Leadership Academy

Trumping Care

Posted by: John Deffenbaugh - Posted on:

The NHS Leadership Academy works with a world-class expert faculty of global business leaders, educators and practitioners. Our programme participants are offered unique opportunities to learn from and talk with each of them. Here, John Deffenbaugh, faculty member from the US, discusses the role of government and the role played by public managers in innovation for the good of the public.

Public managers have been in the spotlight recently. They are the agents of government, and those in Kensington and Chelsea have been strongly criticised for their response to the Grenfell Tower tragedy – for the speed and flexibility of response, for their compassion and for their management.

Let’s not make them scapegoats. Rather, let’s recognise the pivotal role of public managers. Mark Moore at the Harvard Kennedy School has written about their role, and he describes public managers as:

  • Explorers who, with others, seek to discover, define, and produce public value
  • Agents in helping to discover and define what would be valuable to do, instead of simply devising the means for achieving mandated purposes
  • Innovators in changing what public organisations do and how they do it, instead of being responsible only for guaranteeing continuity

Keith Grint develops this further and refers to public managers as Bricoleurs who make creative and resourceful use of whatever materials are at hand, as in ‘Bob le bricoleur’.


Leaders in the NHS who seek to be explorers, agents, innovators and bricoleurs also have a challenge on their hands. Politicians regularly take an unwarranted pot shot at them – recall ‘grey suits and white coats’. But these same leaders are at the forefront of implementing government policy, and it’s worth reflecting on the value of what we have in the UK, in contrast to the US.


Trumpcare has now collapsed in the Senate. This is not to say that the bill is dead – as many wish – but that some more horse-trading needs to take place down the line. If the experience of the House of Representatives is anything to go by, those implacably opposed will come round when the deals are done. The non-partisan Congressional Budget Office (CBO) estimates that 22m Americans would have lost their health coverage. Yet don’t rule out the Senate eventually voting for repeal and/or a new health care programme, erasing Barack Obama’s signature legislative achievement.

Trump vowed on the campaign trail to end Obamacare, called the Affordable Care Act (ACA). As its title says, Obama aimed to extend affordable care to many more Americans – to give them what we take for granted with the NHS. The Republicans now control Congress, and could still repeal Obama’s law and replace it with their own. The irony is that the failed Better Care Reconciliation Act would have directly hurt Trump supporters – those on low income, without insurance, in low paid jobs. Many of these citizens have benefitted from accessing care under the ACA, and now they were threatened with a double whammy – there would also have been constraints on access to Medicaid, the federal health care programme for those from disadvantaged communities.

How is it that America is going in one direction, and Britain the opposite? In America, there is an under-pinning culture of self-improvement, standing on your own two feet, fending for yourself. This goes back to the first settlers from England, and was reinforced as Americans headed west to explore and settle – and in the process take land from native Americans. “Manifest destiny” was the phrase coined to frame this expansion of the white population. The values of self-reliance from this period are woven into the American psyche. This also explains why white Americans voted in significant numbers for Trump – to take their country back from other nationalities, who ironically happen to be immigrants like themselves.

Big government is also anathema to many Americans. There were periods when the state expanded – during the great wars, the Depression, the liberal 1960s – but the view of many Americans about government is best summed up by Ronald Reagan: “The nine most terrifying words in the English language are: I’m from the government and I’m here to help”. Reagan framed it that government was the problem, not the solution. His message was that government should get out of the way and let individuals deal with things. Therefore, some on the right of the Republican party are keen to withdraw all health benefits – not something the right in Britain would even consider.

In many respects, we have followed the American way for almost 40 years, irrespective of who has been in power – the internal market in the NHS, liberalisation of the economy, McDonalds’s on the High Street. There has been a tendency in the NHS to laud all things American – Kaiser Permanente, Intermountain, Virginia Mason. But American culture often does not travel well, and what works in the US does not necessarily mean that it will work well here. We seem to have lost the ability to innovate ourselves, and have become too much of a copy-cat culture.

The need to improve the effectiveness of our own public services was highlighted by the Grenfell Tower fire. This tragedy exposed a wide range of emergent problems with public service provision in Britain: lax fire safety checks, low investment in social housing, local government ineffectiveness. Emergency services performed exceptionally well, but the wider public services support has been found wanting.

Public value was not delivered. The reverse – 80 confirmed deaths and many more evacuated from other tower blocks faced with suspect cladding. What we are seeing now is a renewed focus on the beneficial role of government, and a return to public good. Therefore, as America moves to minimise the role of government, Britain is seeking to improve it.

If public value is to be delivered, then public managers need to make their mark. They can empower themselves. You can empower yourself. Grenfell provides the impetus. Let’s stop following America and innovate ourselves for the public good. Let’s trump Trumpcare.

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