Chris Lancelot: PCT managers' ignorance is far from blissful

I've just experienced one of those Eureka moments.

I've been reading Ben Goldacre's brilliant book Bad Science (Fourth Estate), in which he discusses Justin Kruger and David Dunning's paper 'Unskilled and unaware of it: how difficulties in recognising one's own incompetence lead to inflated self-assessments'.

The title says it all. Look at the graph: it arranges test subjects in order of objective competence, then plots their perceived ability against their actual abilities.

Self-perception of competence is almost constant, irrespective of actual ability - which is why everyone thinks they are a good driver, and why you and I each feel that we are a better-than-average doctor.

The most obvious aspect of this graph, and the most worrying, is the gulf between self-perception and reality in those who know very little. But, even worse, not only are poor performers unable to recognise their own incompetence, they also can't recognise competence in others because this too depends on 'meta-cognition': knowledge about the skill itself.

And here comes the connection. Reading Goldacre's book coincided with the release of a scathing report on NHS commissioning from the health select committee. This accuses PCTs of having misplaced confidence in their own abilities: trusts' perceptions of how they were performing were often removed from reality, and NHS managers often appeared complacent.

Bingo! Suddenly it clicked. It's not the managers' fault, bless 'em: it's their self-perception that's the culprit. They don't know what they don't know, but worse, their lack of understanding means they can't recognise competence or incompetence in those they appoint, so their cluelessness is self-perpetuating.

What is the cure? Clearly, objective external assessment of NHS managers' performance by clinicians is the key. But that is not enough. In future, all interview panels for NHS managers should contain clinicians, to counter the difficulty existing poor managers have in recognising healthcare managerial skills in others and to stop the perpetuation of managerial incompetence.

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