What we have here is failure to communicate

What we have here is failure to communicate…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:

  1. Strong sense of shared values and … traditions
  2. Careful selection, followed by socialisation or indoctrination of new members into the shared values…
  3. 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.


7 responses to “What we have here is failure to communicate

  1. Bravo, Aphra. Brilliant summary, and I must say, a very insightful one considering that you’re neither a doctor nor one of those dodderheads who call themselves managers (okay, I may be slightly biased there). Now all we have to do is print out a copy of this and get it stuck in every hospital in Britain, or somehow get it smacked into Patsy Hewitt’s face (I could employ someone to run up to her and do it at her next public appearance).

    I’m surprised I didn’t discover you sooner! Your articles on MMC and MTAS are, as they say, da bomb, and they show just as much insight as this one does. I’m adding you to my blogroll. Hope you don’t mind the heading I’ve given you 😉

    P.S. “As an outsider and a patient I just want to bang both sets of heads together.

    Amen to that.

  2. A minor comment…

    “What we have here is failure to communicate” is a line from Cool Hand Luke (borrowed by G ‘n R).

    Good article. One solution to the cognitive gap is to choose doctors to fill management positions.

  3. Yes, there should be more doctors in management positions. But IRL many obstacles prevent doctors to take on those tasks.

    In my country changes in laws and other political decisions combined with successful lobbying from the nurses’ trade union have almost wiped out all doctors at management posts the last ten years. Nowadays it’s contradictory to have a medical degree when you apply for a post within the administration. Doctors are only needed for “medical decisions” and within other areas we are not supposed to interfer.

    Nurses, physiotherapists, secretaries or people with economical degrees are preferred. In my county (which run the health care and hospitals) the manager is a social worker, two out of three “next in line” are nurses and less than a third of the Heads of Departments are doctors.

    …and still they wonder why the doctors leave the University Hospital and move abroad…

  4. Thank you all for commenting.

    I am yet to be convinced that doctors would make better managers. A lot of the time this idea stems from the rather arrogant assumption that management is obvious and doctors could do it better. Management isn’t obvious. If it was, then it would already be being done “better”. Doctors who became managers would have to overcome their own blindspots, otherwise they would be just as bad, but in interestingly different ways.

    Personally, I think that it is the duty of managers to be better at managing, (introducing change properly, using the current best-practice for what is called “transformation management” for example), and that it is the responsibility of doctors to accept that their background and training might in fact have given them some blindspots. As I said, I want to bang both sets of heads together, and I’d make ’em walk a mile in each others’ shoes while I was at it.

    What is needed is greater trustworthiness on both sides, and that way there might – slowly – be an increase in trust.


  5. I agree with bits of this. There is certainly a gulf between the way doctors think and the way what you call “managers and administrators” think.

    However, your analysis of the latter set is as yet insufficiently rigorous. The people you lump into the group include

    – policy wonks, with no experience of anything outside (often party) politics
    – career central civil servants
    – persons who have been recruited into policy units in the fond hope that they provide some sort of front-line view, but who are frequently academics of various kinds (even if also qualified medical professionals)
    – both bad and good senior managers in non-provider units (eg PCTS)
    – both bad and good senior managers in provider units (ie dealing with patients – usually hospital trusts)
    – a whole heap of people who are not senior at all, and often have “manager” in their title to make up for beiing paid badly

    Quite a few of these do in fact have their own professional ethos, although it is not the same as doctors’. (And I’m afraid I think that the internal/external compass is ivory-tower tripe).

    There are several related problems. One is that the current government has absolutely no idea how to manage anything (and I mean that as a quite specific comment, not the usual random insult; they can’t do implementation of their wild ideas and also have no idea about the damage caused by the constant stream of reorganisation and volte-faces). It is also very centrist.

    Another is that NHS managers are paid peanuts, so quite a lot of them are………ex-nurses, people who left the private sector for one reason or other, etc, and often people who ARE, in fact, not as intelligent as the average doctor. Not all, of course. But the excellent ones are spread very thing and moreover find it extremely hard to recruit good people beneath them.

    And another is that very few doctors have any idea about what good management should be like (because they don’t see it either inside ot outside the profession whilst they train). So they assume that “management” is what they see, which is all too often poor for the reasons above, even leaving aside the current combative atmosphere caused by edicts from the centre and (especialy) shortage of money. Also, most doctors don’t understand that management is a full-time job; so they think they can drop in, enforce their opinion about the bit they happen to be interested in, and go away again. Consultants who are not involved in management (eg as medical directors) are particularly bad about this. To do management, you have to move on from your original professional work. Other professions have known this for years, and pay some of their top people enough to tempt them to take this route. I recently “found” a trust whose CEO is a doctor. We need more of those.

    And the last issue is that the NHS is just too big and complicated for anyone to manage. Read up on management best practice? You might just as well look in a crystal ball. The NHS as it exists now is, literally, unmanageable. A hospital isn’t. But the NHS is.

    Sorry, long comment. I am middle-aged, had a long career as a successful senior manager in financial services, and am married to someone who used to be a director of various trust hospitals (and was respected by his medical colleagues) so I have long been fascinated by this subject.

  6. A long comment but an immensely informative one, Potentilla, and one which explains a lot about the sorry state of the NHS.

    I’ve had no visibility of how the NHS is run, though I did once share a flat with an NHS manager whose professionalism and idealism impressed me. She left.

    I was struck by the term “clan controls” and its implications in this situation – hence the post.

    Thanks for taking what I said further and steering it in more detailed and experience-based directions.


    PS – you are bang on the money with the NHS being unmanageable, by the way. Oh dear. Oh dearie dearie dear.

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