seen. The supply of PPE has been challenging and an added burden to clinical staff. Whilst I can accept there may be a global shortage of PPE, why it has taken so long to mobilise manufacturing industries to step in and help remains a mystery. It is the kind of initiative that demands a centralised approach, yet it’s been down to local health economies to develop their own contingency solutions.

‘Follow the evidence’ has been the political mantra throughout this pandemic. The scientific evidence base is difficult to evaluate, and at the very least, seems to be a rather politically-managed and moveable feast. The evidence base developed through the pandemic ‘dry run’ ExerciseCygnus, undertaken in 2016 (way after Dame Barbara had left NHS England), has never been published and doesn’t appear to have been acted upon in this particular crisis. Perhaps as I have noted above, the relationship between politicians and experts really does have fifty shades of understanding when it comes to both the science and how it might be used – buts that’s probably too political for me to say – stay safe everyone.