Feudalism under William the Conqueror may seem to have been a time of evil barons, brave knights, and downtrodden peasants, but in management terms it was a very model of the NHS.

At its heart was a complex system of subcontracting and delegation similar to that operating in today's health service, with knights instead of consultants, henchmen not senior house officers, and peasants rather than nurses.

King William I (reigned 1066-87) has been succeeded by the health secretary, Alan Milburn (1999-), and lesser barons have become medical directors, while the much despised leading barons or tenants in chief are today's NHS trust chief executives.

Writing in the Journal of Health Services Research and Policy (2003;8:57-9), the authors say that lessons can be learnt from the problems that beset feudal kings.

They write: “The NHS Plan specifically enjoins us not to repeat the mistakes of the past. By the past, its authors meant, perhaps, the last two or three decades. We would argue, however, that the NHS shares many features with feudal society as it existed in England between the 11th and early 14th century.

“If so, then we have a much-studied model from which we can draw parallels and which may suggest solutions to present-day problems.”

The authors, Ann Evans, senior lecturer at Eastman Dental Institute for Oral Health Care Sciences, London, and Len Tyler, secretary of the Royal College of Paediatrics and Child Health, say that under the feudal system leading barons were given property and in return undertook to give the king knights whenever he needed them, despite not having armies of their own.

“Like many senior managers today, they had accepted proffered new resources and along with them tough new targets that they could not hope to meet themselves. So, like many modern managers, they delegated,” write the authors.

In many cases a single knight was delegated property on condition that he turned up to fight. “Then as now the task could be delegated, but not the responsibility for meeting the target. If the knights were not delivered it remained the tenant-in-chief's head on the block, and not necessarily metaphorically.”

The authors, who suggest that the annual appraisal interview of NHS staff is akin to swearing homage, say that in feudal times the most dangerous place to be in the management structure was high up, because of the intense royal scrutiny. They go on to point out that the most publicised sanctions in the NHS have been taken against chief executives and consultants.

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