Who's kicking who?
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38967.410428.68 (Published 21 September 2006) Cite this as: BMJ 2006;333:645
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Doctors have always had to do some management including time
management. If the current trend continues in the NHS those with pure
clinical/academic accomplishments will find themselves more and more
side lined in favour of career medical managers who are experts in
committees but not so expert in some of the fields they are
representing.Most of these managers have the right to
overrule you even in matters of vital interest to your departments. It
is time we looked at this for the future of those who are mere frontline
staff. There have always been several good and bad models for management.
One is the Japanese model where employees feel they belong to a large
family and every one works towards its improvement. They are rewarded
by being looked after. The fault with this style is that many may
just stumble along without need for improvement. There is then the US
model where merit is rewarded and you stand or fall by your
accomplishments. Here individual talents are nurtured. This is
generally what is followed in the private industry.
The NHS however is developing its own ethos of picking those who
follow the line and rewarding them and ruthlessly eliminating other
voices. Such a system would strangle intellectual vibrancy and those
who want to improve themselves and their departments may find
themselves seeking askance elsewhere. This is a man made or manager
made tragedy of the modern NHS.
Jayaprakash A Gosalakkal
Competing interests:
None declared
Competing interests: No competing interests
Nigel Hawkes states that in the third phase of the Government's
reforms, it has "reinvented the market mechanism".
If true, this might be welcomed. But one is reminded of the way, in
the Lord of the Rings, orcs were described as having been invented in
mockery of elves. The current "market mechanism" is a clunky and
grotesque parody of what was gradually developing in 1990-1999 and in no
way resembles a true market.
In a true market, change takes place at the margin. A new business
(eg Next, Top Shop) can grow fast, while their rapid increase from a small
base only implies a small drop in activity for huge existing businesses.
Likewise, a single GP practice sending a few patients to a private
hospital, which may send a message to the local DGH but will not
immediately cause wholesale redundancies. But if the new model is better,
it will gradually replace the old one.
Labour, in opposition, did a huge disservice by promoting two
false criticisms of the process of change. These were "the two tier
system" and "postcode rationing". By contrast, trying to impose
uniformity means that (a) change is sudden, indigestible, and possibly bad
and (b) local autonomy is not possible.
The usual criticism of markets in health care is that the patient is
not a rational consumer. I submit that the GP is a rational consumer, and
that practice level is the correct ethical and economic level for resource
allocation decisions to be made. Commissioning care on the basis of whole
counties or districts has been tried before and has failed. Practice based
commissioning will only contribute to healthy change in the Health Service
if it is truly practice based and resourced. For this to happen, the
government's intellectual journey away from command-and-control has one
more stage to go.
Competing interests:
None declared
Competing interests: No competing interests
Sir
Nigel Hawkes is to be congratulated for his timely, highly readable
and informative article and the BMJ for continuing to publish topical and
political pieces, which can be cited in any discussion on service delivery
in contrast to some "drier" competitor journals.
As an NHS clinician, I am naturally delighted at the extra investment
put into the NHS by New Labour and completely understand the desire of the
politicians to see some tangible outcomes for this investment and equity
of care (hence the until recent obsession with measureable targets -
however little the "tick box" mentality reflected what was really
happening to patients and however distorting the attendant perverse
incentives). All the same, Hawkes is quite correct in saying that the
elected government has effectively spent a decade re-inventing the
organisational structure it inherited in 1997.
Not only has this been a hugely wasteful process but it has by its
nature created general management posts whose whole rationale is change
management, process reengineering, or more precisely the demonstration
that these imperatives and milestones have been met. It is hard to
conceive of patient care without frontline clinical staff to deliver it,
essential ancillary staff to support it and a core of general managers to
run the operation. However, there are many other posts which would not
even exist without constant change management to oversee or without the
externally imposed structures (such as parallel commissioning by small
PCTs now amalgamated). Despite repeated assertions that the NHS is
undermanaged our yardstick should be to cull all posts whose whole
function is an entirely artificial construct and plough the money into
clinical and support services.
Many of these staff come from clinical backgrounds and have therefore
abandoned their original professional calling and find themselves in a
conflict of interest with their own profession, as well as removing
themselves from the bedside where their skills might provide more tangible
benefit. They are also performance managed on meeting organisational
objetives and therefore face the choice of being "corporate" or "on
message" or making no further progress. Questioning the sanity of the
latest round of performance objectives would be career suicide. Their
rationale is to implement whatever imperative comes down stream.
In the meantime [1] it is alleged that the government have spent £70
billion on private sector management consultancy (money which if kept
within the public sector could have averted the latest round of financial
crises in acute trusts) and more on the sacred cow of PFI.
Real transformation in public services is brought about by the staff
who actually deliver those services. As Maddock [2] said in an article
which everyone should read on transformational leadership in the public
sector. "Those with an understandind of the change management process have
no power to effect real change. Those with the power have little
understanding of the change management process"
David Oliver
[1] "Making Modernisation Work - narratives, change strategies and
people management in the public sector", 2001, Su Maddock. University of
Manchester Business School.
[2] Craig D.[2005] Plundering the Public Sector. How new labour
stole with £70m of your money and gave it to management consultants.
Competing interests:
None declared
Competing interests: No competing interests
The question "Who's Kicking Who?" was once put more grammatically and
with even more brutal brevity by one of History's most compulsive power
addicts - Vladimir Ilyich Ulyanov, aka Lenin,in his famous almost
Einsteinian reduction of all Politics to the simple formula:-
"Who Whom?" ie Who has the power over Whom?
This maxim was even more graphically expressed by his successor, Josef
Stalin, who once remarked "No person, no problem!"
Even after tens of millions of deaths, this successor was still
finding problems...
Competing interests:
None declared
Competing interests: No competing interests
We will go where we please, we will discuss what we like and we will
never be brow-beaten by bullies. That's what it means to be British."
Dr John Reid at the Labour part conference.Manchester 2006
"I always humbly ask my Party Secretary for instructions and never indulge
in the luxury of taking the initiative. I carry out his instructions even
when I know them to be wrong. At meetings I never speak unless told to do
so. Then I simply repeat whatever was said by our Group Leader or the
Party secretary." (Life and death in Shanghai.Nien Cheng) as quoted by Dr
Rod Storring
I wonder what is closer to everyday reality for most hospital doctors
in the NHS? Dr Reid tells us in Britain we have the right to discuss what
we like but that right is pretty useless if others have right to deprive
you of what is rightfully yours for expressing that right. We are said to
have the right not to be brow beaten by bullies. Again it depends on who
is monitoring this right of ours and whose side these authorities are on.
The kicking goes on and the author is right in saying that there are
two sides, the kickers and those being kicked. I however do not believe
that this was all truly intentional but that the Government and others
stumbled into the current morass and are looking for a way out. A start
would be to consider those who have learned medicine and specialised in
its application as friends in this task and not as those who have to be
shunned.
Regards
Jayaprakash A Gosalakkal
Competing interests:
None declared
Competing interests: No competing interests
When I applied for medical school there were still some colleges
which required Latin O level. I failed Latin O level, but I passed
English. To kick is a transitive verb. The subject should be in the
nominative case and the object in accusative. Few nouns in English are
inflected, but personal pronouns are. He does not kick I, he kicks me.
And I do not kick he, I kick him. Whom do I kick? Not who.
I thought that this is what subeditors are for. I find this sort of thing
lamentable in tabloids. I think that a journal which aspires to some
degree of learning might be expected to conform to some canons of grammar.
Competing interests:
None declared
Competing interests: No competing interests
Hawkes[1] provides one of the clearest accounts of the barrage of
politically motivated changes the NHS in England has ever had to endure.
This outstanding article cuts through political correctness, pointing out
the true motivations for recent government policy – money, power and
control.
The rushed implementation of proposed changes to postgraduate medical
education are a particular concern[2] and serves as a pertinent example.
One of the five key principles for reforming senior house officer
training, originally set out by the Chief Medical Officer in August 2002,
was that ‘training should allow for individually tailored or personal
programmes’.[3] In other words, doctor choice.
However, Modernising Medical Careers material published 18 September
2006, regarding online application into specialist/GP training states that
‘specialty trainees will be able to apply for two specialty groups and two
units of application (UoA) for each specialty’.[4] This reverses the
current position of doctor choice and flexibility of speciality and
location, to one of inflexible and limited choices – allocation. The
prospect of being forced to move at relatively short notice, particularly
difficult for those with families, to any location within the four UK
countries, in order to work or train in possibly an undesired specialty,
reminds doctors who is doing the kicking. Ultimately, poor morale and lack
of interest in one’s specialty will result in a deterioration of patient
care.[5]
[1] Hawkes N. NHS reorganisation: Who's kicking who? BMJ 2006;333:645
-48.
[2] Allan R. Modernising Medical Careers. Clinical Medicine
2006;6:229-30.
[3] Department of Health. Donaldson L. Unfinished business. Proposals
for reform of the Senior House Officer grade. London: DoH, 21 August 2002.
[4] Modernising Medical Careers. Training Tomorrow’s Doctors. An
Update for Applicants to Specialist/GP Training 2007. Published 18
September 2006.
http://www.mmc.nhs.uk/download_files/MMC%20presentation%20for%20applican...
(accessed 25 September 2006)
[5] Grunfeld E, Zitzelsberger L, Coristine M, Whelan TJ, Aspelund F,
Evans WK. Job stress and job satisfaction of cancer care workers.
Psychooncology. 2005;14:61-9.
Competing interests:
None declared
Competing interests: No competing interests
Nigel Hawkes’ description of English healthcare is uncannily
accurate: painfully so for those of us that have given much of our time
(the best years of our lives?) to supporting the “New NHS”; for which, now
read the “Old NHS”. He is right to identify the “Kicking Hierarchy” as
being important.
I have often wondered how it is that we are all so proud of the
“National Health Service” – as we tell people that we meet on our foreign
holidays – but that we complain endlessly about the “NHS”. Are they not
the same: the “National Health Service” and the “NHS”? I would argue that
they are not.
The National Health Service (although invented by a far-sighted
politician) is a much-loved collaboration between Patients, the Public,
Doctors, Nurses and the UK Government. Like the British Constitution, or a
well-functioning family, it works without very much being written down. It
is immensely powerful – any government that was seen to threaten it would
be doomed – but the power exists only because people care for it.
The NHS is an administrative agency of the government that exists to
ensure that the money collected by the government for the National Health
Service is spent well. Unlike the National Health Service itself, the NHS
is prone to being officious, bureaucratic, over-controlling and frequently
just a pain. The NHS is meant to be a supporting structure and, at its
best, it can do this very well. Even so, the NHS is relatively weak, and
trembles at the sight of government ministers – just as government
ministers tremble at the sight of the National Health Service.
So here we have the true hierarchy. The National Health Service kicks
the Government and the Government kicks the NHS. So next time you get an
unintelligible letter with the NHS logo on it, remember that it has come
from one of your servants.
Competing interests:
I was PEC Chair of South Leeds PCT for three years.
Competing interests: No competing interests
Dear Sir
I must congratulate Nigel Hawkes for so elegantly dissecting the
complexities of my own lived NHS experiences from both within and without
that system.
The pain will go on until people collaborate together, or are enabled
to. I do not believe that we will ever reach such a point with any
Government, especially the one currently at the helm with all of its
OCD(anal) and ADHD(hyperactive 'innovationitis') characteristics.
The psychopathology of all those who gain power is quickly revealed and
their toxic influences on our work and culture
soon established via the Newtonian pulleys and levers that operate from
London using machinery that has had hundreds of years of refinement to
exact the maximum degree of discomfort from those who dare to step out of
line. And we are kidded (or we kid ourselves) that we live in a democracy
because Tesco's is open on Sundays and we can have the choice of 94 aisles
and 200 toothbrushes, whilst the potential for a Civilisation established
on the foundations of Quality and Values is blighted in the womb by the
recurrent short-termism of those who require the fawning reassurance of
their advisors and allies and the adulation of the next photo-opportunity
or Media Adrenalin-Junkie.
Nope, it is high time for protest. For a start we must all mobilise
as taxpayers and protest by with-holding some of our essential core-
funding, thus ensuring that our vital oil is removed from these
dysfunctional engines and their engineers. Whilst doing this, those of us
who are fired-up enough must work towards pressing for the de-regulation
of health and social care, education and essential infrastructure. It is
time for the electorate to be far more radical. Whilst we set about this
task (and there are those of us who will), we could do worse than persuade
all our friends, colleagues and neighbours to vote automatically for the
main Opposition Party every four years, if for no other reason than to
prevent Party political complacency and to ensure that the toys are taken
away regularly enough to prevent them being continually broken (or worse
still "modernised").
Yours Faithfully
Dr Chris Manning
Competing interests:
None declared
Competing interests: No competing interests
Prediction comes true
Editor:
I read with interest the article by Nigel Hawkes and in the same
issue of the journal the news item “The difference a Day makes”.
Unfortunately, I was right in my prediction when I first saw the attempted
invasion of England by a Kaiser type health care system to replace the
NHS.
My unfortunate but prophetic words in your journal in 2002 “with the
globalization of the healthcare providers (pharmaceutical companies,
insurance companies, health maintenance organizations, etc.), acting
through the auspices of the powerful world trade organization, Europe and
Canada run the very real risk of acquiring our (the U.S.A.) very inhumane,
wasteful and diseased healthcare system”.
As to how badly your health care system is doing your newspapers and
ours all depict the shortcomings of a single payer system. This not only
highlights the problems with your system so that your citizens dwell on
it, and want to replace it, but it discourages American citizens from
considering a just and workable replacement to our healthcare system.
Unfortunately, everyone believes the news media but what they forget is an
old saying “Freedom of the press is restricted only to those who own one”.
Need I say more?
Sincerely,
David S. David, MD FACP
Clinical Professor of Medicine,
UCLA School of Medicine
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REFERENCES
1.Hawkes N. Who is Kicking Who? BMJ 2006; 333:645-48 (23 September)
2.David DS. Working Knowledge would have been needed for comparison. BMJ
2002; 324:1332 (1 June)
Competing interests:
None declared
Competing interests: No competing interests