Every time I want to stop writing about MMC and MTAS I think of something else to add. Hot damn.
As it says at the start of Guns’n’Roses’ Civil War– “Wha-at we hev he-ere is faylyure to communicate”. Or to put it another way, what we have here is a deep down culture clash.
I know this is nothing new to those involved; doctors and bean-counters have been bewailing each others’ failure to understand the simplest things for a decade or so now, but something I read recently brought this into sharp focus. You see, I think it’s more than a matter of language. I think it’s about cognitive processes. Recently I’ve been reading about “strategic controls”, or how you get managers in large organisations to behave in ways which will move the organisation in the direction you want it to go. After a discussion about setting goals, (quite an interesting one, if you like that sort of thing), the authors of this particular piece say:
Ouchi … claims that it is sometimes hard to specify the sorts of actions that will be required to bring about the desired outcome. … in these circumstances Ouchi suggests ‘clan’ controls may be preferable…. The features [he] stresses are:
- Strong sense of shared values and … traditions
- Careful selection, followed by socialisation or indoctrination of new members into the shared values…
- Ability to trust individual clan members to act in pursuit of clan goals without ‘senior management’ control.
The strength of the clan is that individual clan members can be relied upon to pursue the common goals spontaneously. (My emphases).
Now that just sounds like members of a Profession behaving like members of a Profession to me. But it does illustrate an interesting point, one I alluded to when I discussed the MTAS questions. There is a real and dangerous conceptual and cognitive gulf within the NHS between those who administrate or issue diktats about it and the practitioners whose service they deliver. You see, no matter how (small-p) professionally the administrators and civil servants behave, they are not members of a (large-P) Profession, certainly not a vocational one. You have to want to be a doctor to want to be a doctor, but everyone I know who works in the civil service fell into it by accident.
Most people have an external compass – most people need targets and goals and assessments and initiatives and visions and mission-statements and all that stuff because deep down inside we are bods with a day-job. And no harm in that. I love my day-job and I’m good at it. The world turns round because of bods with day-jobs.
Doctors on the other hand have an internal compass. Whether it stems from their vocation, or from the “shared values, traditions and …. socialisation” is neither here nor there. Their internal compass determines what they prioritise and how they set those priorities. It also makes them blind to the importance of the things that are – well – not important to them. (This is not a criticism, it’s an observation).
The gulf itself would not be a problem if it was accompanied by trust. But nobody trusts anyone else in this situation. Patients don’t trust doctors. Doctors don’t trust administrators or accountants. Administrators and accountants don’t trust practitioners. And none of us can trust Blair, Hewitt or, I suspect, Cameron.
What grieves me is that all too often I see doctors falling into the trap of thinking that they are the brightest person in the room especially when the other people in the metaphorical room are administrators. Doctors are used to having vast amount of information at the tips of their neurons and they are trained to evaluate the evidence-base before forming their opinion. Much of their sense of identity comes from their Profession. All of this structures their thinking in all sorts of ways. But I also think that it makes them dangerously quick to dismiss administrative initiatives sprung on them by people whose cognition has developed differently, whose thinking patterns have not been formed by 5 years of scientific training at University followed by however many years of hard Practice on the wards. The doctors’ values, tradition and socialisation have given them clear and focused insight in one direction and blind-spots in another.
Now, I would be the first to admit that the evidence-base for management theory does not include randomised double-blind controlled trials, but there is an evidence-base for good management practice all the same. Targets and the like are implemented because they can be shown to work … in industry. As I’ve said, those of us who work outside the public sector don’t have that internal compass, and we need targets to tell us what to aim for. Shocking if you are a doctor, obvious if you aren’t. The strategists should of course notice that, as Ouchi points out, strategic controls are irrelevent and just plain don’t work with doctors.
However, it’s not the managers’ and administrators’ fault that they have not developed the same professional instincts that Doctors have. It’s not their fault that they need strategic controls. The fact that doctors don’t need strategic controls is masked by the managers’ and administrators’ own blind-spot.
The key point is that none of this is voluntary. None of it is conscious. All of it is based on assumptions so basic that those involved don’t even realise that they are making them.
Those involved in strategic decision-making for the NHS have an absolute duty to overcome their own blindspots by reading their own evidence-base and founding their plans on best management practice. Heaven knows, enough of them are studying for their Masters of Public Administration degrees. But it does not help when the doctors’ blindspot leads them to dismiss what is being inflicted on them is no more than “the latest management fad”. Both groups need to cut the other a bit more slack. As an outsider and a patient I just want to bang both sets of heads together.
I’m coming to believe that this cognitive gap is the most dangerous thing in the whole sorry situation and that NHS is falling headlong into it.
Goold, M. and Quinn, J. J. (1990). The paradox of strategic controls. The Strategic Management Journal, 11, 43-57.
Ouchi, W.G. (1979). A conceptual framework for the design of organizational control mechanisms. Management Science. 25(9), 833-848.
Ouchi, W.G. (1980). Markets, bureaucracies and clans. Administrative Science Quarterly. 25. 129-141.