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The NHS is the UK’s national, now subject to Scottish and Welsh local control, health care provision, covering everything from serious hospital treatment to local doctors.  Created in 1948, it is the largest organisation Europe and the fifth largest in the world! No surprise then that there are a few management difficulties.
It is difficult to discuss an organisation of 1,330,000 people as a single entity but a systems view of the NHS raises some interesting points.
My interest was sparked by an article in The Times (July 5, 2007) regarding the second review (in two years) aimed at boosting staff morale. Given that GPs’ (local doctors) salaries are now up in the £250,000 pa bracket I wondered if this was proof that money doesn’t motivate!
Alan Johnson, the Health Secretary, reportedly said “We’ve put a lot of money in, but that hasn’t led to a lot of happy bunnies”. These are the unhappy bunnies we trust with our lives!
It seems that medical staff, like scientists, lawyers and other professionals, believe the task of management simply does not exist. Professionals know what is right and how to best achieve it. They are so steeped in their technical speciality that no other viewpoint stands a chance. There is a deep chasm between the technical staff and the management/administration in most organisations. The medical profession seems to be the most extreme. One has to ask why.
Medical staff make life or death decisions every day. There will never be enough money for everything for everyone. Although there is very little public discussion on the morality of withholding treatment, it is the routine practice to deny treatment to those who will benefit less by dint of age, weight, unhealthy habit, survival rate or even local supply constraints.
This has to be an emotionally upsetting decision to make. The health care professionals will either suffer emotionally with every loss or become hardened to the situation and lose empathy with their patients. This loss of empathy is an established characteristic in the police and prison services.
Consider the feelings of this group of intelligent, hard-working, caring people living with denying treatment to people due to lack of resources, basically lack of money.
Imagine the frustration at spending resources on reporting targets, which show great improvements, when you see the truth every day. Then to make matters worse, their own substantial pay rises mean lack of funds to maintain services! How do the medical staff feel then? Now they are part of the problem as they are taking some of the funds that could have been spent on patient care. Only the very strong willed will be able to resist switching their thoughts and feelings to maximising pay and viewing the patient’s treatment as targets to hit. Festinger’s Cognitive Dissonance theory says you can only hold contradictory beliefs for a short time.
These are caring people and their consciences will not let them forget – no wonder they are not “happy bunnies”. These words must have caused a surge of rage at the lack of understanding shown by their bosses.
One has to pity Sir Ara Darzi who has been asked to conduct this year’s review of the NHS.
It is just not conceivable that an organisation of this size and complexity can be fixed by someone saying “ah ha, it’s obvious we should do x, y and z and all will be well”.
 Sadly this is the model of change in the UK’s national services. Someone, with the ear of our servants in government, has an idea and we spend tens of billions of pounds changing everything to the new way, with insufficent evidence or experience that it is a good idea in practice! How about allowing different areas to experiment and encouraging diversity?
In fact what we need is for the medical staff to be motivated to behave in a way that supports the objectives of the organisation – which may be different from their professional motivation.
There needs to be strong management to insist on this appropriate behaviour and improve productivity dramatically (because more people should be treated). Why not create competing solutions through local experiment? Some will be better served than others as better ways of working are found. Is that not preferable to everyone receiving less health care than is practicable? The best methods can be adopted and the experimentation allowed to continue.
When Matrons had control of their wards they were clean and MRSA was not a public threat (a 10% bleach solution kills MRSA). That proven, effective local control was lost. We need local control, local experimentation with the “local management” subject to local accountability.
This means elected local health provider management boards. The voting public will then be responsible for choosing from competing manifestos and the life-or-death finance based decisions will be a matter of public choice.
Unfortunately the UK has shown a corporatist, centralising trend under governments in the last 30 years and losing centralised control of the NHS is not on the agenda.
The NHS is too important to be left to the mercy of remote politicians, bureaucrats or medical staff.
Time for strong management with local accountability.
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