The text below is reproduced with permission from Radcliffe e-bulletins “Leadership for Doctors” number 21 and is co-authored by Stephen Curran and myself. Earlier bulletins can be found under the Leadership for Doctors tab above.
To lead in an organisation it is necessary to understand it. This is not an easy task for health care systems which are often complex and, increasingly in the English setting, fragmented organisations. The English part of the British NHS is the setting that the authors are most familiar with. Since political devolution of control of health services to Wales and Scotland, different parts of the UK health service have developed in different ways, so that one can no longer refer to the British NHS as a whole.
There are many different tools for understanding organisations and we intend to address this in two ways. In this bulletin we will give a brief historical account of the origins of the NHS and its development, concentrating on the English setting for the more recent history. In the next bulletin we will examine more general ways of understanding organisations that can be applied in many different settings. In particular we will focus on the work of Gareth Morgan who, in a highly influential work, Images of Organisations, used metaphors as a way of developing understanding. He listed 8 metaphors (Box 1):
|1. Machines,2. Organisms,3. Brains,4. Cultures,
5. Political systems,
6. Psychic prisons,
7. Flux and transformation, and
8. Instruments of domination.
Box 1 “Metaphors” or Images of Organisations (after Morgan)
These metaphors (and others) can help us think about organisations; but it is also important to remember that they represent aspects of reality and all are incomplete in themselves. Using only one metaphor can severely restrict our thinking and our capacity to find creative solutions as leaders. The person who views organisations as machines and people as “cogs” in the machinery may find the people don’t agree! People who see English NHS organisations only as agents within the NHS “market place” (another metaphor) will also find their understanding is limited. In the next bulletin we will explore some of these metaphors in more detail but, for now, as we recap the history of the health system in the UK (and more recently in England) after the end of the Second World War, it may be useful to consider how these different images apply to the different stages of development.
A brief history of the NHS
“The collective principle asserts that… no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.”
—Aneurin Bevan, In Place of Fear, p100 (1)
The British NHS came into being in 1948, after the Second World War. The underlying cultural assumption was that this was an expression of kinship and mutual responsibility (see Intelligent Kindness (2)). Bevan, as Minister of Health, oversaw its inception in a time of great financial difficulty. It was essentially shaped on mechanistic or bureaucratic lines with a top-down ‘command and control’ structure. Control was partly by central government through Regional Boards, partly by local executive committees (general practitioners, opticians, dentists and pharmacies) and partly by local government (public health and ambulance services). Teaching hospitals retained a degree of independence with their own Boards of Governors. The centralised structure modelled on the Emergency Medical Service which had performed well in the face of the disruption and casualties caused by the bombing of cities during the Second World War. There were incremental changes over many years.
Then, in the 1990s, under the influence of economic theorists from Europe and the USA, there was a fundamental change with the introduction of a market-oriented system with a purchaser-provider split, at least at the secondary care level. Now the underlying philosophy was increasingly individualistic and materialistic. For a thorough consideration of the changes this has gradually wrought in the way patients and clinical staff are regarded and supported in the Healthcare system, see, again, Intelligent Kindness (2). A service ethos was partly replaced by a market ethos, where organisations competed for customers (patients) via their GPs and where financial efficiency was the bottom line.
In England, commissioning has been through several iterations, starting with Fundholding General Practices and moving through Primary Care Trusts to (supposedly) GP led Clinical Commissioning Groups. Commissioners were helped in their tasks by various organisations like National Institute for Health and Clinical Excellence (NICE), which set standards and approved treatments for NHS use at the (English) national level, with different arrangements in different parts of the UK. The tension between the old ‘service model’ and the new ‘commissioner-provider’ model was high in the area of service design. The old system tended to rely on the expertise of local clinicians, especially consultants. The new system relied on evidence abstracted at a higher level through organisations like NICE. There was a potential for more superficial uniformity but perhaps at the expense of innovation, expertise, local application and inspired clinical leadership.
In an attempt to ensure that standards were maintained there were inspectorates (the Care Quality Commission, CQC, in its latest incarnation). These created a high anxiety environment which contributed to the disruption of the very caring culture that the CQC might have been expected to promote. Another organisation ‘Monitor’, was concerned mainly with the financial viability of Foundation Trusts. The inadequacy of these arrangements was nicely demonstrated in 2009 when the Mid-Staffordshire NHS Trust, in its anxiety to achieve Foundation status, concentrated on financial savings, cutting clinical staff and disregarding a marked excess mortality. A subsequent investigation by the Healthcare Commission (the predecessor to the Care Quality Commission) found, among other failings, that the Trust had shed too many clinical staff in an effort to balance the books. From the narrow point of view of Monitor, they succeeded, being granted Foundation Status just before the Healthcare Commission commenced its inquiry. Nor did the Healthcare Commission come out of the episode covered in glory. The excess mortality was first picked up by a semi-independent public health monitoring body called ‘Dr Foster’, www.drfosterintelligence.co.uk, not by the Commission. A further Public Inquiry led by Robert Francis Q.C. resulted in the eponymous Francis Report (http://www.midstaffspublicinquiry.com/report).
Strategic Health Authorities at Regional level tried to hold it all together and provided support to the PCTs but these have now been abolished and replaced by CCGs and various other bodies. The detailed situation varies from year to year but the basic division was and still is into commissioning bodies and provider organisations with separate standard setting and inspecting bodies. There is also an increasing involvement of multi-national “for profit” healthcare providers and commissioners.
At the time of writing it is too early to predict all the effects of the current reorganisation but some of the possible implications are briefly outlined in Box 2. We are now in the middle of these changes and managing the transition to the new system will demand a great deal of skill and flexibility from doctors in both primary and secondary care organisations.
Competition and commercialisation: Choice of provider organisations will be extended to ‘any willing provider’. There is a risk of commercial organisations ‘cherry picking’ the easy-to-provide and profitable services leaving Foundation Trusts to deal with the difficult and costly. However Foundation Trusts themselves will become much more commercially oriented so that conditions that are persistent and difficult to manage may be relatively neglected. There is also a risk that large commercial organisations will provide services as “loss leaders” until they have driven out competition from Foundation Trusts and Social Enterprises (see below)
Secondary care provision: Secondary care NHS organisations will become or become part of Foundation Trusts or Social Enterprises. The latter have been described as membership organisations which create surplus to reinvest in their core purpose, thus giving incentive to act, be decisive and save to do more community good. One example the authors are familiar with Is NAViGO (http://navigocare.co.uk/) which provides mental health services and has a membership of staff, service users and carers with equal voting rights. This model has the merit of service users and employees being serious stakeholders in the organisation and having more influence on its direction. Unless there is close collaboration the expertise of secondary care clinicians in both types of organisation in planning and designing services will be wasted.
Commissioning consortia: Consortia have to be of sufficient size to fulfil many of the functions currently filled by Primary Care Trusts. With the ever-continuing development of medicine, services will continue to be delivered in the community and through the Primary Care Team whenever possible. This may lead to conflict of interest and loss of quality in services for vulnerable groups who need a high level of expertise but who are best managed in the community (for example people with long-standing mental health problems). There is also the risk that private organisations will move in to support GP Commissioning in a way that perverts the aim of the NHS from healthcare to profit.
Box 2: Some possible “pressure points” in the latest re-organisation.
Examine what is happening in your area in terms of commissioning and provision:
- How far are the concerns described above being realised?
- Are other issues emerging? How are they being resolved?
- How far have consultants and general practitioners (other than those in senior management positions) been able to avoid/address any issues that have arisen?
- How far have consultants and general practitioners who are involved in senior management positions been able to influence matters?
Make a list of the benefits to patients that have genuinely arisen from the new arrangements and of the problems for patients that have arisen:
- Which is greater?
Make a list of the benefits and costs (including emotional costs like anxiety and insecurity) to staff.
- Which is greater?
We have to work with the changes and systems that politicians (in their wisdom) impose – so how can we increase the benefits and mitigate the costs?
We will be examining some of the metaphors used to help understand organisations in the next bulletin. We would like to close this bulletin by referring back to the change of culture in the (English) NHS from a co-operative enterprise for the common good to a market-place culture where there is at least a danger of excessive profit for the few becoming more important than the common good.
Ballatt and Campling (2) point out that working with ill people, particularly those who have long-standing illness or are dying is in itself anxiety-provoking and needs the cultivation of an attitude of “intelligent kindness”. They identify some of the pressures that they believe are undermining this culture in two chapters entitled “Unsettling times” and “The pull towards perversion”. One of their arguments is that the constant re-organisation (or “re-disorganisation”) of the NHS in recent times is counterproductive and engenders anxieties in staff that can disable them from meeting the needs of patients. They also identify what they call “corrupting forces” that encourage inappropriate anxiety and defensive attitudes in staff. They list these as:
- The active promotion of a competitive market economy on the basis of a commodified view of needs, skills and service.
- The process of “industrialising” healthcare, turning work undertaken by skilled individuals in relationships with patients into the mechanical delivery of processes and systems.
- The framework and currency of specification, regulation and performance management.
They argue that these forces engender high levels of anxiety in clinical staff which mitigate against the kindly delivery of care.
In your personal, local situation how are you handling the tensions generated by:
- Instability in the healthcare system?
- The promotion of a competitive “market economy”?
- Processes of industrialising and fragmenting care?
- Increasing specification, regulation and performance management?
How can we as professionals and leaders develop resilience in ourselves and those we lead to deal with these pressures in a positive way and not to allow our human vocation to care for those who are ill to be subverted?
1. Bevan, Aneurin. In Place of Fear. Whitefish : Kessinger Publishing LLC, (facsimile reprint) 2010. 978-1163810118.
2. Ballatt, John and Campling, Penelope. Intelligent Kindness: reforming the culture of healthcare. London : Royal College of Psychiatrists, 2011.