Annual appraisal and liege homage: why the British NHS is fundamentally a feudal organisation

Abstract

A study of the past can help us understand present-day management structures. Strong parallels can be seen between the present-day British National Health Service (NHS) and English feudal society in the early Middle Ages. Both systems are hierarchical, both show limited mobility between layers in the hierarchies and in both there is a strong element of central control coexisting with significant day-to-day delegation of responsibility. Ceremony plays a key role in relationships, such as through the swearing of liege homage in feudal society and through formal assessment and appraisal in the modern NHS. Although the NHS clearly does not show parallels for every element of feudal society, it is possible to draw practical lessons from the comparison, particularly relating to the ownership of problems, team-working and appraisal.