Her Majesty’s Opposition

6 10 2009

As the political conference season draws to a close, a colleague of mine made the point that clinicians within the hospital Consultant Medical Staff Committee are analagous to the political opposition.

Considering and extending this I believe it does offer an interesting view as to the different roles clinicians may play in the management of the hospital.

Some are directly involved in committees of power although restricted in their ultimate influence by not being a member of the ruling party. Some exert influence through lobbying using skills and contacts developed over time. Sadly others engage purely in “yaa boo” politics attempting at every step to block and criticise the party in power.

Ultimately the role of the opposition is to hold the government to account because without them the government would not be responsible or effective for society as a whole. Clearly however the two sides hold very different opinions and philosophies over how and why things should be done but both, whatever our personal feelings, are actually striving for the greater good. Issues about election would be interesting to explore!

(Quite pleased in being positive again!)

Somewhere over the rainbow…

6 09 2009

Is it a fantasy? Is it a dream? Is it a story of a search for missing characteristics? Is it possible or is it even Kansas?

In preparation for my recent essay I came across the Really Learning Website and a “subjective think piece” written by Valerie Iles that explores the introduction of management into the NHS over the last twenty years, its relative successes and alternative approaches.

The piece is insightful, thought provoking and challenging. You should read it. It finishes with a paragraph that summarises much of what I have blogged about over the last few months.

“As we challenged our assumptions we might also recognise as fundamentally flawed the notion that any management consultant or policy advice team is better at devising structures and processes for the complex, dynamic interdependent set of systems, that together comprise our national health care, than are the people working within them. It is not Roy Griffiths’ fault that his prescription took the system as a whole in the wrong direction for 20 years, but we must make sure we never again allow one person’s view  to prevail. We must find ways of allowing locally relevant solutions to develop and flourish, devised, owned and implemented by local teams of clinicians and managers, held to account only for their outcomes and not for implementing a centrally prescribed set of processes. “

It wasn’t The Wizard that changed things.

All is not as it appears.

12 08 2009

The recent gap in posting has been partly due to the large amount of work I have been putting into our degree assignment. This morning I (hope I) put the finishing touches to the wee beastie and popped it in a zip file. My paper is on “Engagement of clinicians and management in the NHS” and after considering the issue in terms of organisational structure, strategic planning and clinical leadership I do think I have some useful thoughts.

One of the principal causes of poor engagement is that, contrary to the Mintzberg classification of organisational structures, hospitals (or ours at least) are not being run as the professional bureaucracy that the clinicians expect but as a machine bureaucracy.

I appreciate that for some of my readers I might as well be speaking Polish but I am also encouraged that many people read this who are not approaching the topic from an in depth study of organisational taxonomy and yet show an interest and insight. I think it helps me to try and explain this (to myself) in different terms so I will try and do the same for you.

In a managed professional bureaucracy the “operating core” (clinicans) are the source of production and because of the specialised nature of what is produced (clinical care) the core have a large degree of autonomy, control over performance and are supported in this by the “strategic apex” (management).

A good example of a machine bureaucracy would be a factory with highly specialized, routine tasks; formalized procedures in the core; a proliferation of rules, regulations, and formalized communication throughout the organization.

Unfortunately, in the modern NHS the latter rings more bells than the former. Drives for performance, merged and centrally managed waiting lists, cross covering, out-sourcing, the lack of core professionals  influence or even be involvement in strategic planning, imposition of “guidelines” and “protocols” may be viewed as a move away from the autonomy and professionalism expected of a managed professional bureaucracy.

Bate proposes changing the culture of a hospital as the “experiment” of clinical directorates has failed. He may be right. What is sure is that the current structure is not as the operating core would like, nor as Mintzberg suggests it should be. Perhaps this partly explains the lack of engagement between clinicians and management.


Satisficing and the Damascene moment

7 05 2009

Last week I was away visiting a colleague and rather like Saul of Tarsus I had a moment of clarity and understanding as I travelled. Somewhere in the air over the Adriatic as I read, “The Exceptional Manager: Making the Difference” (Delbridge, Gratton and Johnson 2006)  I read a paragraph containing the word satisficing. With an explanation of that word came my own, personal, Damascene moment.

The concept of bounded reality in philosophy was described by Herbert Simon (1956) to encapsulate the decision making process of an individual faced with a finite amount of time and the limitations of their own knowledge and experience. The decision that is arrived at amounts to necessary simplification of the situation and subsequent interpretation and decision making on the basis of previous experience. The result is seldom optimal but hopefully acceptable. Thus it is held to be a satisfactory, sufficing decision; satisficing.

This behaviour is exemplified by the consensus approach of group decision making and also the short-term view of resource management. It is commended by many as an optimal strategy in management.

As a surgeon this sort of decision making and behaviour is anathema. What is required in surgical practice is not a “best guess in the time available” approach. Study of all available knowledge of a problem, utilising the combined and continually advancing wisdom of a group on a subject and a set of limited, predictable outcomes allows optimal decision making within a finite amount of time and (hopefully) the best answer.

My mistake, changed in a moment of clarity and understanding, is that management practice is not the same as surgical practice; decision making and behaviour in management is necessarily satisficing.

Perhaps this exposes my naivety but this after all is a learning journey.

“…there’s something wrong, can you hear me Major Tom?”

18 04 2009

Sue Llewelyn in her paper, “clinicians as medical managers,” addresses some of the issues of doctors in roles of management. At the centre of her thesis is the use of analogy; the clinician manager as a two way window. This she asserts allows each group to effectively view the other through the faciliation of the window. The suggestion is, that originating from a medical background the window will garner respect from clinical colleagues offering medical insight into the world of management and working within  management gain respect from managers and offer insight into the world of medicine from management.

The topic of the clinician-manager interface seems to come up a lot in conversation around me, even without me bringing it up. Doctors want to talk about it; most have strong opinions on the matter. There’s alway a lot of negativity and, a little respect here please people, I always try to turn the conversation towards positivity and solutions for the problem rather than simply allowing the routine regression to negativity and criticism.

Recently I think I have hit on the problem. It’s not about respect, it’s not about experience, it’s not about understanding or insight, authority or knowledge, hieracrchies, budgets, control or indepencence. It is not about departmental interactions, committees or working parties, cascaded emails or a newsletter stapled to your payslip. It’s not about looking.

It’s about communication.

Yes, it is a complex professional bureaucracy with multi-faceted relationships and interactions but at the very centre of them, and of course every relationship, is communication. Without effective communication every relationship is doomed whether that is between kids in the playground, star crossed lovers, governments or even between clinicians and management. And the key word here is between.


“Can you hear me Major Tom?”

Clinicians are from Venus, Managers are from Mars

4 04 2009

It is encouraging that my failure to post on a regular basis stimulated a request for output from a loyal reader, thanks B. In response I posted yesterday; “Managers are from Mars, Clinicians are from Venus. Discuss.” Sadly, no-one did!

The book, from which the title is culled, discusses the difficulties and differences between the sexes within relationships essentially surmising that they are as beings from separate planets. The complexities of professional relationships within hospitals, which may (or may not) be the basis of my Action Research thesis, I believe mirrors this disparity. Managers and clinicians are as different as beings from another planet; Managers are from Mars and Clinicians are from Venus.


The academic literature is not awash with discourses on this matter. As I work through this I am grateful to various colleagues for their support and notification of individual papers and particular to Ed for unearthing this  article from Amer Kaissi: Manager-Physician Relationships- An Organizational Theory Perspective, The Health Care Manager Volume 24, Number 2, pp. 165-176

Although the paper is written from an American perspective it has a lot to say that is relevant to the almost diametrically opposite cultural stances of British clinicians and managers. The table below summarises some of those differences.

Area   Managers
Central logic   Rationalization, efficiency   Collegial control, expertise
View of work   Make a living   Work is living

Primary loyalty   To the organization   To the patient
Responsibility   Shared   Personal
Tolerance for ambiguity   High   Low
Patient focus   Broad   Narrow
Time frame of action   Middle-long   Short
View of resources   limited   Unlimited

Basis of knowledge   Social and management sciences   Biomedical sciences
Exposure to others while in training   Little   Great
Relationships   Hierarchical   Collegial
Career development   Hierarchical advancement   Achievement
Vocabulary   Cost, benefit, revenue   Quality, patient outcomes

Perhaps, like the book of the title, some of the findings and statements of this paper may appear somewhat obvious. These differences will clearly affect many clinician-manager interactions, even without ladders of inference. The ability to recognise and work effectively with (or despite) such differences requires insight, skill and patience. On both sides.

What do you think? Are managers from Mars and clinicians from Venus? Despite being so different can you see how the two can work effectively together?

Clinicians are from Venus, Managers are from Mars

3 04 2009



A world of difference.

17 03 2009

Two stories are currently dominating the news reports; Mid Staffordshire NHS Trust and Royal Bank of Scotland. Two stories of management pursuing goals deemed laudable, each receiving recognition within its own field of “success” only to have revealed the ultimate costs of those achievements.

Sir Fred Goodwin and the Board of the Royal Bank of Scotland are not the cause of the current financial “downturn”. There is no doubt that behaviour such as theirs contributed significantly to the failure of the Group and the subsequent, some would say required, major Government support of the Bank. Mr Goodwin received a knighthood, “for services to banking” and is currently involved in some discussion, shall we say, regarding the value of his pension/pay-off/ severance/reward from the company. Currently, the financial reward for his “services to banking” is to be paid probably tax free to a value that has as many digits as my mobile phone number. He has simply “retired”.

The management group of Mid Staffordshire NHS Trust strove through their actions in the three years leading up to 2008 to fulfill the Government standards regarding financial probity and clinical targets. The Trust was given the accolade of Foundation Status in recognition of its efforts in achieving those quality standards.  The “Annual Healthcare check” from the Healthcare Commision for 2007-8 can be found here. A snapshot of their performance is below.


Impressive eh?

Today, it is being widely reported that the Health Commision has found that the management pursuit and achievement of their stated goals was at the expense of clinical care. During this same three year period it is reported that there has been significant failures of management and clinical governance lead to unnecessary suffering and a significant number of deaths. How exactly this fits with the report issued last year is open to conjecture.

I’m sure we’re all pleased to hear that the senior managers of this Foundation Trust have “retired” too.

There’s so much I feel about this whole situation and its wider context that just breaks my heart.  Perhaps leaving it unsaid speaks louder than any words.


Back to analogies- intended versus realised strategies on the football pitch

15 03 2009

emergent-strategyThe 1998 paper Mintzberg, Quinn and Ghosal (1998) looked into organisations with and without explicit strategic plans, the effect of this on the staff within the organisation and the ultimate outcome. Importantly, and intriguingly, the principal finding was that the realised strategy of the organisation was not directly related to the intended, deliberate strategy, the precise and explicit plan of the organisation, but more an outworking of the non deliberate and hugely variable strategies of the work force; emergent strategy.

This all sounds very complex until you put it into an analogy, once again I have returned to the football pitch.

The current manager of Albion Rovers is Paul Martin. Before a match he will gather information about his team, the opposition and their usual tactics, possibly even the weather and the referee, to come up with his intended strategy. His team will be briefed with this, given explanations about pressing plays and the mid-field width, the role of wingers and the man to man defence. This deliberate strategy is inculcated into the team right up to the point where they cross the white line.

courtesy Paul Reilly

courtesy Paul Reilly

And then it all falls to bits as Forfar change to the long ball game as the weather turns, worse still four players on the Rovers team get booked and with the  midfield failing to deliver their expected dominance, all this brings about the realised strategy of a 4 nil humping the likes of which they haven’t seen for a while.

The manager sets out an intended strategy, the team play out their own individual strategies, some in the knowledge and direction of the manager’s deliberate strategy, some not, and the realised outcome is a combination of all these; emergent strategy.

Sadly, the reality wasn’t what was the intended strategic goal!

Confirming evidence trap- i KNEW it!

21 02 2009

It’s obvious really isn’t it? You can clearly see that the defender (in blue) has made contact with the ball and therefore, whether in or out of the box, it is a fair tackle.

It’s obvious really isn’t it? You can clearly see that the attacker (in red) has clearly been scythed down  inside the box and it must be therefore be a penalty.

It’s obvious really isn’t it?  Cristiano Ronaldo (in red) will go down like a sack of potatoes at the slightest gust of breeze. The man is a born cheat. That’s a fair tackle.

It’s obvious really isn’t it? Just because Cristiano Ronaldo has a reputation (justified or otherwise) for “going down” in the penalty box no-one ever believes that a tackle on him is unfair. That’s a penalty.

We seek data from the information presented to us, but, as in the ladder of inference, we must also be aware that subconsciously we seek out information that will confirm our beliefs and understandings about the world and at the same time ignore those that confound such views. This is the “confirming evidence” trap.

The reason for bringing this up here is that I am hoping to identify issues that may confound  the true view of information I gather for my thesis and also to highlight the risk of such behaviour in leadership and management.

It is essential that as information is gathered that evidence is sought from both sides of the debate and that equal rigour is applied in determining its veracity. One must accept that personally held views colour interpretation and be honest in our assessments potentially even seeking confirmation from alternate sources.

This does not necessarily mean our views are wrong, merely that we should seek evidence from all sides of the debate before making decisions.

Who would be a referee eh?

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