The People Manager
Outside the main hospital doors is not just the patients unofficial smoking area its where you score. It shouldn't be a surprise that illegal drugs are available to patients or that drug addicts have health problems but it does make their stay on the ward more of a challenge. The patient on methadone who also requires strong pain killers following their operation still sneaks out to score. Shooting up in the gents passes out, bangs their head and ends up in A&E with a smashed face that requires stitches and no memory of what happened. The consultant orders the ward to remove his wheelchair and so sister locks it in a store room. The patients persistent pleas to have it returned arose the suspicions of the ward staff, they search the wheelchair and find in the padded seat a hollowed out section with a wrap inside. The hospital would discharge him even though he still needs treatment but social services are adamant that with two young children on the at risk registrar he can't return to the family home whilst still using. He continues to take up an expensive hospital bed due to his drug problem and homeless rather than his medical needs. Is this the type of situation the integration of health and social care will tackle.
We could learn a lot from the private sector. But we could learn even more from large not for profit organisations that adopt the business know-how of the private sector with the social ethos of the public sector.
By examining how these organisations operate in practise we could see how hospital trusts might develop in the future. After all, isn’t that where foundation status is leading? Hospital trusts will be competitive, efficient and patent focused just like the best commercial businesses in the private sector. And those that aren’t will be taken over, merged or cease to exist just like in the private sector. But unlike the private sector they will not be profit driven, this should sit more comfortable with the medical professions ethics.
My experience of working in the not for profit sector led me to a different conclusion. The first surprise was that unlike the voluntary sector the not for profit sector did not adopt local authority pay and conditions, it paid senior managers more and frontline staff less.
In another practice taken from the private sector, no one knew what anyone else earned as senior managers negotiated their own salaries each year linked to their annual appraisal. Only after I hlft did I discover a colleague was paid several thousands more for the same job simply because they had negotiated a higher starting salary.
Profit over performance
The turnover of senior managers was dramatic; reorganisations were used to purge those not in tune with the new direction. All this was made possible by the fact that trade unions were not recognised and the board did not concern itself with HR issues. In fact, the board only concerned itself with the bottom line.
‘Success was measured in terms of growth driven by the chief executive’s ego rather than a sound business case’
As a head of service I regularly attended board meetings but not to discuss quality of care or the implications of budget decisions but plans for growth and the PR opportunities this offered. Marketing was considered important to attract new business and a considerable amount of senior management time was spent trying to win public sector contracts. Glossy brochures and expensive videos were produced in support of this.
While individual services were not required to make a profit, they needed to in order to cross-subsidise loss making services. However, if a service in a particular area was loss making with little prospect of breaking even then it was closed. This was a financial decision; it didn’t involve consulting with existing service users, staff or the local community, which gave a lie to the rhetoric on customer engagement or community involvement.
When I took up a senior management post at a large housing association I thought that the not for profit sector would offer the business know-how of the private sector and the social ethos of the public sector. I was wrong. The not for profit sector lacked the openness and accountability of local government and in the absence of the pursuit of profit it measured success in terms of growth driven by the chief executive’s ego rather than a sound business case. Not a good model for NHS trusts.
‘Many now see personal budgets as a backdoor way of getting families to top up budgets’
Personal budgets – where the client is given the money to purchase their own services – was first piloted in social services to great effect for people with a physical disability. The problem came when the government insisted that personal budgets should be made available to those over 65.
The number of people was overwhelming. Unlike the people who had a disability, there was no great enthusiasm among older people to take responsibility for organising and purchasing their own care. In a climate of financial austerity people began to realise the money they were allocated was insufficient to meet there needs.
- Stevens unveils ‘radical’ personal budgets plan for health and social care
- Exclusive: Major hospital trust ‘very interested’ in becoming a social enterprise
The government’s overambitious targets forced local authorities to introduce watered down versions of the model, so many people had a personal budget in name only; their care package remained the same, they continued to use the same traditional services from the same narrow range of providers, all that was different was that they now had a social work assessment that expressed there needs in financial terms.
While personal budgets were officially promoted as increasing people’s choice and control, many now see them as a backdoor way of getting families to top up budgets.
Social enterprises were seen as an acceptable way of outsourcing services while avoiding the accusations of privatisation. An in-house social service home care service could become a not for profit organisation in which employees were shareholders. The idea was that staff would share in the success of the organisation, employees would have a greater say in how the business was run and there would not be the huge pay differentials found in the private sector.
Freed from the bureaucracy of local government and with reduced overheads, these organisations could be competitive. Whilevery attractive to labour authorities keen not to be seen privatising social services the idea has not taken off from the small pilots dotted around the country.
‘Governments have a history of imposing what hasn’t quiet worked in one area of the public sector on to another’
The private sector is more competitive. Giving staff more say means they can veto changes to their basic pay, overtime rates, number of payed days holiday or sick pay. If they don’t have these powers and are told that the alternative to changes in pay and conditions is redundancies then they say “how is this different to working in the private sector?” Social enterprises may be more open about decisions but unless they are competitive there is no profit to share out at the end of the year. A modest profit in a small private sector company translates to a new car for the owner and a Caribbean holiday for the senior managers – the same money shared equally between all staff in a social enterprise is a new pair of shoes.
While an NHS trust could become a not for profit organisation it difficult to see how such large, complex organisations could share decision making with all staff or how they could adopt an egalitarian approach to status and pay when the gap between a porter and a consultant is so big.
Successive governments have a history of imposing what hasn’t quiet worked in one area of the public sector on to another in the hope that this time it might just work. What next: local eligibility criteria and rationing?
The theme was an authentic Viking feast in a long hall, so they were all dressed as Vikings, eating roast ox and getting drunk on mead. We were hours out ofReykjavík. Night was creeping in and the temperature was dropping, so you couldn’t leave the hall without blistering from the cold.
‘Our European neighbours were not restricted by our historic commitment to services being free at the point of delivery’
It was the final night of a three-day health and social care conference sponsored by a Russian telecoms company, hosted by a US private heath insurance firm, with conference speakers from Scandinavia and delegates from across Europe.
The conference language was English, the agenda the challenge of an ageing population (officially), the opportunities of privatisation (unofficially). NHS trusts were well represented, as were the men in grey suits from the Department of Health (all wearing horned helmets, including a drunk guy telling everyone that this stereotype was historically inaccurate).
We learned that the Scandinavian model was not as generous as we had assumed, that the German healthcare system was efficient, the French system expensive and rather inconveniently that a recent study had shown the NHS to be good vale for money and the US private healthcare system the worst value for money.
‘People living longer, new cures and more effective treatments – these are good things’
Our European neighbours were not restricted by our historic commitment to services being free at the point of delivery, so they imposed charges that the patient then claimed back if they were eligible. The French charge for a visit to a GP that some in our party thought would discourage unnecessary visits until they realised how much paper work was generated.
Encouraged by the Scandinavian contingent and much to the frustration of our US hosts, we concluded that the NHS is a ravenous animal with an insatiable appetite. This is not just because of an ageing population or developments in expensive treatments. It is also because of rising expectations.
People living longer, new cures and more effective treatments – these are good things. As a result we naturally expect to live longer and enjoy better health than our grandparents’ generation. Most of us are prepared to pay more for the peace of mind that should we become ill we will get the best treatment. Most of us realise that this means higher taxes or a greater share of taxation going on the NHS. All we need to do now is persuade the politicians.
You read it in the job adverts. It appears in the qualities necessary for the post and it’s often an interview question: are you a team player? The honest answer would be no, but you say yes. You’re good at what you do. You have a track record to back it up.
‘The star player may resent others for being ineffective, lacking imagination and having limited abilities’
You’re a leader, you’re decisive, determined, persuasive, creative and industrious. When you are in charge the team delivers. Trouble is when your not in charge. In the structure you both lead a team and are a member of a team. You are the service head but you are a member of the senior management team. The qualities that got you the senior management post were your outstanding individual talent, but your chief executive and your colleagues expect you to be a team player.
The individual who is not a team player is the one who doesn’t do their fair share; you need a member of the senior management team to open and close the conference – they’re too busy unless it directly relates to their service. Yu need a member of the team to represent the department on a corporate working group – they don’t think it’s relevant to them. You ask a member of the team to speak at the service users’ forum – they don’t think it’s the best use of their time. And then there is the special pleading around the budget cuts.
What’s best for the individual manager and their services may not be best for the rest of the organisation. The star player may resent others for being ineffective, lacking imagination and having limited abilities. But it’s a team and you can’t just do your own thing.
The team puts up with this behaviour because they recognise the talent, they admire the ability and they also bask in some reflected glory. That is until things go wrong. That’s when team spirit is most needed, but when those lacking it are most likely to disassociate themselves. Seeking to protect their own reputations, they move to a better team – assuming they have not already been shown the door.
Senior managers are by nature not good team players, but they recognise that on occasions they need to do their bit. Perhaps a better analogy is a choir, and every successful choir needs a few soloists.
We were told the banks were too big to fail, is the same true of the NHS?
Can the NHS be allowed to fail in an election year? No, so we can expect some one-off money to keep it out of the headlines in the run up to a general election.
‘What will a failing NHS look like?’
But what then? Further privatisation if the Conservatives get back in, and if Labour win not much different because we can’t have yet another reorganisation. So more of the same but with an increase in funding in real terms for year one and a stay on hospital closures.
What will a failing NHS look like? Ambulances queuing outside hospitals, being unable to get a GP appointment; mental health services being described as a “car crash” by senior managers; the annual winter crisis in A&E all year round; scandals about poor care, poor food and dirty hospitals; open conflict between hospitals and local authority social services over bed blocking; hospital trusts declaring themselves bankrupt, forced mergers, expensive drugs which extend life expectancy for the terminally ill being declared unaffordable; IVF and cosmetic surgery no longer available on the NHS; ward closures, redundancies and staffing shortages; performance targets no longer published…
I wasn’t surprised to find a full page article on dementia in The Guardian, I was surprised to find it in the business section. I was not an article about the money to be made out of private health care for people with dementia, but a story about the cost to business of the increasing numbers of people with dementia.
‘As people work longer, the frequency of people developing dementia while in employment increases’
The issues that concern business are different to those of heath and social care. The employer identifies HR issues: how do we deal with employees whose competence is affected by the onset of dementia? What implications are there for the annual appraisal process? What adjustments would a good employer be expected to make if an employee came to them with a diagnoses of dementia? How do we deal with the stigma attached to this disease and whispering campaigns that seek to undermine the individual who of course could be a senior manager?
Does our policy on employees as carers adequately cover those carding for someone with dementia, what circumstances might they experience that would be different from catering for someone who is physically frail or has a learning disability? (Neighbours contacting you at work saying your mother is wandering the streets, or frequent phone calls from a confused and forgetful parent who insists your meeting is interrupted). What implications are there for flexible working, how will you respond to more requests to go part time and what implications are there for increased requests for early retirement?
How can you gauge the likely impact on the business when employees are reluctant to identify themselves as carers and afraid to confide in their managers that their GP thinks they may be experiencing the symptoms of the early stages of dementia?
The article did not offer any solutions but emphasised the need for increased awareness, open dialogue and a supportive environment.
The worry is that this hidden disability may be left to HR to deal with on a case by case bases, ignoring the reality that as people work longer, the frequency of people developing dementia while in employment increases.
‘If you suspect the chair is showing all the signs of early onset dementia, what should the organisation’s response be?’
Rather than the traditional dementia awareness session, perhaps you might be able to better engage the board and senior management team with the issues by viewing an episode or two of The West Wing.
Those of you who remember the show will recall that the president hides the fact that he has multiple sclerosis but as he nears the completion of his second term the symptoms become pronounced and periodically disabling. Perhaps not unlike the real life situation where a president was said to have early onset dementia which had to be hidden from the public for fear he would be forced out of office. We don’t know what goes on behind the scenes at the White House in real life but we are given an insight in to what might have been happening in The West Wing.
The discussion then could be if you suspect the chair is showing all the signs of early onset dementia, what should the organisation’s response be?
You expect it from the local press and radio. The communication team warned you that a blog might need some vetting of responses before they were posted. The staff survey was bound to attract comments from people who think they know better. Likewise, was there ever a consultation exercise that resulted in a helpful consensus of opinion?
Suddenly everyone is an expert.
‘You can chose to accept or reject advice but if things don’t work out you have to take responsibility’
They say an effective leader knows when to take advice and let’s face it, there is never any shortage of it. So when should you listen and when should you push ahead regardless? Who should you listen to and how should you select your advisers?
As a senior manager you may recognise that the patient is an expert in what care works for them. As a senior manager you recognise that the frontline manager is often in the best position to make a decision. You may acknowledge the expertise and skills of the specialist professional. But you have the bigger picture.
Judged on outcomes
Maybe you turn to a management consultant for some impartial advice – help me understand what’s happening, show me a different way of doing this, tell me how others have tackled this problem. The response never seems that clear cut and invariably involves further work they are happy to carry out, for a very competitive fee.
While everyone thinks they are an expert, those who have genuine expertise rarely describe themselves as such, preferring instead to call themselves specialists. This means they have devoted a lot of time and gained a lot of experience in a very narrow area. The specialist tells you something you didn’t know, gives you some insight and maybe tells you something interesting. But is it useful?
You can chose to accept or reject advice but if things don’t work out you can not turn round and say, “I was just following advice.” As a leader you have to take responsibility. If only we were judged on the quality of thinking behind our decisions rather than the outcomes.
The language of business draws heavily on sporting metaphors, not least during events like the World Cup. Business is about competition, so we talk of beating the competition, appointing winners to senior management posts and judging progress by moving up the league table.
‘The construction metaphor fits with the restructuring of the NHS and other parts of the public sector’
The message is that we can only succeed at the expense of others, when in the public sector the opposite is true. A local authority has many more partners than opponents. The public sector is a complex mixture of completion, cooperation and integration and it really isn’t helpful to compare it to a football match. The language we use needs to reflect this.
Last month the chief executive of Marks & Spencer defended the company’s failure to hit three of its four sales targets by explaining “we needed to do a lot of heavy lifting” – meaning we had a few big issues to sort out before we could get on with the building work. The construction metaphor fits with the restructuring of the NHS and other parts of the public sector, especially when linked with phrases like “less architecture more engineering”; meaning less emphases on the vision and structure more on making it work.
An ageing Ford Cortina
My favourite analogy comes from the chief executive of Talk Talk, who describes the company as “an ageing Ford Cortina going flat out in the fast lane of the M4 in the pouring rain. We are always hammering along faster than anyone thinks is sensible, with things not quite right, but huge enthusiasm.” This certainly captures my time in social services. These metaphors are a better fit than sports ones or, worse, military ones.
We could make more use of the family as a metaphor for how the public sector operates but we don’t tend to use parenting terms to describe our relationships with staff and partners, such as setting boundaries, providing financial support and nurturing, as this “paternalistic” style is out of fashion. We sometimes refer to partnerships as like marriages requiring trust, shared responsibilities, a willingness to make it work and being able to rely on each other. Of course there are the arguments, usually over money or whether our contribution gets the recognition we feel it deserves, and sometimes there are acrimonious break-ups.
What we need is a business language that reflects the reality of the public sector. Any ideas?
How can a school be judged to be “outstanding” and 12 months latter the same school, with the same teachers, the same head and the same governors, be reassessed as “inadequate”?
‘Some inspectors in health describe the process as more like a “lynch mob” than done by professional regulators’
How can a local authority children’s service be judged to be “serving most children well, with good prospects for improvements”, and then, following a death in care, be placed in special measures?
How come some social service departments end up in special measures and others, also low on the performance table, do not?
The suspicion is that reports are subject to ministerial interference. I am aware of inspection reports, shared in draft with the organisation for factual accuracy, which initially appear to indicate a good or satisfactory service, but when published, have changed in tone, inflating minor criticisms into major concerns, and with a final judgment of “poor” or “inadequate”.
Doing what’s expected
The inspectors may have rigorously followed their tick box process; the quotes from service users, staff and partner agencies may be valid, albeit out of context; their performance data may be accurate, if selective; but the final judgement needs to be signed off by their boss, who knows what the minister expects.
Chief inspectors receive frequent briefings from senior civil servants explaining what the minister expects. Ministers have been accused of sending in inspectors to find the evidence to support their view that a hospital board is resisting centralising services; the school would be better off as an academy; or that the local authority is opposing opening up services to the private sector.
This has led some inspectors in health to describe the process as more like a “lynch mob” than done by professional regulators.
‘Ministers must resist the temptation to interfere in inspections and stop using them to promote a party political agenda’
Whether it’s Ofsted or the Care Quality Commissions, inspectors’ judgments are frequently dismissed as arbitrary and subjective. In reply, the inspectors accuse hospitals and schools of being defensive and more concerned with protecting their reputation than addressing areas for improvement.
Inspectors say they are given insufficient time to undertake inspections. What you get is not management consultants advising on how to improve services, but a snapshot of a service and a distilling of a lot of complex information into a very simplistic statement, to which too much importance is then attached.
Ministers must resist the temptation to interfere in inspections and stop using them to promote a party political agenda.
Inspectors need to be seen as impartial and should be resourced to undertake in-depth inspections over three weeks, not three days.
Hospitals, social services and schools need to accept positive criticism. But the whole process would be more beneficial to service users, patients and parents if the outcome was a list of strengths and areas for improvements, not a one-word judgment.