Steadying the NHSBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7561.254 (Published 27 July 2006) Cite this as: BMJ 2006;333:254
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Tony Watson advocated a model describing the nature and tasks of
management. The external and internal view of an organization should be
balanced. Integration should facilitate differentiation through a
continual assessment of the Structure Strategy and Control systems of the
organization. Heavy top down management from government to board level,
however is focusing all the attention on externally imposed targets.
Little thought is given to the internal needs of the organisation.
Indeed, integration is overbearing and the drive for standardisation is
stifling the differentiation.
Henry Mintzberg identifies four almost opposing forces in a hospital
that Degeling attributes to ?colonization ?. Process thinking is alien to
the Doctor, Manager, Nurse and Patient who are conditioned to a system
that likewise does not facilitate collaborative and systems thinking.
Tony Watson?s model as applied to the NHS and the hospital is less
than balanced. External focus overshadows the internal needs of the
individual, team and organization. Control through stifling integration
fails to allow for the differentiation concomitant with socio-
technological advancement. Our Health Care has inherited structures,
strategies and control systems that fundamentally have not been reviewed
since inception and the culure and meaning of our work is lost.
Marx coined the term alienation - it is an apt term to apply to the
highly skilled and dedicated workforce of the NHS. There is a lack of
pride in workmanship as the workforce, as described in Demmings work, is
,'bruised battered, denigated and demoralised by the target driven culture
promalgated by automatons and beaurocrats. We are suffering from the
'structuration' described by Giddens.
Lastly, I believe it is becoming an oxymoron to refer to our health
care institutions as TRUSTS - do we really TRUST our staff!
1 Watson T. Organising and managing work. Prentice Hall, Financial Times, 2002.
2 Mintzberg H. Managing care and cure- up and down and in and out. Health Services Management Research 2002;15(3):193.
3 Deming WE. Out of crisis. MIT, 1982.
Competing interests: No competing interests
The NHS ‘sick’ but not terminal?
By Dr Mary Belshaw
My cancer experience
When I was diagnosed with early breast cancer 2years ago, despite
being covered by private health care through my husbands work, I decided
to opt for care under the NHS. I did not feel that I would get
comprehensive and joined up care in the private sector without travelling
long distances from my home and thought that the NHS would offer a better
quality of care for both major emergencies and acute conditions such as
cancer. I was wrong.
I had 12 months treatment under the NHS (diagnosis, surgery,
chemotherapy and radiotherapy) and a further 12 months treatment in the
private sector. (for intravenous Herceptin). The NHS failed to fund
Herceptin when I needed it. My local PCT trust agreed to fund Herceptin
for early breast cancer 6 months after BUPA agreed to fund it but this
would have been to late for me.
As a GP I had prior knowledge and some advantage about the workings
of NHS especially locally and this proved to have both advantages and
disadvantages. I had no significant contact with health care services
prior to my illness but I have been a lifelong supporter of the NHS and
had never considered the need for private health care.
Health care in the private sector
I have had a unique opportunity to compare both systems though I am
very aware that without the support of the NHS in training doctors and
nurses and providing the capital for the major equipment such as
radiotherapy suites the private sector could not be sustainable except in
very large regional centres.
My experience in the private sector was of a very swift response to
funding for Herceptin from BUPA. BUPA reviewed the HERA trial results and
agreed to fund Herceptin within 2-3 weeks whilst my local PCT took six
months before agreeing to fund Herceptin for early breast cancer.
The care I have received from my oncologist (same as NHS oncologist)
and the nurses on the chemotherapy ward has been excellent. I received
practical, emotional and comprehensive care from mainly one nurse at a
local hospital where I could park at 15minutes drive from my home. She
coped with a difficult cannulation and appeared to do the job that several
different nurses did in the NHS. (Ward nurse, breast care and chemotherapy
advisor rolled into one). I did not have to cope with seeing patients with
more advanced cancer or overhearing other patient’s consultations.
My care on the NHS
On the NHS the quality and speed of diagnosis by my GP and the
hospital team was excellent and swift. The standard of nursing on the
surgical ward and care during radiotherapy treatment and from my
oncologist has been excellent. There was a 10 week wait for radiotherapy
on the NHS but as I requested being listed for this whilst receiving
chemotherapy I had radiotherapy at the optimum time. The waiting list to
see the oncologist could have been weeks without care for the efforts of
the breast care nurses who re-giggled a clinic for me to be fitted in. The
quality of my surgery was excellent thought the surgeon lacked the skills
to cope with the emotional side of cancer.
The number of nurses involved in the care during my chemotherapy was
approximately 16. There were 3-4 breast care nurses, 3 chemotherapy
nurses, a research nurse and 6-8 nurses on the chemotherapy ward who
actually gave me the treatment. The different roles and continuity of care
within this large network was quite confusing even for me as a GP to
understand. The Foundation hospital was 20 minutes from my home and
parking was very difficult and cost £2 for any duration of stay.
All the staff worked under extreme pressure and the nurses on the
chemotherapy ward did not take meal or other breaks and some showed signs
of stress. The telephone lines for the breast care nurses were frequently
engaged or on answer phone. The NHS had all the signs of working under
severe pressure and I felt the service was swamped by cancer cases. All
the nurses spent a lot of time doing administration, chasing up
appointments, pathology results, pharmacy and doctors.
The chemotherapy ward was very busy and patients with early breast
cancer were mixed with patients with more advanced cancer and
consultations with doctors were sometimes made with lack of privacy on
open wards whilst patients are receiving treatment. My oncologist usually
saw me in a private room.
Back to work as a GP
After taking 11 months of work I went back to work whilst on
Herceptin treatment in an over heated ‘sick’ new NHS, LIFT, health centre.
(Targeted to be built and running very quickly before the last general
Back at work I am beginning to feel battle weary. Some things have
improved and the 2 week rule for cancer referrals is one notable example.
In other areas especially in the areas of chronic diseases and prevention
the NHS is noticeably failing patients. GPs and patients continue to
experience extreme difficulties in accessing secondary health services for
the mentally ill and other chronic illness. The waiting list and lack of
services of children with mental health problems is a national scandal.
The almost routine descriptions by patients of poor standards of care and
low moral on NHS wards are a constant back ground to my GP consultations.
The bureaucratic nightmare of choose and book is causing confusion for
patients and extra work for GP surgeries.
Hospitals are arranging follow up appointments for patients at
arbitrary times in the future which appear to be quite unrelated to
clinical need. (No doubt responding to further government targets.) The
PCT in order to keep their star status implore us to keep our 48hour
access targets and helpfully tell us on which days they will telephone to
check when the next appointment will be available. Our reward is several
thousands pounds and the PCT keeps its star and the PCT chief exec would
keep his/ her job (except he/she doesn’t want it because of being on long
A sojourn in communist Russia
Around fifteen years ago I spent 3 hours in Moscow Airport canteen
with a breakfast voucher waiting being served a breakfast. There was a lot
of activity and lots of trolleys with food on past me but unfortunately I
missed the plate and cutlery trolley which perhaps had passed 30 minutes
before I arrived at 60a.m. After a 3 hour wait no one was willing to
serve me and I snatched an egg from a parked trolley. Lots of others left
hungry. Moral was very low and the staff took a long break at peak
breakfast time. Sometimes I see parallels in our large and bureaucratic
The NHS today
I am very cynical about NHS targets which can only measure figures.
All healthcare workers and managers are aware that these figures can and
are routinely manipulated by NHS PCTs and hospital trusts. The target then
becomes the chief executives keeping their own jobs and hospitals and PCTs
gaining the desired star rating.
The two chief executives of our local PCT and hospital trusts have
been on long term sick and retired early (rumoured to be stress)
presumably due to the stress of being unable to achieve the unachievable.
Meanwhile the ‘immeasurable’ quality indicators such as staff moral,
(low), physiotherapy on neurology wards (cut), nurses to look after and
feed the sick and elderly (cut) continue to decline. There is a
widespread belief amongst the workers on the coal face (doctors and
nurses) that the emphasis on targets hasn’t improved patient care.
The latest NHS funding crisis has resulted in both doctors and nurses
redundancies and a freezing of many posts with resultant unemployment for
many newly trained nurses and midwives. Doctors in training have been left
in the lurch at short notice about training posts. This and random, purely
commercial cuts in services have brought the secondary care services to
the lowest point I have experienced in the whole of my 25 year career in
The use of the words ‘funding and care crisis’ is so routine in the NHS
that it has almost become routine language for NHS workers and the
press to use. But this is what it means from personal experience as a GP
The BMJ analysis and comment on the subject of NHS independence of
29th July is very timely and the comments about steadying the NHS were
particularly relevant. The NHS still has many great qualities but the
greatest is the dedication of its workforce.
The NHS is being meddled with too much to score political points and
money is being wasted on achieving targets of dubious value and in double
payments for many services (when the private sector is used to help
achieve NHS targets). A whole generation of young doctors and nurses in
training have been disillusioned and have now lost the only redeeming
feature of NHS work, which is job security. These doctors and nurses may
be lost from the NHS for ever. We have certainly and inevitably lost their
confidence and goodwill. Enough is enough. It is time for a radical
rethink about the how the NHS is both funded and managed.
The doctors and nurses who devote their careers to the NHS and the
majority of patients who rely on the NHS for their health deserve better
than this terrible mess.
Competing interests: No competing interests
One warms to Donald Berwick's steadfast support for the NHS,
eloquently expressed again now. We forgive him for his error and that of
the other authors in this series of articles in writing about the NHS as a
UK model when commenting only on the NHS in England as directed from
Westminster. The NHS in Scotland, in particular, is different in many
There is of course a need to survey and audit the differences with
the other home nations and I communicated that suggestion to the authors
of a paper last year (Richard G A Feachem and Neelam K Sekhri Moving
towards true integration BMJ, Apr 2005; 330: 787 - 788) about the NHS in
England. They too seemed unaware from a distance that England is not the
In Scotland, I was glad that two reforms ago when we got Local Health
Care Cooperatives, they had no commissioning responsibility. There was
enough to do without that. Just when LHCCs had matured and might have
taken on that challenge, reform has produced Community Health Partnerships
which in my area have yet to have a whimper of a profile some 18 months
after their birth.
Competing interests: No competing interests