In a hierarchical NHS, how can managers help create a world of equals where everyone contributes?

In her article about using the lean approach to eliminate the waste that managers never see (Lesley Wright on walking the walk), Lesley Wright left us with a key question: ‘In the hierarchical NHS, to whom will empowerment be the greatest challenge: managers or frontline staff?’

Why is there an NHS hierarchy? What is empowerment? What are the roles of managers and frontline staff?

Wherever humans gather, a pecking order will develop. One of the most useful models to explain how hierarchies are established is transactional analysis. This looks at the basic verbal and non-verbal transactions between humans.

In the transactional analysis model, individuals are made up of three psychological parts: parent, adult and child. ‘Parent’ behaviour is learned from our parents and acts to control or nurture children. Our ‘child’ responses stay with us as playful or adapted behaviours.

In a formal hierarchy of managers and the managed, ‘parent’ control is expected, and it expects an adapted (conforming) ‘child’ response. Many NHS managers enjoy a nurturing ‘parent’ role, too, so verbal and non-verbal transactions in the NHS often involve parent-child transactions.

However, NHS employees are educated adults, not children. What happens if the implicit hierarchical transaction is upset or crossed? For example, an employee in adult mode asks an open question or presents some facts at a meeting. How should the manager respond to this potential challenge to their ‘parent’ authority?

If they maintain the parent-child relationship by drawing on their implicit power in the hierarchy, conflict will result. To avoid conflict, managers have to move on (preferably up the hierarchy and often with a reputation for bullying) or learn to respond with adult behaviour in a world of equals.

How can we establish a world of equals in the NHS? How can managers become experts in their own right and add real value to their colleagues?

In the NHS, all frontline staff are experts on their part in the process. The issue is that they can’t see beyond their part of the process. The unfilled role in the NHS is that of a process manager - someone who makes the whole process visible, preferably beyond the boundaries of any single department or organisation. If such a person can demonstrate the waste in the process and the impact on staff and patients, why should anyone want to carry on wasting their time and resources? Empowerment is the result.

Here is a role waiting for managers to fill - an adult role built on open questions (for example: ‘Where does this form end up?’) and facts (eight out of 10 prescriptions are incorrect when they arrive in pharmacy). For such a role to add value, adult to adult relationships have to be the norm.

Currently, managers in the NHS learn to manage people. But in a lean business culture, there is no such thing as the divine right of management. Managers should learn to manage processes and respect people.