The new Government wants to be seen to be re-invigorating the NHS, but its chief executive is keen to avoid further costly re-organisation. Isn't it frustrating, Andrew Davidson asks him, working to an agenda over which he never has full control?
They call it one of the toughest management jobs in Britain. One million-plus workforce, £34 billion budget, constant political pressure, incessant media attention, your business literally a matter of life and death to many of your customers.
Yet ask most people to name the current chief executive of the National Health Service - which celebrates its 50th anniversary in July - and they will give you a blank look. Even after the flurry of pre-Christmas publicity over the Government's White Paper on health, The New NHS, few people outside the service are any the wiser. Alan who? Leading from the front is not, it seems, a likely characteristic of NHS bosses.
Fair comment? Well maybe, retorts Alan Langlands in his soft Glaswegian brogue, refusing to rise to the bait. But leadership, he explains, comes in more forms than just the macho, riding-a-white-charger variety. 'Leadership in the health service,' he says, 'is about something more subtle than that. It's about influencing skills, about being able to understand the problems of working across professional boundaries, about releasing creative energy within organisations.' It is also, of course, supremely about consensus management, taking your people with you towards shared goals. It's a tough enough game when your 'people' include everyone from £120,000-a-year hospital bosses and heart surgeons to nurses and domestic cleaners earning less than a tenth as much; and it becomes even more difficult, some would say impossible, when your political masters keep moving the goal posts.
But if the pressure of managing Europe's biggest workforce is weighing heavily on Langlands' shoulders, he doesn't show it. Tall, broad and greying with a warm smile and a cautious, inquisitive manner, he gives off the kind of calm reassurance that comes from years of experience of dealing with people. When we meet, before Christmas at the Department of Health in Whitehall - he splits his week between London and the NHS Executive head office in Leeds - he shows few signs of any White Paper nerves.
He sits at the end of the table in a conference room across from his office, shirtsleeves on the table, cup of tea in front of him next to a pile of photocopies, his pudgy features set firm in thoughtful concentration.
There are no airs and graces, just a pragmatic stolidity that reminds you of how the old-style trade union leaders used to conduct themselves.
The reforms outlined in the White Paper - giving family doctors a greater say in how health services are bought and scrapping the half-hearted attempt to create an internal market in the NHS - are believed to have Langlands' mark stamped upon them. No one is quite sure yet how far-reaching the changes are going to be, but already it appears as if two potentially conflicting aims have been met: the Government's desire to look like it is radically re-invigorating the NHS, and Langlands' desire not to get the service involved in any more costly re-organisation.
So, business as usual after the latest reforms? 'I have got my aims,' he says, his eyes twinkling, 'like providing better health and better services, and I also have my management agenda: to follow a coherent policy, to strengthen the scientific and educational base of the health service, and to improve the capability of management, especially local management.
If I can keep faith with these things, it doesn't matter to me too much what the structure is, but it does matter that we don't spend too much time taking our eye off the ball going through another process of restructuring and upheaval. I think the new government is very clear about that. The last thing the NHS needs is another huge organisational change.'
On which point, most people are agreed. The previous set of changes, ushered in with full public relations pizzazz by Kenneth Clarke at the end of the '80s, were among the most radical ever imposed on the NHS, instituting a split between purchasers and providers of health services and creating a raft of semi-autonomous trusts to manage their own affairs.
They were an attempt not just to introduce more market forces into the system but also to address the increasing pressure on the service created by technological advances and social expectations. Nearly a decade on, most who work within the service agree that they have only been partially successful - perhaps because they were only partially implemented, as the potential political fallout of a fully market-driven system was swiftly judged to be too great to contemplate. It was not all bad, however. Now the NHS is acknowledged, pound for pound, to be probably one of the most efficient health services in the world. The problem, as anyone who uses it knows, is that the quality of service is hugely variable. So the NHS, once care-driven, then cost-driven, must now find an equilibrium again.
If it does, Langlands is probably the man who will walk away with most of the credit. Born and brought up on a council estate on the south side of Glasgow, the son of a sailor who worked his way through a variety of jobs - carpet weaver, shipping clerk, transport manager - Langlands has shown a deft political touch in avoiding much of the personal acrimony that has dogged health service management in the last decade. He says watching his father cope with everything life threw at him was his first great lesson. 'I saw him struggle with redundancy, technology, young brash managers who knew half as much as he did. It was quite a learning experience, and he never gave up.' That sense of perseverance and focus has been Langlands' managerial trademark. 'Alan has the most extraordinary resilience,' says Sir Graham Hart, former permanent secretary at the Department of Health and a long-term Langlands fan. 'He can soak up pressure like a sponge and he always keeps calm in a crisis, which is essential in the health service.'
It is that resilience, combined with his approachability and a knack for simplifying complex problems, which marks him out, say those who have worked with him. He is only 45, yet exudes a maturity beyond his years. He can speak to anyone, grasp the issues quickly, sidestep any provocation and communicate what he wants as efficiently to a staff nurse as to a hospital chief executive. At the same time he is renowned as a stickler for detail and a hard driver of people. He is the health service's safest pair of hands for a generation, they say, the man trusted by both Conservative and Labour governments, and judged by some to be the best manager the public sector has got at the moment.
Langlands, married with two children, has worked in the service long enough to have seen the NHS in all its incarnations. Joining straight after reading a pure science degree at Glasgow University in the early '70s, he has moved through posts in Edinburgh and London. He has left the NHS only once, in 1989, to work briefly in management consultancy.
On his return, he swiftly made it to the top, replacing Sir Duncan Nichol, who received a mountain of bad publicity when he left the NHS to join BUPA in 1994. The selection panel which gave Langlands the job included Sir Graham Day, the former Rover chief. According to others present, Day was bowled over by Langlands' management acumen.
Had being a management consultant helped? Not really, says Langlands, it was hardly a key influence. Ironically, those who know him say he actually leapt into the private sector because he was so disillusioned with the Clarke reforms. Perhaps because of his exit from the NHS then, and because of his role in diluting the Conservative reforms since, Langlands is seen by some NHS managers as being distinctly luke-warm about the internal market, a stance which, according to others, occasionally made his position of neutrality during the last general election seem rather awkward. Is it true? No, says Langlands, he left the NHS to set up a health arm for Towers Perrin management consultants because by then, as a district general manager working for Harrow Health Authority, he felt his career was in a rut. He was only at Towers Perrin for two years before he was lured back into the service with a plum post at North West Thames Health Authority.
As for past references to his 'leftish leanings' in the newspaper cuttings - 'one newspaper cutting' he points out, correctly - it is just rubbish.
'I have no political views, and I certainly didn't set out during the election to give the impression that I was sympathetic to the Labour party proposals for the NHS. I think what I found myself doing, and this is the interesting point, was coming to terms with the idea that there was likely to be a change. If you are a conventional civil servant you play until the final whistle, wait for the result of the election, then work in support of the new government. I found myself in a managerial mind-set, and I guess most managers in big business think like this: if there is going to be a change you have to start repositioning to ensure proper stability and continuity. I think that is terribly important.'
Yet it is hard to see how any manager in a service under political control can avoid tying themselves up in knots. For a manager like Langlands, having to defend first one set of reforms - even if he is diluting them - then another, must cause complications. For example, the Government has pledged, without giving any detail, to reduce the number of managers in the system. Langlands, like everyone else in the service, will not be drawn on just how this is going to be achieved, even though many at trust level say it is simply political posturing and cannot be done. And likewise, as NHS boss, Langlands is on record as defending the idea of GP fundholding (whereby certain GPs could take their budgets out of health authority hands and buy their own hospital services, often enabling their patients to jump the queue for operations). Now, under the reforms proposed by the new White Paper, he has to dismantle fundholding because the Government says it is bad. Instead, it has a new idea: local groups of GPs buying services. Sorry? Groups good, fundholding bad. Two legs, four legs. Doesn't every NHS boss feel rather like they are performing in a mediocre version of Animal Farm ?
Langlands smiles. 'I don't think GP fundholding was a bad idea, but it was only a means to an end. The end is providing better primary care services in this country, breaking down the institutionalised separation of primary and secondary (ie hospital-based) care. The end is providing people with better services close to their home. Both governments have the same end. In fact I have as many discussions with this Government about cost efficiency as I did with the last one.'
And of course, you could argue that part of Langlands' success - the subtle leader again - was to persuade the Government to look at modifying, rather than scrapping, the fundholder idea. But in the end, isn't it frustrating to be always working to an agenda that you never fully have control of?
Not at all, he says. 'I think there are certain things I can do, that I feel I have been doing, that transcend government. I think I have a responsibility to develop policies for health services in this country that are coherent and have the commitment of the staff working in the NHS. I think I have a responsibility and indeed quite a strong passion about strengthening the scientific and educational base of health services: national research and development, the processes of clinical audit, encouraging ideas of clinical education. I also have responsibility for developing the capability of health service management. We have been developing a cadre of leaders and managers in the health service for the last 10 years, and that is a long haul. These are things that transcend government.'
So is he happy with the standard of management in the NHS? The Clarke reforms needed more managers to administer them, leading to accusations that the system was being flooded with 'bureaucrats in BMWs' all chasing pieces of paper. Yet as bed shortages worsened and winter crises loomed, it was not hard to find evidence that the renewed emphasis on management wasn't working. Would he agree? Langlands chooses his words carefully.
'I think the environment is very tough for a lot of people in the health service - that raises questions about the effectiveness of management at local level, I don't think we have a good record of human resource management at local level. But I think people are beginning to understand the importance of it.'
And how does he cope with the sheer size of the service and the conflicting loyalties and interests of those within it? According to Andrew Pettigrew, professor of strategy and organisation at Warwick Business School where Langlands is a board member, anyone managing that needs to be able to simplify priorities. He describes Langlands' key strength as his ability to conceptualise. 'There is no private sector organisation that is as large or as complex as the health service,' says Pettigrew. 'A lot of that complexity is focused in on those who run it and if you cannot simplify, you will get into difficulties. Alan has that ability to think clearly about complex problems.'
One of the complexities is just sorting out the power relationships between different levels of NHS bosses. For example, there is no direct line of authority from the chief executive of the NHS to individual trust chief executives (some of whom earn more than Langlands' salary of around £100,000-a-year). The chief executive of the NHS implements policy set by the secretary of state for health and is officially the accounting officer for NHS expenditure, which includes trusts' external financing. Individual trust bosses are accountable for their own finances. But the chief executive of the NHS cannot call trust bosses into his office and carpet them for not doing what he wants. They report only to their boards which in turn report to the secretary of state. All the NHS boss can do is make life uncomfortable for a trust chief executive by removing that person's accountable officer status and asking the secretary of state to intervene. No wonder Langlands emphasises subtlety as a key leadership quality.
Couldn't the line of authority be more direct? No, says Langlands, there are 427 trust chief executives and 100 health authority bosses (the latest reforms pledge to reduce this number but haven't said when). He could not have over 500 people reporting to him. 'I just don't believe you can run an organisation of this size as a hierarchy. Just think about the complexity of each trust and what they are doing. Each trust is probably the biggest employer in their local town. The idea that someone can sit in Whitehall or Leeds and second-guess them is laughable.'
But in the end, who are health service staff loyal to? Their professions?
Individual trusts? The NHS? Since the issue of local pay bargaining was fudged - Langlands admits that the previous government had neither the will nor the cash to push it through - a lot of trust chief executives seem to be operating with their hands tied behind their back anyway. The tensions between what the centre and the periphery regard as important must be huge. In London, in particular, the whole issue of authority and reform seems to have collapsed into a muddle over how to switch resources into primary care. Strategy changes are legion, hospital closures and mergers have generated intense acrimony, high-profile campaigns to save famous old names like Bart's and Guy's have attracted vocal support. Has all that been well managed?
Langlands purses his lips. 'One of the great paradoxes is that some of the more able managers have worked in London yet have been unable to tackle what must be the most complex change problems in the health service. Just think what you would need to make really radical change to London's health service. You would need public acceptability, political will, capital investment, commitment from the opinion formers among the staff, and very capable transition managers. All of these things have never been present at one time to allow these changes to occur. There have been successful changes but they have always gone unrecognised.'
Yet the evidence of service failure is there for anyone to see. You only have to talk to people who work on the bottom rungs of the NHS. For them, in a point well made over the past year, it really does seem like there are two different worlds in the health service now: that of the chairmen, chief executives and top doctors who talk of objectives pursued and goals achieved, and those of the nurses and cleaners who see the queues and the seemingly never-ending daily crisis in the wards. Like so much in the NHS, they are contradictory views, but both correct in their own ways.
You have to ask: will they ever be resolved? You won't get an answer, of course.
But that has always been the way with the NHS, which, for all its faults and design flaws, is still a rather remarkable achievement. And the important point, adds Langlands, is that it is going in the right direction. 'The question that I always ask people who are dissatisfied with the NHS is: when did you last go to see your family doctor? Because most people don't see that as the NHS. People like their GP service, they like the idea of the development of primary care, of meeting a practice nurse, of getting grand professors out of the hospitals conducting clinics just five minutes from patients' homes.' He acknowledges that the shift in focus to primary care has not yet been well explained (for instance, how many of the general public even know what the term means?) but when people understand it, they back it.
So where will he be on anniversary day, Sunday 5 July? Not pottering in his garden at home outside Harrogate, that's for sure. But somewhere local, he says. 'It's terribly important that we localise the celebrations.
The NHS is at its best when it operates as an integral part of the local community it serves.' And he wants the anniversary to be more than just a PR exercise, but also the starting point for a 'realistic discussion' about the NHS's future.
His own contract runs out in April 2000. At the moment, he says, he has no idea of what he will do next. Run BUPA? He gives me a dirty look. 'I will not be going to BUPA, I am sure of that.'
There is an old joke, which it is probably unfair of me to tell, that bosses get rather more interested in giving interviews to management magazines when they get past the halfway point in their contracts ... Langlands sticks his bottom lip out. 'I have never really spent a lot of time plotting my next move. I will be 48, and I think I will find it extremely difficult to work in another part of the health service. I will probably have to do something completely different.' He pauses, gazing toward the window with its view over a Whitehall side street. 'Whatever it is, I hope it is complex. I like complexities.'
1952 Born 29 May in Glasgow
Educated Allan Glen's School, Glasgow and University of Glasgow
1974 Graduate trainee, NHS Scotland
1976 Executive, Argyll and Clyde Health Board
1978 Executive, Simpson Memorial Maternity Pavilion, Elsie Inglis Hospital
1981 Unit administrator, Middlesex and University College hospitals, London
1985 District general manager, Harrow Health Authority
1989 Practice leader, Health Care, Towers Perrin
1991 General manager, North West Thames Regional Health Authority
1993 Deputy chief executive, NHS Executive
1994 Chief executive, NHS Executive
WHAT PEOPLE SAY
'Alan is very good at conceptualising, he has great flexibility of mind and is a very approachable manager. He also has a calmness that is essential if you are working in Whitehall, because it is replete with panics and crises.'
Andrew Pettigrew, professor of strategy and organisation, Warwick Business School
'Alan is a very clever and subtle manager. He is extremely diplomatic and sure-footed in coping with political trouble, and is a very reassuring person to deal with, never coruscating. I think he is one of the small number of really exceptional leaders we have in this country.'
Sir Graham Hart, former private secretary, Department of Health
'Alan is ideal for the job because he sees the big picture and understands the importance of going for a coherent approach, but he is also realistic and honest about resources.'
Tony Shaw, chief executive, Southampton and South West Hampshire Health Authority
'Alan works with a degree of informality that is important, he has very good interpersonal skills and relates to the field very well. He is always out and about. He is not a centrist.'
Sir Michael Peckham, director of the school of public policy, University College London, and former director of r&d, NHS.