Journal of Hospital & Medical Management

A brief retrospective reflection following experience as a therapist, manager and then medical researcher in the National Health Service in the UK. Examples are used which demonstrate how the integrity and purpose of a managerial system can be undermined. As in health – to be forewarned is to be forearmed and prevention is the best policy.

“Stop cut it there“ shouted the Principal. The lights in the auditorium suddenly went on, illuminating the previously darkened proceedings, and everyone altered their mode to What’s happening? What’s wrong?

“You can’t ask that” the Principal continued. He was looking at me incredulously. My crime was that in my assigned role as an interviewer on a recruitment panel I had dared to ask the applicant, among other questions, how many days she had off sick in the previous year.

Just to explain the situation: I had won a place at a university on a post -graduate rehabilitation course to study two focal topics: One research, the second management systems. This initiative was to prepare senior professionals in the field to become managers following the Griffiths report. This report was commissioned to address the urgent necessity to stop the bottomless purse of funding and make the National Health Service in the UK efficient and effective by adopting a managerial system: The research component was charged with wheedling out the subjectivity of treatments replacing treatments which did not passed scientific scrutiny with those which demonstrated that the treatments did what they had demonstrably shown to be effective - in others words seeking objectivity.

The management component was to herald, facilitate and instigate budgetary accountability replacing the old system. The belief was that money would be saved and that the health service could continue itself healthier and more important sustainable. It is worth noting that the National Health Service is on a par with a national treasure – any political party which in any way sabotages the NHS is politically doomed.

I was interested in the research component as opposed to managerial systems, but I could see the need for the realism and that the two pronged approach was both complimentary and necessary. My background was as a farmer’s daughter, so business decisions practicality and a certain realism were part of my DNA. In my own realm as a therapist up to that point there was no link between the treatment and the proven outcome. As an example: massage was part of the treatment but apart from the patients enjoying it nobody could verify that it was effective? Objectifying various treatments using research techniques was therefore necessary.

The course was designed to teach management skills to those who were the most likely candidates to hold the first managerial posts in the new management system. So here I was on this new course aimed at propelling therapists into a new age backed up with realistic costing, hiring and firing personnel, a management system. Adopting the very system used in industry concerned with cutting out superfluous and non essential expenditure. Where profit margins could produce profit. Very basically the ethos of the managerial system was sensible and resembled the farm – The farm which was my background could not afford “hangers on” it had to cut out the sentimentality. An example: a cow which was barren could not contribute and had to be culled. Everything on the farm had to be justified including my own position. I had from an early age needed to contribute. As my age and my height changed my responsibilities grew commensally. I had to milk a cow before school and when I returned from school not to do homework but to do what was considered “real” work. School was a statutory edict tolerated but not encouraged.

So against this background and moving forward in my life and needing to progress, here I was with other mature professionals taking advantage of their own futures, the needs of the country and the treatment of their patients. They were a very likeable group and we all enjoyed being back learning and embracing the university life again. We had all worked in clinics, hospitals, and departments with a responsibility towards the rehabilitation of the patients. So to be in one another’s company learning and comparing notes and experience was exhilarating.

To return to the morning in the lecture theatre: A small part of the assessment for the management section of the course was concerned with recruitment procedure. Called hiring and firing. This entailed:

• The formulation of a job description.

• Compiling the advertisement advertising the job.

• Arranging the interviewees.

• The interview.

• And the letter providing the result to the applicants.

On this particular day we were being filmed and assessed as we carried out the interviews. We had done our background work: poured over the ideal client necessary for the position to be filled and the skills needed. We had written succinct advertisements in journals and periodicals. Then we decided on the interviewers. Next we decided the shortlist. Lastly we had booked the venue. My assignment in all this was as I have mentioned to question each applicant on their present welfare, circumstances, hobbies etc. in a kind and diplomatic manner. My colleagues on the panel kicked off with their areas of inquiry then it was my turn. The dramatic beginning when the filming was stopped and the lights suddenly went on was a shock not just for me but for everyone else. I was not credited with being dogmatic or assertive just the reverse. Nevertheless in itself with hindsight it was indicative. I personally was also shocked but not dramatically so - more interested.

Why and what was the reason my question which was merely about absenteeism caused so dramatic a reaction? Wasn’t this at the heart of the need to save? Wasn’t absenteeism rife in the NHS? Didn’t everyone one knows that staff would ring in sick on Fridays or Mondays to prolong the weekend? Didn’t we all know the various strategies employed to get out of our responsibilities? Didn’t we all know of staff supposed to be driving to see patients in the community and not keeping their appointments and do their shopping on the way? The midwives who would turn up to a newly born mother and baby at 11 am just ready for a smoke and a coffee that the poor mother would provide after she had bathed and attended to the baby?

If I was a manager who had undertaken to provide a service within a budget didn’t I need to know everything about my staff? To insure I could provide an effective efficient service within budget? I dug in my heels realising that the lecturers had no experience in running a business at all. I argued there and then that if someone was continually off sick the burden of their absence would be carried by other staff! Furthermore if I had to recruit agency staff I would soon be in budget deficit. However there was no agreement and I was treated as if I was a criminal. The filming was continued. That instruction “stop there” should have had greater impact – it should have alerted me that here was a system the antithesis of what I had been immersed in on the farm. Sadly I did not heed the warning – I was subsequently offered a management job which I unwisely took only to find similar situations arising.

Changing from one system to another (NHS versus managerial NHS) is predictably initially wasteful, inefficient, and ineffective. In the old system the matron was responsible for running the hospital whereas the doctors were accountable for the patient. I along with Occupational therapist, physiotherapists etc. were state registered but supplementary to medicine (paramedics). Meaning the patients were the responsibility of the doctors who devolved treatment to the paramedics. However with the managerial system the doctors lost their control and the matrons were replaced by managers - many managers. In essence the tight system was replaced by many more managers mostly nurses, and paramedics who knew nothing about management with its jargon, and inherent procedures and implications. Not to mention the business savvy necessary. This dilution from a matron who ran her hospital with dedication, and military precision on the one hand, and the doctors who could dictate what they wanted and needed to treat was replaced by an inferior system doomed to fail.

The altercation I caused was at the heart of the problem. The caring professions at the core attract self-selected carers. The NHS is made up of an amalgam of such people. Sickness is their business, their attraction - their life. I was asked as a favour to help a nurse prepare for an interview – she was pre-occupied with illness: in herself, in her family, even her pets. She made it her business to nurse everyone and everything. She advised radical management to everyone urging them to make appointments to visit the doctor, for trivial complaints. Getting second opinions, when they weren’t indicated etc. She herself was always off sick as were her family. Her profession was being a nurse her life was being a nurse.

Her request to me was to help her get promotion and to become a sister in an outpatient department. She had applied for promotion before but was never successful. She appealed to me - why had she been over looked? She didn’t understand. The interview started off with me asking questions that I would need to ask if I was a manager making the selection.

When I broached her own health she was in her element – here was a subject which captivated her. She listed her ailments and the treatment clearly animated. She told me she had been off sick for four months in the previous year. How could I possibly ignore this information if I as the manager was responsible for providing the out – patient service? Even though I went to great lengths to sympathetically explain to her that her interview technique was flawed she thankfully failed to get the job.

Discussion

This brief account demonstrates from personal experience in the “caring profession” how in delivering a service in this case healing and care, there is a recognised need to accept a management strategy and structure. However it is also acknowledged and to be expected that if the integrity of the whole system is executed on skewed foundations the purpose and outcome are compromised. It therefore follows it is indeed imperative and healthy to speculate how and in what circumstances comprisation may occur? Self-selection in all walks of life is generally accepted as positive. However self-selection within a profession may undermine the function and integrity of system. This is particularly relevant in the so called caring professions who either consciously or unconsciously impute entrenched personal needs into the system. The lessons learnt are that management systems can undermine the very function for which they are intended to provide. And that further more seemingly highly focussed personal with the same characteristics can sabotage the system.

Years later the unrealistic unsustainable NHS system is still in crisis. A safety net for every expectation, whether it is a medical social or mental condition: The ever open door. The door that encourages reliance, and discourages self-responsibility and resilience. While it embraces ‘every need’ it is unable to cater for the core need for which it was originally aimed – to heal the sick – A sick system.