The text below is reproduced with permission from Radcliffe e-bulletins “Leadership for Doctors” number 22 and is co-authored by Stephen Curran and myself. Earlier bulletins can be found under the Leadership for Doctors tab above.
The medical profession, rightly, have an education that is biased towards “the sciences” and evidence-based practice. We are less “at home” in what used to be called “the humanities”, yet we all recognise that a good knowledge of science is not enough. If we are going to elicit signs and symptoms from patients, help them understand their problems and engage them in treatment we need a variety of interpersonal skills. We also need a whole set of different tools for understanding what is going on in complicated managerial situations. We have already discussed the use of the “Parent-Adult–Child” metaphor derived from Transactional Analysis (see issue 18). In the last Bulletin, we re-introduced metaphors as a powerful way of understanding organisations. Often these metaphors may be more implicit than explicit, leading to implicit expectations about how people in the organisation will behave and consequent disappointment. Metaphors are tools of enormous but limited value. We need to be able to apply them with discernment and with understanding of their limitations. We need to recognise when other people are understanding organisations from a different implicit viewpoint, with different assumptions. Gareth Morgan (1) discusses eight powerful metaphors that help us to understand organisations:
- Organisations as machines
- Organisations as organisms
- Organisations as brains: learning and self- organisation
- Organisations as cultures: creating social reality
- Organisations as political systems: interests, conflicts and power
- Organisations as psychic prisons
- Organisation as flux and transformation
- Organisations as instruments of domination
All these metaphors can help us to understand an organisation (and they all have limitations). Good doctor-managers will seek to take a number of different points of view as they grapple with an organisational problem. Other metaphors will occur, too, such as organisational diagnosis and treatment! In our book Practical Management and Leadership for Doctors (2) we discuss two of Morgan’s metaphors in more detail: organisations as cultures and organisations as flux and change.
Here we will focus on understanding organisations as cultures. This choice is not arbitrary. One of the authors found the concept of organisations as cultures particularly useful when he first moved into medical management. It helped enormously to understand that different parts of the NHS have different cultures, implying different modes of operation, motivators, success criteria and time frames.
The idea of management cultures first came to prominence following the phenomenal success of Japanese industry after the Second World War. Academics who studied management realised that there were cultural factors at work. Another, more topical, example is the “bonus culture” in banks that preceded the financial crash of 2008. In this case it is possible to make a case that traces the diffusion of American child rearing practice first into American commercial culture and then into the global marketplace. The idea is very simple. Wanted behaviour should be rewarded, preferably with tangible rewards. So, the theorist might argue, the practice of giving children sweets for being good led to the practice of giving fund managers bonuses for doing their job “well” (i.e. securing short term profits). Fuelled by greed, this led to ever more complex schemes for “making money” and then to disaster! Culture, in this case “the bonus culture”, can be very powerful.
Charles Handy is sometime described as the only “home grown” British “management guru”. Indeed the term “management guru” was allegedly coined by a journalist to describe him. Writing at the end of the 20th century (3), he described four dominant cultures in modern organisations. He identified each with a god from Greek mythology (reflecting his own classical education). His scheme undoubtedly over-simplifies but is still incredibly helpful in understanding why different bits of the organisation behave in different ways. Handy also proposed an important theory of “cultural propriety” that suggests that all the cultures are equally valid but that each has its place. To this we would add the importance of cultural sensitivity in the manager. People in different management cultures are motivated in different ways and influenced by different rewards. To extend Handy’s metaphor, the “god” of the “bonus culture” might be called “profit” or “money”.
Table 1 (taken from Practical Management and Leadership for Doctors) lists some of the attributes of the four cultures described by Handy.
|“God” and Culture||Attributes||Best suited to:||Control & Influence|
|Zeus: the “club” culture||Based on knowing (the top) people, makes speedy, intuitive decisions||Small entrepreneurial (often family) businesses. Also found at senior levels in politics!||Personal praise or punishment from the “boss”. Who you know is more important than what you know|
|Apollo: the “role” culture||Related to the “machine” metaphor essentially sees people according to their roles, as replaceable parts in the organisation||Routine tasks where change is minimal and unexpected variation unusual; surprisingly common in the NHS given the amount and pace of change||Impersonal exercise of economic and political power to enforce standards and procedures. Room size, desk size, car size = “status”|
|Athena: the “task “ culture||Focus on the continual and successful definition and solution of problems||Team working to solve problems where complexity and variety are common. A common culture for the clinician. May waste time/resources in routine settings||Personal commitment to the task, rewarded by success. Team members valued for their competencies rather than who they know or their role “labels”|
|Dionysus: the “existential” or “craft” culture.||The organisation is there to enable Dionysians to achieve their purpose.||Situations where individual talents or skills are most important. Also found in clinical practice.||Enjoyment intrinsic to the exercise of skills (which may include meeting the needs of others)|
Table 1 NHS perspective on Charles Handy’s dominant cultures of organisations (from Practical Management and Leadership for Doctors (2)
Handy’s book includes a questionnaire for individuals to look at their own cultural preferences and those of their organisations.
Exercise 1: Consider your own organisation. How does it work at various levels? If you work in a clinical team, does the team subdivide to tackle the tasks around the individual needs of patients or are you more a collection of individualists, each exercising their own skills in the service of patients but without much co-ordination? Do different disciplines in the team work according to different models? What about the immediate organisation you work for? How important is the enforcement of standards and procedures? Do conflicts arise between different cultures? How much scope is there for team working? Are people expected to enjoy their work? How does your organisation compare with the wider health service in terms of its dominant “gods”? How do your own cultural expectations mesh with those of the organisation?
Consider how appropriate different cultures are for different tasks. How do Athenans or Dionysians feel in an Apollonian organisation? What are the vices and virtues of each culture? If you really want to get a grip on this have a look at the book “The Gods of Management” (3) and try the questionnaire in the chapter on “the gods at work”.
Doctors working in the health service often see themselves as “Athenans” or “Dionysians” working in organisations that are still predominantly “Apollonian”. This causes tension. The difference is summed up in different ways that we picture organisations. The typical management diagram is hierarchical with a controlling box at the top and various numbers of layers between the top and the people who actually do the work at the bottom. This kind of diagram is “Apollonian” in Handy’s terms. The picture that more accurately describes the situation from the clinician’s perspective would be a series of concentric circles with the patient in the centre surrounded by their family and carers. The next circle might be the “primary care” services of general practice and personal social services. Around that is a circle of secondary care services and around them again are the commissioners. Finally comes the circle that represents the “top layer” (but the most remote from the patient) the NHS Commissioning Board, and the various inspectorates and standard setting organisations. A picture of this illustration appears in Chapter 3 of Practical Psychiatry of Old Age (2)
However, doctors in management need to have a wider appreciation of the culture(s) of the health service. Handy does not suggest that one culture is “better” than another. He speaks of “cultural appropriateness”. Thus a role culture may be good at regular, repetitive tasks such as paying all our salaries but hopeless at dealing with the complexities of a real-life clinical emergency where the team culture is generally most appropriate. Problems arise when the different cultures do not know their place in the wider scheme of things. One of the tasks for a medical manager is to ensure that cultural appropriateness is not violated. Another task is to understand the different cultures and their different languages (“jargon”) so as to be able adequately to represent one to the other without misunderstanding.
Another way at looking at cultures in Healthcare is to examine the development of Health Services in the UK in the last century. Before the NHS there was a “market” culture, supplemented by various forms of insurance and the individual charitable donation of time to “the poor” by some doctors and organisations. The early NHS was predominantly a top-down organisation with strong elements of role culture but with clinicians relatively free to function independently, a structure we have previously pictured as “bureaucratic dangle” with the various layers of management hardly connecting with clinical teams (or interfering with “clinical freedom”). We have called this a “service culture”. Then, under the influence of economic and political theorists, the “internal market” was introduced, here described as the “commissioner-provider” culture. This was designed to remedy the so called “producer capture” where the “workers” of public service industries were (somewhat insultingly) seen as running the business for their own benefit. Gains in efficiency were also predicted (though the long term efficiency of markets in healthcare must now be in some doubt). It has been taken a step further in recent years with the deliberate (and de-stabilising) opening up of health care provision to “for profit” organisations. Finally, running alongside this evolution, we have the wider phenomenon of the consumer culture. Table 2 gives a much simplified account of the characteristics of these different cultures. As the English NHS evolves, the consumer model, as presented here, is essentially a market model with service commissioners (and individual General Practitioners) acting as moderators and purchasers of service on behalf of consumers.
|Who “knows“ best?||Buyer||Provider||Commissioner||Service user|
|Who disposes of resources?||Buyer||Provider||Commissioner||Service user limited by commissioner|
|Who is in charge?||Buyer||Provider||Commissioner||Service user (in theory!)|
|Some advantages:||Good for those with lots of money||Providers do know more. Needs altruism in workers to work well.||Interests of different stakeholders considered||Service user is “empowered”|
|Some disadvantages:||Bad for those who are poor||“Producer capture”- run in interest of workers not users||Costly extra layers of management Duplication of supporting functions||Costly extra layers of management. Service user empowerment may be illusory|
Table 2 Evolution and Development of dominant cultures in English Health Services
The overall structure of the Health Service is (some would say unfortunately) a matter for politicians. However, as NHS leaders and managers we can do our best to ensure that, in our area of influence, the organisational culture is understood and developed in the most appropriate direction possible. Consider also how control and influence are exercised in different parts of your organisation and how explicit understanding can help make you more effective. Consider also how an inappropriate understanding can cause unnecessary conflict and offence. Finally think about the implicit values behind different cultures and how they can also cause hidden conflict. Remember that as a manager your job is to work with the world as it is, as a leader you may also be privileged to change it a little!
1. Morgan, G. Images of Organizations. London : Sage , 2006.
2. Wattis, J and S, Curran. Practical Management and Leadership for Doctors. London : Radcliffe, 2011.
3. Handy, C. The Gods of Management . London : Arrow Business Books, 1995.