History repeats itself, it has to, no-one listens

14 01 2009

The quote is variously attributed to Steven Turner or Laurence Peter (author of the Peter Principle) and, rather like Hegel, questions society’s progress with its failure to learn lessons from the past.

As I was compiling the post on the NHS as a Communist society I discovered an archive the BBC have posted of interviews with various politicians and physicians around the time of institution of the NHS. In one, Aneurin Bevan, one of the architects gives a quick summary of where the service is in 1949, one year after its inception. Please have a listen.

The most telling phrase is,

“most shortcomings revealed (in the service) are not the result of intrinsic defects of the service itself but because of the overwhelming volume of need.”

Can’t you just hear Mr Balls, the current Health Secretary saying that too?

The original needs of the NHS have been met and there is no doubting the fact that our Nation’s health has been dramatically improved since that time. What is clear however is that despite all the finance poured in since that time there still remains an overwhelming volume, if different need.

This is the challenge of the modern NHS and what is required of both managers and clinical leaders is to manage those limited resources equally amongst all to deliver the best care possible. Whether this is achieved is the debate we must all be involved with. This is the interface between physicians and clinical management.
History will repeat itself if no-one listens to the stories of the past. What lessons have we learnt?

The NHS is a communist society

8 01 2009

I’m not the first and I won’t be the last to make that statement however shocking it might be to Daily Mail readers; the NHS is a communist society. Both in terms of the true Marxist concept and sadly too in the outworkings of post totalitarianism the NHS displays many characteristics of communism.

The first to make the comment was the man voted No.1 Welsh Hero, by Wales, in 2004;  Aneurin Bevan. One of the architects of the NHS, Bevan articulated this fact early on in his treatise, “In Place of Fear;”  when he says (p100), “a free health service is pure socialism and as such it is opposed to the hedonism of capitalist society.” I may return to that comparison later…

The ideals of the NHS, when conceived, were that

  • services were provided free at the point of use;
  • services were financed from central taxation;
  • everyone was eligible for care (even people temporarily resident or visiting the country).

These tenets, buffeted by time, financial turmoil and even the Iron Lady herself have remained intact and a rally cry since the inception of the NHS in the late 1940s. We should be very proud of what we have achieved and work in, even despite our current concerns.

Regular readers should note that this is a fact, not metaphor or analogy. Those latter terms however might be easily applied to the politburo type structure of governance that is totally contrary to the original concept, to the inability of central government to fulfill major tasks such as Electronic Patient Record, to totalitarian approaches to infection control, to funding overall and to many other topics we return to like poor jazz musicians riffing forever on the same chord sequence. Please add your own metaphors in the comments section.

I wonder if this communist structure and ideal throws further confusion on the concepts of management and leadership when applied to health care? The initial market philosophy of Griffiths and his “new public management”  clearly did not work and was reviled by many within the organisation. Even despite the subsequent radical changes in approach and terminology incorporating and understanding of the concepts of a managed professional bureaucracy I wonder if the basic communism of the whole is actually part of the reason that management is so difficult and in particular the interface between clinicians and management so abrasive.

The NHS is a communist society. We have to accept that and incorporate that into our management strategies and understanding, Comrade.

The Four Arts of a Scholar – 四艺

23 12 2008

As I mentioned in a previous post, my nom de plume comes partly as an expression of my learning status; insei, a student.

The ancient Chinese believed that a Scholar needed to learn and study to be proficient in the four arts; qin琴, qi棋, shu书, and hua画  and thus become accepted in discussions amongst other educated men.  Importantly these skills themselves of playing a musical instrument, playing a complex board game, calligraphic poetry and painting were not the end point for the scholar. Acquiring these skills was a demonstration of the individual’s strength in reason, creation, expression and dexterity.

We recently watched a video presentation from MIT involving a discussion between Ricardo Semler and Henry Mintzberg in which the latter bemoans the current state of management and leadership. I intend to discuss a few of the points made in later blogs but concentrate in this on this concept of training for management.

Mintzberg comments in the video that he believes candidates for MBA courses should not be sought directly from graduate schools but from industry itself. He believes the candidate should have learnt the arts and crafts of their business by experience, progressed upwards through the organisation so that then, when training in management they might apply their own experience to their learning of management principles rather than take the learnt experience of others and apply it to a job they don’t understand.

The ancients (and I don’t mean Prof Mintzberg) appreciated that to take on such responsibilities one must have experience and understanding of  life expressed in “the four arts” before taking on scholarly pursuits and similarly Mintzberg feels that experiential understanding of the organisation is central to the training of a manager why then do so many clinicians in the NHS move directly into management with no formal training in what is clearly a complex and difficult task?

I believe I have learnt my arts of the scholar (ars longa vita brevis) and now I am learning the skills required for management and clinical leadership. I am being encouraged to take on a managerial role in my organisation without having any experience or training in such a task.  Should I do so and learn by my mistakes or is it better to listen to those with wisdom and first gain insight to then apply that knowledgeably?

I would value, as always, comments on this.

What drives you?

22 11 2008

I’ve been doing a lot of talking recently and the one question I have been asking of my clinical peers is, “What motivates and incentivises you?”

It strikes me that in business the engine is profit and that unfortunately is also is the case in many Medical systems, particularly North America. I recently read the blog of a CEO in Beth Israel Hospital, Boston (Paul Levy) where his decision to buy a da Vinci robot (don’t get me started on that) was simply because everyone else has one and thus good business sense!

In the UK however our Health Service is almost the opposite and decisions are made due to the restriction of funds rather than attracting them. Mr Levy points out that having the robot will allow his service to attract and retain the highest quality doctors as well as deliver something the public feels it needs.

My question then is what motivates our Health Service from the very lowest level through to the highest? It certainly isn’t money (which is a good thing) but incentivising medical staff similarly does not play a major role in decision making processes. Moreover, the drive of the senior staff is clearly different from the lower levels and returns to the question I asked earlier about what direction we are going in?

What do you think? What drives and incentivises you in the NHS?

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