Sir Gerry Robinson, who fronted the OU/BBC coproduction, Can Gerry Robinson Fix The NHS? claims the National Health Service should not be exempt from the cuts that other departments will face as the coalition government forges ahead with its bid to reduce national debt. Here, Dr Bob Price, Director of Postgraduate Awards in Advancing Healthcare Practice at the OU, takes a closer look…
The proposal that the NHS should not be exempt from public spending cuts during a time of financial austerity isn´t particularly surprising given Gerry Robinson´s investigation of NHS businesses in his thought provoking TV series on better management.
At the heart of such a critique is the argument that healthcare can be addressed using the same sound business and management principles as other consumer-focused services, those that are delivered through the commercial sector. Too many layers of management undermine the chances of success. The principles of setting clear goals, using coherent planning processes and careful monitoring of work underway apply everywhere. Issues of quality and quality assurance can and should be worked out more transparently in the way that we associate with the best of business practice.
But it is fair to acknowledge that the NHS, as a business, poses some unique and challenging questions to the leader. First, the relationship with the customer is a complicated and often extended one. Patients and their families are increasingly acting as partners in care, responsible in significant part for their own health and wellbeing and decisions made there. The NHS product is therefore a constantly negotiated one, and one that is in great demand by more or less well resourced, informed and skilful consumers of healthcare.
Second, the product is not entirely within the control of healthcare services. A significant amount of care slips into the remit of social services and there are contentious issues then as regards which service is responsible for which elements of support. It is worth reflecting whether such blurring of the product - who delivers what - is quite such a problem in the commercial world, a place where the market may set simpler requirements of service purchasers and providers.
Protecting professional territory
Having highlighted two complexities of leadership requirements associated with the NHS it is also fair to acknowledge that healthcare has yet to adequately grapple with some internal challenges. Coherent leadership depends upon a clear understanding of the resource available and in this instance that is a human and an intellectual resource. Much of the wealth of the NHS is embedded in the expertise and skills of practitioners. Mobilising that resource to strategic purpose, getting the different resources to combine to enhanced effect, depends upon the leader´s ability to convince practitioners that working with and for the team is more important than protecting professional territory.
Now, 10 years into a new century we are still working through the shift from profession dominated healthcare to more corporate and collegiate forms of healthcare provision, a process that began over 30 years ago. There are promising developments, including extended role practice, questions about why a given professional must lead particular elements of service delivery, but progress has been slower than anticipated and in part this is associated with the ways in which clinical and general management leads interact in healthcare organisations.
A plethora of clinical leaders carrying different titles and advocating different causes, some of whom rotate into the role, may negotiate best practice with general managers. Divisions between what has been thought of as ´management´ and other forms of leadership (clinical or practice) need to be revisited. Not until these matters are addressed would a strategic and service protecting cut in healthcare resources prove successful. Simply substituting clinical leadership for general management will not solve the problem. Challenges of professional silo thinking and territorial concerns between the professions have still to be answered. At the heart of the question, can or should healthcare services be cut, (and by implication, cut at the management level, with leaner and more streamlined working), is the debate about whether and if so, how fast we can persuade healthcare practitioners to think of themselves as healthcare workers.