Dismantling the NHS?

Evaluating the Impact of Health Reforms

Exworthy, Mark, Mannion, Russell

• Publisher: Policy Press
• Year: 2016
• ISBN:
  9781447330257
• Topic: Medicine
• Subtopic: Health Policy

This book provides an in-depth analysis of the NHS reforms ushered in by UK Coalition Government under the 2012 Health and Social Care Act, arguably the most extensive reforms ever introduced in the NHS. Contributions from leading researchers from the UK, the US and New Zealand examine the reforms in the contexts of national health policy, commissioning and service provision, governance and others. Collectively, the chapters presents a broader assessment of the trajectory of health reforms in the context of marketisation, the rise of health consumerism and the revelation of medical scandals. This is essential reading for those studying the NHS, those who work in it, and those who seek to gain a better understanding of this key public service.

Section D:
Governance

THIRTEEN

Setting the workers free? Managers in the (once again) reformed NHS

Paula Hyde and Mark Exworthy

Introduction

Despite repeated reorganisations, the NHS continues to be under severe pressure as it faces profound challenges in terms of growing patient demand, shrinking resources and a rise in external competition. More than ever, it depends upon the effort, knowledge and expertise of its workers. Managing the healthcare workforce was a central focus for Coalition government reforms and it continues to present several challenges; not least that demand for workers often exceeds supply and workforce is often the single most expensive budget item. Thus, it attracts (political, media and public) attention during times of recession and budget constraints (Hyde and McBride, 2011).

The NHS is regularly described by the size of its workforce – often erroneously as the third largest in the world (after the Chinese army and the Indian railways). In fact, it is the fifth largest employer after the US Department of Defense (3.2m), the Chinese military (2.3m), the US supermarket chain, Walmart (2.1m) and McDonald’s (1.9m) (Alexander, 2012). In 2015, the NHS workforce amounted to 1.3 million (Health Education England, nd). Together with a further 1.6 million working in social care, the health and social care workforce accounts for 1 in 10 jobs in the UK (Imison, 2015, 20).

The NHS wage bill is £45 billion (DDRB, 2016, 7), accounting for about 40% of the total NHS budget (Kings Fund, 2010) and the majority of health expenditure across all health systems. For NHS providers in England, this amounts to ‘about two thirds’ of their total expenditure (Lafond, 2015, 11). Moreover, the NHS is marked by the diversity of employment, with over 300 occupations and over 1,000 employing organisations (Health Education England, nd). Although managerial decision-making can go some way towards mitigating shortages and containing costs (through training and development, for example), workforce planning and establishing new ways of working are sophisticated procedures that require strategic and operational coordination if they are to improve organisational performance (Hyde and McBride, 2011). Therefore, managers matter (King’s Fund, 2011).

Over the past 30 years or so, a series of health reforms have affected the NHS workforce. As a result of these and combined with the more recent austerity policies, there has been a growing impact upon pay, skill mix, morale and motivation of all staff. While not discounting the effect of reforms upon all staff (especially clinical staff), we focus, in this chapter, upon NHS managers. We do so because managers straddle the macro-, meso- and micro- levels of NHS reform and have been a central focus for recent structural reforms. Also, Powell et al (2014) show the strong link between HRM practices and organisational performance; a focus on improving staff satisfaction, wellbeing and sickness absence may act as a precursor to better services (2014, 94). Moreover, the discourse of managerialism (which managers are thought to enact) is having major ramifications across the NHS. As such, we argue that these questions and implications are emblematic of wider developments facing the NHS.

Despite the widely recognised significance of staff in the NHS, only one of the three books exploring previous NHS reforms since 1991 (Le Grand et al, 1998; Mays et al 2011; Robinson and Le Grand, 1994) includes a chapter on staffing (namely, Buchan and Seccombe, 1994). Their chapter adopted a (then) traditional focus on personnel management and industrial relations. It did not address broader considerations of the forms and consequences of staffing reforms, especially managerialism. More recent assessments of health reforms (for example, King’s Fund Mid-term assessment; Gregory et al, 2012) also pay scant attention to staffing issues. The focus tends to be on technical policy instruments relating to efficiency, patient safety and so on. One exception is Appleby et al (2015), devoting 6 of its 68 pages to ‘staff’ but it focuses largely on staff numbers. This lack of attention on staffing is surprising considering that market-style reforms from 1991 were predicated on new forms of managerialism wrought by New Public Management (NPM) across the UK public sector (Ferlie et al, 2005) and specifically the NHS Management Inquiry report introducing NHS managers (Griffiths, 1983). Without NPM and without Griffiths managers, it would be hard to foresee how many of the subsequent NHS reforms which have been the subject of evaluation could have been effected.

By contrast, this chapter identifies recent trends in staffing across the NHS and specifically builds on a growing body of research on NHS managers and NPM. Some of this evidence has been applied to recent reforms (for example, see Hyde et al, 2016; McCann et al, 2015). We take a broad sweep from the 1980s but focus mainly on the 2010–2015 period of the Coalition government. We frame our argument in terms of the shift towards entrepreneurialism.

The remainder of this chapter is divided into two sections. The first examines the context of and background to recent reforms of NHS staffing. The second examines the state of NHS management and identifies the challenges that remain.

The changing NHS workforce during the Coalition: ‘rebalancing towards clinical staffing’?

In the main section of this chapter, we explore the key dimensions of the Coalition reforms as they relate to NHS staff, specifically managers. We focus not simply on the staff as individuals but also on the discourses which the reforms espoused. These dimensions include: managerialism, hybrid managers, staff numbers, redundancy and re-employment, temporary staff, and pay

Managers and managerialism

Government reforms over the last 30 years, which have been broadly labelled as NPM (Hood, 1991), introduced powerful versions of ‘managerialism’ (Klikauer, 2013).¹ These reforms are not limited to health alone as they have affected housing, social care, policing, the armed forces and education. They have, however, proven particularly difficult to realise in health services (Ackroyd et al, 2007).

The Coalition reforms beginning with the White Paper ‘Liberating the NHS’ (2010), built on 30 years of reform that first institutionalised management in the NHS (as a result of the Griffiths Report, 1983) and then introduced a quasi-market in 1991 that positioned managers as ‘business people’ in preparation for market competition. Later, new business units were created in the form of Foundation Trusts (from 2004 onwards). The NHS, as a series of financially distinct entities, started to receive payments for individual patient care (through Payment by Results from 2003/04) rather than block contract. Managers were thus positioned as leaders who could both enact change and be directed by the national agenda (Bresnen et al, 2015).

During the implementation of the Coalition government reforms, NHS managers have operated in a broad sociopolitical environment which has continued the logic of NPM² such that managers have simultaneously been the problem and the answer (Greener, 2004). They are beset by policy reforms, system-wide restructuring, marketisation, resource shortages and increasing demand for services. A ‘newspaper’ view of NHS managers regards them as ‘pen pushers’ who represent levels of wasteful bureaucracy in large organisations. This is especially true with the rise of discourses about leadership, which often disparage management (Martin and Learmonth, 2012; Bresnen et al, 2015). Coalition government reforms to the NHS have continued the neoliberal challenge to the notion of collective provision of public health care.

As well as proposing major cuts to management costs, the passing of the Health and Social Care Act (2012) opened up the NHS further to private companies. The NHS was set to be delayered by abolishing 151 Primary Care Trusts and 10 Strategic Health Authorities. It was proposed to replace these two layers, however, with 300–500 GP Consortia overseen by an NHS Commissioning Board. (In the end, 211 CCGs were established in 2013.) ‘Liberation’ came to refer to the liberation of services to public or private provision in a competitive consumer market. Managers of provider services had to become increasingly entrepreneurial in a multi-commissioning, competitiondriven health service. These entrepreneurial activities have been undertaken somewhat reluctantly by NHS managers to ensure year by year organisational survival (Exworthy et al, 2015) and some managers have fought for contracts outside their main area of health provision to maintain financial income year on year (Hyde et al, 2016).

Reforms brought in under the Coalition government affected middle managers specifically. Seen as being in need of reform or removal, these managers were pressed to become more effective, more efficient, more entrepreneurial (for example, Harvey et al, 2014). Senior NHS management teams had already shifted towards ‘rational’ cultures and away from ‘clan’ culture making them more likely to pursue competitive strategies (Mannion et al, 2009). Perhaps paradoxically, however, the move towards managerialism reinforced a ‘utopia of rules’ (Graeber, 2015) even as it rhetorically attacked management traditions of bureaucracy and control. The notion of managerial autonomy thus becomes illusory as central constraints become more powerful, though perhaps less visible (Hoque et al, 2004).

The title of this chapter (‘setting the workers free’) paraphrases the Coalition government’s white paper ‘Equity and excellence: liberating the NHS’ (2010, 9) ‘We will create an environment where staff and organisations enjoy greater freedom and clearer incentives to flourish’.

‘Liberating the workers’ can thus be understood in two ways; first, as an encouragement to staff to become more opportunistic, risk-taking and innovative, and second, by implication, staff to be less constrained by central direction or oversight. Exworthy et al (2011) distinguish between ‘freedom to’ (innovate) and ‘freedom from’ (centralisation). The ‘freedoms’ of Foundation Trusts did not, however, always ‘liberate’ staff as managers had often become inured to centralisation and adopted riskaverse behaviour in an uncertain policy climate (Exworthy et al, 2011). The innovation/centralisation distinction creates further opportunities both for disaggregation of the NHS (into discrete, autonomous organisations) and for independent sector organisations to employ (often former NHS) staff. Former public sector staff who now work in private organisations may still, however, retain strong affiliations with public sector values (Waring, 2015). Indeed, this was the justification of independent sector treatment centres (Gabbay et al, 2011).

The Coalition reforms have not always been unfavourable to all managers. By design and out of necessity, entrepreneurialism has been at the forefront of reforms. This has entailed a greater need for managers to balance their competing roles: stakeholder, entrepreneurial and political (Currie et al, 2008). As a result, Hyde et al (2016, 176) argue that ‘[a] new cadre of managers, working to commercial goals, are emerging, and managers in NHS departments – such as marketing, publicity, communications and human resources, where they aren’t already outsourced – are coming to resemble those of other commercial corporations.’ Yet managers need to also be aware of competing interests such as NHS and other organisations, local public and political institutions.

The ‘new cadre’ of NHS managers have been successful in delegating tasks to middle and junior managers even as their numbers decrease and their range and volume of responsibilities increase, and NHS management roles draw upon differences in professional background, career trajectory and cross-organisational mobility. Middle managers have filled gaps in service, as functional managers such as HR and Finance devolve functional responsibilities to lower levels of management (Hyde et al, 2012, 17). Moreover, managers have sought innovative ways to reconcile declining budgets with rising demand. The instruments in the Health and Social care Act (2012), for example, allowed managers in NHS Foundation Trusts to increase their organisation’s income from non-NHS sources, such as car parking, retail space and medical tourists and so on (Lunt et al, 2015).

Recent research suggests that the working lives of most middle and junior managers, particularly those in clinical, hybrid and operational management roles, are considerably more pressured and insecure than they once were (Hyde et al, 2016). Moreover, the overall demotion of need for care as a determinant of resource allocation has been a widespread finding, one that was deeply troubling for NHS managers across the board (Bresnen et al, 2014; McCann et al, 2015). Managers often found themselves only being able to secure finances for services for short periods at a time before having to reapply for funding in competition with commercial providers. In this sense, falling tariffs under PbR have shifted still further the managerial landscape towards greater uncertainty. They constantly had to balance patient safety with limited available resources (consider, for example, Mid-Staffordshire NHS Trust). They carried responsibility for making cuts and for making sure there was no loss of service: an impossible demand to satisfy all the stakeholders involved. For many managers, complying with governance policies through information management was also a significant draw on their time. Aside from the actual burden of data collection, their attention was often diverted onto the short-term survival of their organisations. At a micro-level, some clinical roles such as matron were being eliminated and post-holders were moved to short-term contracts at lower grades (Hyde et al, 2016).

Middle managers continue to face intense pressure as they formed the target for cuts at the same time as being responsible for implementing change. This has had the consequential effects of increased workload, spans of control, and performance demands. The nature of NHS managerial work has changed with negative effects on careers, job tasks and responsibilities and quality of working life as a direct result of NPM and aggressive managerialism. NHS managers constantly filled the holes in a rapidly changing system and their engagement was essential to the everyday running of health services.

Hybrid managers

The turn first towards and then away from managers as a solution has also served to reduce clinical professionals’ power in favour of markets and to raise questions about the balance of power (between managers and clinicians) in health care organisations. Many managers in the NHS are also clinicians of various typ...

Table of contents

• Cover
• Title page
• Copyright
• Contents
• List of tables, figures and boxes
• Glossary
• Notes on contributors
• Foreword by Rudolf Klein
• Section A: Health reforms in context
• Section B: National health policy
• Section C: Commissioning and service provision
• Section D: Governance
• Section E: Conclusions