If markets or management aren’t the remedy to the NHS mess, what is? Valerie Iles sees an answer coming from unexpected quarters.

In the previous issue of Mint Magazine Laurie Langton-Langbourne ascribed the problems of the NHS to neoliberalism, singling out three facets for special blame: marketisation, privatisation and underfunding.  In doing so he followed a long line of economists diagnosing the ills of health systems and prescribing solutions from within their particular economic drug cupboard. As always there are elements of those arguments that can be helpful – and some that can be misleading – and to understand which is which we need to explore the particular features and dynamics of health and health care that distinguish them from many other areas of life.

“As patients, our increasing longevity, and our accompanying sense of entitlement to it, sits uncomfortably between our sense of consumer rights and our deepest existential fears.”

On looking at those features, five observations become clear:

  • the emotional and behavioural dynamics of care are understood better by sociologists and anthropologists than by economists;

  • economists treat complex situations simplistically;

  • economists apply simplistic versions of Left and Right ideology; and

  • economists don’t truly understand the role of the NHS in people’s lives.

If we examine each of these observations in turn we can get a better picture of where the solutions to the NHS’ problems may come from.

Dynamics

Newcomers to NHS boards are often amazed at the behavioural dynamics within healthcare organisations. While Sir Lancelot Spratt – the pompous chief surgeon played by James Robertson Justice – is thankfully no more, differences in status between different specialties and roles still influence discussions every minute of every day throughout the health service. Yet almost no economists factor this into their recommendations.

“Newcomers to NHS boards are often amazed at the behavioural dynamics within healthcare organisations.”

Status used wisely is valuable and in any case we can’t destroy it. But we need to observe its impacts rather than pretend it doesn’t exist. Economists and managers rely on organisational hierarchies and logic-based decision-making which do not apply here as they do elsewhere because, whether as NHS staff or as seekers of health care and funders of the health care system, we do not allow them to.

Are status differences irrelevant? Or are you immune to them? Suppose you had to choose between funding urgently needed kit in Accident and Emergency (A&E) or extra staff on a psychiatric ward for the elderly or cancer treatment or child and adolescent mental health services?[1]

When we look, we find that throughout the service some groups of staff and some specialties of care are higher in social status than others. And although this is widely experienced it is almost never voiced in constructive ways. Instead it influences decisions in a way that is innately understood (to insiders) but unsayable and hence invisible to those advising from the outside.

“We can only ‘muddle through’ as elegantly as we can.”

Tasked with bringing good management practice to the NHS in the 1980s, the then managing director of a successful supermarket, Roy Griffiths, removed the then management teams of doctors, nurses and administrators, and replaced them with a single general manager. His rationale was that “if Florence Nightingale were here with her lamp today she would be trying to find out who is in charge”. And indeed decision making did become quicker, the complex dynamics that those team members had represented (and embodied) no longer prolonged discussions. Implementation though was a different matter: without all the pre-decision negotiation there was resistance, misunderstanding and withdrawal.

How do these particular behavioural dynamics arise? Health care professionals (HCPs) are no brighter than those in many other industries, nor are they more altruistic. The technical complexity of the heath care task is also no greater than in many other fields. (It’s worth noting that engineers save as many lives as doctors in equally fascinating careers).

Yet these the same hierarchies persist in health systems around the world. Perhaps it is to do with the nature of health itself, of its relationship with life and death, with fitness and disability. In other words the “asymmetries of information” in health care are present in the most meaningful of things. As patients, our increasing longevity, and our accompanying sense of entitlement to it, sits uncomfortably between our sense of consumer rights and our deepest existential fears. As HCPs we are caught between our desire to do the best for our patients and our irritation at their expectation of fast-food service levels.

Insight into this matters because these dynamics affect everyday decisions in subtle and not so subtle ways, and lead to behaviours and dynamics quite unlike those in other industries. These dynamics are amenable to research and reflection – but by sociologists, anthropologists, ethnographers, some psychologists, even some philosophers, and relevant historians. The lens of the economist does not easily accommodate the particularities observable by others; their lexicon (even that of behavioural economists) cannot deal with these emotional and behavioural details.

In other words economists need a depth of insight currently missing. And not only in the area of status.

Complex situations

In the 1970s  influential systems theorist, Russell Ackoff, observed that situations can be described as puzzles, problems or messes.

A puzzle, he said, has an answer, a right way forward. You may need research to find it out, but there is a right way to go.  Problems have no right answer, but better and worse ways of approaching them. Here research is less definitive and guidance from experts is helpful.

A mess is a complex system of multiple interacting problems and puzzles. Here there is no right or wrong way forward, we can only “muddle through”[2]as elegantly as we can. We move a step at a time, sometimes forwards, sometimes sideways or back. We may have hopes of arriving at a particular destination, just as often we are trying to move away from the existing situation to a better one without knowing exactly what that is. In a mess we make a move, not certain what will happen next. Others may look back later and see that action X led to situation Y and ultimately to outcome Z but that is “spurious retrospective coherence” that is not predictable in the moment of taking the decision.

“It’s fair to conclude that managerialism is a much more dangerous aspect of Neoliberalism than the threats of marketisation and privatisation.”

In health care we encounter many puzzles, and here evidence from Randomised Controlled Trials (RCTs) can lead to useful, pre-defined pathways of care, and to audits of how well staff are implementing those pathways. We also come across many problems for which, with experts’ advice, we develop guidelines that can be audited but with a lighter touch than the pathways arising from RCT evidence. In tackling these problems, conventional management practices are helpful.

But much of healthcare involves messes and here the standard management practices have little place. Evidence from RCTs is almost useless and there is justifiable resentment of a “tyranny of evidence”. And it’s the use of such practices to address a mess that leads to the disparagement of management and the charge of “Managerialism” [3]. In a mess we cannot manage by pathways, protocols and numbers. They will contribute but they must not take precedence over helping people develop and use their abilities to muddle through as elegantly as possible.

So in our impatient and data-driven age, The NHS – like other sectors – is increasingly treating messes as puzzles. Managers are not taught how to manage people through relationships and conversations. Instead they are encouraged to manage performance using data dashboards. When things do not work out well, instead of investigating and illuminating the constituents of the mess in question (to aid elegant future muddling) we look for people to chastise and blame.

It is this treatment of messes as puzzles that leads to managerialist tropes such as:

  • league tables to identify relative performance of different hospitals or schools;

  • choice and competition – usually quasi competition and under-informed choice –  where a market is called upon to do the work of thoughtful resource allocators working to a broad, multifaceted agenda;

  • care being seen as a consumer good, with its consumer champion – the national Healthwatch committee; and

  • the skills mix being radically and inappropriately impoverished, because efficiency studies ignore the quality of judgment that lies behind the tasks undertaken.

Nevertheless these exercises can provide useful challenges and there is still a need to overcome the self-righteousness of many involved in health and social care. While managerialism has assumed a dominant position in the US and UK, it appears to me to have been used more thoughtfully in other European and Nordic countries. In this, I suggest, it parallels attitudes to Neoliberalism.

So it’s fair to conclude that managerialism is a much more dangerous aspect of Neoliberalism than the threats of marketisation and privatisation in Langton-Langbourne’s diagnosis.

While Griffiths was an early proponent of increasing the reach of managerialism, it progressed apace during the ‘80s and ‘90s, throughout the economy. In the NHS underfunding – as Langton-Langbourne was right to observe – certainly exacerbated this. Every time efficiencies were called for, staff numbers were cut and, to “protect the front line”, posts seen as managerial were among the first to go. Naturally the work those managers did disappeared with them, including the most important part of their role: supporting, challenging and enabling front-line staff to be the clinicians they aspired to be.

This was a huge loss – shared by industry as a whole – as organisations shifted from managing people to managing performance. The impact on motivation, competence, care and performance is being felt across the whole public sector, indeed the whole economy – it is probably the largest cause of our inability to increase productivity – but nowhere more so than the NHS.

How have fallen prey to this? Perhaps because of our first-past-the-post two-party political system?

Left and Right

Over the past four decades there has been a persistent diagnosis from the political Left, that “the NHS isn’t performing, it needs more money” while the Right has judged “the NHS isn’t performing productively what it needs is the pressure of a market”.  Over the decades the truth has swung from one to the other, and occasionally aligned with both.

So from the Right we have seen ever more resource-hungry layers of quasi-market structures and an unsubstantiated belief that outsourcing is more efficient than in-house provision. It’s a belief that is only possible to maintain by failing to include costs incurred elsewhere in the system.

From the Left we saw the visionary Blair-Brown expenditure on the NHS become tragically mis-implemented under the excessive Managerialism of Alan Milburn. Brilliantly ambitious targets were set: 18-month waiting lists were to be reduced to 18 weeks and a visit to A&E should not take more than four hours.

 With the right organisational climate this could have been the challenge of a lifetime, and one we would still be celebrating. However, to achieve this, individual hospital chief operating officers were held personally accountable for implementing the targets with their whole career on the line if they failed. This, in hospitals employing thousands of staff, most of whom they did not manage, and who had nothing to gain from the shortened wait. This is what led to lines painted on the floors of A&E so that people could be discharged within the four hours by being moved to the other side of it. And instead of redesigning inpatient systems, the extra money was used on additional capacity, replicating existing design flaws. Naturally as money has shrunk again this additional capacity has shrunk too and the results are becoming obvious.

The aims of both sets of politicians were no doubt honorable, and with the kind of sensitive adaptation that would have taken place in a different political system –where compromises need to be made between parties – they could all have stood a chance. Applied with bullish vigour and little cross party scrutiny, they did not.

But there is another feature of our health system that gets in the way.

Understanding

For an organisation described as the nation’s religion, we understand very little about the role the NHS really plays in the lives of our population – including the people who use it and those who simply know it is there. Even those working in it can see it very differently when they themselves become patients, and we know almost nothing about the beliefs hopes, and expectations of the other 64 million of us.

Our wishes are invoked by senior NHS strategists when it suits them, but without any good evidence. For example we are now often told that what we want is “care closer to home”. This usually accompanies proposals to close local hospitals in favour of specialist centres with much more care supposedly moved into the community. Arguments then rage with local politicians siding with public protestations, often whipped up by campaigning local newspapers.

Neither side in these disputes has any real understanding of what it is members of the public want from the NHS or what it is they are thinking when they say the NHS is wonderful. Is it just that it is free?

There are lots of ways of making it free. Is it that we trust its staff because we do not think they are advising us in their own financial interests? Is it that we believe the entire NHS budget goes into direct patient care that it is better value for money when there are no shareholders, even though we know almost nothing about how the money is actually spent? Are we losing confidence in it as our general practitioners become less accessible? We all have opinions but we just don’t know.  No-one does.

The research to find this out would need to be sophisticated and multi-method. It would require considerable time and resource, and, because this is not a puzzle, the results would be contested. They would be enlightening, helpful, definitely worth having and using, but could not be neatly divided into the tidy “health needs” relied upon by economists and managers.

Clearly the way to overcome the shortfalls of managerialism and is through information; credible, relevant information about real services and real people.

High-status HCPs resist collecting data for managerialist information systems but history tells us that if data already collected for clinical purposes, can be aggregated into information about their service, they can become excited about it.

This is the complete inverse of the misconceived managerialist, NHS-wide computer system that hit the rocks and cost billions a few years ago. It is much more akin to experiments undertaken as part of a resource management initiative in the 1990s before the neoliberal take over and then Prime Minister, Margaret Thatcher’s, introduction of the purchaser-provider split.

Not that a split was a bad idea; before it, many hospitals were offering services that appealed to the career interests of their clinicians but failed to meet the needs of their communities. Some sort of challenge was needed.

Imagine though, instead of managers battling with each other about contracts based on tariffs set nationally, that clinicians met with teams of information experts, drawing on data from around the country and across the globe, to discuss population needs, epidemiological trends, patterns of service and outcomes, real costs, and an in-depth understanding of patients longings and of the way they perceive their relationship with the local NHS.

Handled skillfully at a number of different levels (team, specialty, organisation, locality and so on) this could enable or prompt the kind of challenging, motivating conversation that would enable services to make the very most of their resources, and develop a different, more valuable, relationship with patients, colleagues and managers.

Yes, it would be very different from the relationships we have today, perhaps more akin to those within the newer organisations such as CLAHRCSand AHSNs, where clinicians actively and enthusiastically explore new and different ways of doing things.

All this requires an understanding and discussion of the NHS (and any health system) so much richer than even a broad understanding of economics provides. For all the reasons given here, health care needs the analysis of sociologists, historians, ethnographers, philosophers, information scientists, and so many more, to provide a multidimensional focus on what is peculiar and particular to this special area of human life.

References:

[1] The behaviour of our politicians (astute enough to know public priorities) is indicative see this article.

[2] The Science of “Muddling Through”,  Charles E. Lindblom, Public Administration Review, Vol. 19, No. 2 (Spring, 1959), pp. 79-88, Published by: Blackwell Publishing on behalf of the American Society for Public Administration

[3] Henry Mintzberg prefers the capital letters as he notes the inappropriate dominance of such approaches

Valerie Iles

Valerie has an in-depth understanding of management and leadership theory, a breadth of practical experience of the behaviours and dynamics of healthcare organisations and a wide-ranging interest in other fields …

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