Managing health & social care final essay
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Final assignment discussing the political agenda of May 2010 and the implications to the NHS of a coalition government.
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Managing health & social care final essay
- 1. A review of how organisations are having to change, to meet the demands for modernising Health and Social Care; With a focus on Birmingham East & North PCT BUSM 3913
- 3. NHS Structure in 2010
- 4. Current Structure of CHS within BENPct
- 5. An overview of types of Structure
Notes de l'éditeur
- My name is Ellie Fegan and I am employed by Birmingham East and North Primary Care Trust, as Head of Stroke Services and Clinical Lead for the Community Stroke Team. The following presentation will aim to outline briefly, what Structure, Culture and Management Style means and relate these terms to the organisation I work for, highlighting the imminent changes that are happening due to organisational change. As a result, there will be an impact upon the structure, culture and management style, currently adopted by the Trust and I will aim to identify how these need to change to meet a modernising health and social care system. I will also look at how these challenges can be met as well as assessing the implications for myself and the team I manage.
- For any organisation to work effectively, it is vital to have some form of structure , regardless of how static or flexible it is. The structure adopted, will include mechanisms for reducing uncertainty, as outlined by Galbraith (1973) and these include; Making rules • setting goals • building in buffers • smoothing the boundaries • creating self contained units or departments. Involvement and integration through communication, is paramount for an organisational structure to be effective. Health and Social Care organisations tend to operate in a very volatile environment, with high levels of specialisation, wide ranging services and increasing demands on high quality standards. Therefore, the structure needs to be planned carefully, taking into consideration all of the elements involved, as this will determine the effectiveness and efficiency of information flow, decision making and level of co-ordination. Culture is related to the beliefs, customs, practices and social behaviour of a particular group of people. Culture can be tangible or covertly displayed ; the design of a building, interior design, style of offices, are only visible to see and give the first impression, of an organisations culture. NHS buildings tend to be official, clinical and unwelcoming places, with lots of locked doors, stark floor coverings and strip lighting. A BMI private hospital will demonstrate plush reception areas, with soft seating, low lighting, and deep pile carpets. Covertly, culture lies in the type of people an organisation employs; for example, their status in society, their career aspirations, level of education and actual ability: these are all reflections of the organisation’s culture. Schein in 1984, agrees with the two types of culture mentioned above and argues that neither approach is wrong, just different. Management Style has been studied endlessly and I feel passionate that Mant, in 1984, truly defined Management Style succinctly and accurately. Bipods are in control, dominate and seduce in order of self survival. This type of flawed leadership eventually leads to self destruction. James MacGregor Burns calls this “Transactional Leadership” while Adorno uses the term “Authoritarian Personality”. In contrast to the Bipod leader is the Tripod leader, who Mant suggests, run personal risks in pursuit of some high purpose and can observe themselves in their relationships. These leaders are usually, teachers, supportive managers, etc. MacGregor Burns describes this type of leader as “Transformational and Mant argues that we need much more of this type, in our schools, businesses and politics.
- The NHS can be divided into 2 structures; Primary and Secondary Care. I am involved in the Primary Care setting and am a Community focused practitioner, as opposed to being hospital based. Primary Care Trusts control 80% of the NHS budget and commission services from secondary care. Primary Care is the first point of contact for most service users and includes GP’s, dentists, opticians etc. Secondary care, or acute healthcare, usually follows referral from a GP or other health professional, unless it is an accident or emergency and the service user attends for immediate attention to A & E. The very initiation of the NHS came about on July 5 th , 1948, by the then minister of health, Aneurin Bevan. The 3 core principles of the NHS were; That it meets the needs of everyone That it is free at the point of delivery That is based on clinical need and not on the ability to pay In July 2000, a modernisation programme added a further 10 principles, all of which run through every thread of the service on a daily basis and 60 years after Aneurin Bevan realised his vision. As well as the principles introduced in the modernisation programme, the NHS Constitution along with the 1998 ‘Working Together’ document, recommended the following values to underpin the management and development of NHS staff; Fairness and equality, Flexibility, Efficiency and Partnership, Respect, Compassion, Quality of care, Improving Lives, Working Together and Everyone Counts. As a manager, the principles laid down lead me to incorporate an open climate into my team; Honest, caring, egalitarian, forgiving and with an ethos of giving constructive feedback. I feel it is important to be a very “hands on” manager, who is approachable, adaptable and flexible. I have an open door policy and only ask for privacy when I definetly require it, for meetings, appraisals, supervision or counselling sessions.
- Structurally, the Department of Health runs the National Health Service. The secretary of state for health, is the Head of the Department of Health and reports to the Prime Minister. The Department of Health controls England’s 10 Strategic Health Authorities, which oversees all NHS activities in England. Each SHA supervises all it’s local NHS Trusts, of which BENPCT is one. The current structure of BENPct is multi-faceted. As well as the structure shown, the Trust is responsible for the Workforce Planning and HR Directorate, Primary Care Directorate, Information and Technology Directorate and the Commissioning Directorate. The part of the BENPCT I am situated in, is the Community Health Services Directorate, under the Provider Arm, as outlined above. The Director of Operations directly manages two Service Directors, one for Long Term Conditions and one for Rehabilitation, who hierarchically manage the individual Heads of Services. The Heads of Services manage their own teams ie. Stroke, Intermediate care, District nurses etc. The Director of CHS has a span of Control over two service Directors, while they each have a Span of Control of three. Each Head of Service then manages an individual team and will have a Span of Control for five to forty staff, depending on the team. The advantage of a structure such as the hierarchal structure demonstrated in BENPCT, is that one to one meetings happen on a regular basis between the up line manager and their deputy. This method of communication ensures that every link in the structure has access to management support and supervision. No one person has communication overload or is less accessible to certain members of the organisation. Because the span of control for each manager is generally kept in single figures, there are clear lines to follow of who to contact with for information. As well as the formal structure of information processing, managers need to develop the art of informal networking and less formal channels of communication. This can be extremely beneficial as this method of communication can build up a massively invaluable and beneficial network of communication links.
- Analysing the Structure of BENPct, leads me to believe that all of theses types of Structures are present in the Trust I work for, in varying degrees, throughout different departments and at different times, depending on the challenges being faced by the organisation as a whole. Essentially, a hierarchical and centralised structure is presented all of the time, and running through these elements are Span of Control, Line Management and Delegation as a matter of course. By nature of the role of the NHS, Specialisation, Formalisation, Professionalization and Authority are all elements of Structure that filtrate through various departments, constantly ie. General Practice, Medical Teams, hospital wards. In my experience, the two elements of Structure least used are Co-ordination and Empowerment. Organisation theorists call Co-ordination, “Integration” and this is not something the NHS generally do well. Working in silos is a very common practice within NHS departments, and is regularly identified as harmful. Also, empowering our staff is an element of Structure, not embedded in the culture of BENPct. Empowerment is about the removal of obstacles and constraints, to allow an individual to do a job they are supposed to be doing. All too often, managers delegate without empowering. Crainer(1998) stated that “Managers should remember that when they perform a task which someone else could do, they prevent themselves from doing something which only they can do”. As a manager, it is important to remember the concept of macro and micro communication; when organisations change, communication systems and processes also change. Because the NHS is a complex organisation, where formal structures need to enhance the flow of information between staff and service users, using Quirke, 1997 is beneficial :- Raising Awareness through newsletters, achieving understanding through road shows, gaining support through training, generating involvement through feedback sessions and earning commitment through review meetings will all lead to excellent communication.
- As well as needing a formalised structure to ensure uniformity and standardisation, a structure is needed so problems are prevented, as described by Child in 1984; these problems include Depressed motivation and morale as decisions feel inconsistent A delay in quality decision making as the decision makers have no one to delegate to and no one to offer suggestions to them Conflict and a lack of co-ordination as departments do not communicate, conflicting priorities within departments and operational managers are not involved in planning processes Rapidly rising costs due to increased paperwork and procedures and a disproportionate number of senior managers to junior staff. Mintzberg, 1995 described a Structure as “The total of the ways in which an organisation’s labour is divided into distinct tasks and co-ordination that links the technology, tasks and human components of the organisation to ensure that the organisation accomplishes it’s purposes”. I agree that for an organisation as large as BENPCT, with over 1400 members of staff, a definitive and formalised structure within the organisation is essential. As well as this type of structure, I feel that by building excellent relationships with partnership agencies, as well as other organisations who provide similar services, is an informal way of building structure and stability. Understanding more about the needs of service users and other customers as well as improving the organisation’s public relations and it’s ability to influence the media etc is imperative for effective and valuable communication.
- The link between the Structure of an organisation and the Culture of an organisation is vital, as a good understanding of organisational structure and culture is one of the hallmarks of effective managers.”Culture is a major factor in the appropriateness of management’s methods of motivation . In addition to arrangements for carrying out of for organisational processes, management has a responsibility for creating a climate in which people are motivated to work willingly and effectively” (Mullins, 1996). BENPCT has a business focus that concentrates on the NHS Key Performance Indicators, the CQC indicators, Service User expectations, quality and customer care. As well as the culture of an organisation, information is crucial to effective communication, which in turn is crucial for the achievement of objectives. Therefore a culture of standardisation is required, especially in the NHS, where massive amounts of data are handled constantly. Formal codes, rules and procedures are in place, for how things should be done and by whom. Accountability is the main reason why such regulation in essential. Policies and procedures are provided for every task and activity and Equality Impact Assessments (EIA’s) must be completed for every single patient related action. The organisation I work for is totally hierarchical, with the CEO leading from the top. BENPCT operates under the Culture of “Role”, often stereotyped as Bureaucracy. Logic and rationality are at the centre of this culture, and the CHS depends and relies upon it’s specialities, it’s functions and it’s strengths; District Nursing, Stroke care, Intermediate care,etc. A narrow band of senior management (SMT) sit at the top and the Job Description is more often than not, more important than the person who fills it. Rules, policies and procedures are at the forefront of everything we do and are the major methods of influence. This is very evident in the organisation I work in, and theorists suggest that this type of culture will succeed as long as it can operate in a stable environment. Here lies the challenge for BENPCT; Role culture is slow to accept change and forges ahead with it’s own vision instead of accepting the need for change. BENPCT will be merging with Heart of Birmingham PCT and South PCT, later this year and with the current culture as it is, this will be a potentially disastrous and painful time for many managers. Handy also uses the 4 types of Role culture; Role, task, personal and Power . He considers Role to mean Bureaucratic, Task to mean expert power and task groups, Personal to mean individual stars structure is minimal and Power is centrally controlled and depends on trust and empathy. Taking all of this into consideration, the current changes happening to BENPCT will have a massive impact upon the current culture and merging with 2 other PCT’s, will define a new and unknown culture.
- Challenges and changes to Health and Social care are interlinked at all levels, from the Strategic Health Authority, all the way through to the frontline nursing and medical staff. Following an options appraisal being presented to the SHA, by all 3 PCT’s in January 2010, the merger of BENPCT, HoB (Heart of Birmingham PCT) and South Birmingham PCT has been made a directive. The Commissioning Arm of the 3 PCT’s will merge as a result of the impending Public spending freeze. This was due to take place by May 2010 however, has now been halted to October 2010, due to a number of workforce planning issues. Each PCT took responsibility for examining all of their individual services, to ensure that they were financially viable and patient focused, to secure a place in the “New World” – The single PCT, with one Commissioning Arm. The alternative option was to maintain the 3 PCT’s as they currently are and make efficiency savings in other areas; this has not been adopted. Changes from here on in are massive and far reaching; The creation of a SINGLE senior management team, as opposed to the 3 current SMT’s The appointment of ONE Chief Executive Officer, as opposed to the 3 current CEO’s The amalgamation of Community Health Services ie. District Nursing Teams, Health Visiting Teams, Rehabilitation Teams etc The appointment of Heads of Service to support the amalgamated Community teams The Transfer of Undertakings Protection of Employment arrangements (TUPE) Possible redundancies The Options Appraisal for the individual Service Lines, under the CHS; Vertical Integration, Social Enterprise, Horizontal Integrations Cost Improvement Programme – Cost reduction efficiency savings of 3 – 5%, handed down to ALL budget holders
- So, the Conservatives want to regain the current structure of Primary Care Trusts – as I am writing this, we have a hung parliament and BENPCT is on a journey to merging with 2 other PCT’s in Birmingham. The Strategic health Authorities would also be retained and therefore safe under a Conservative Government. The reduction of administration costs within the NHS, would come through the top slicing , of the top one-third of Senior managers, within the NHS. Any member of staff on a salary of £30,000 or more, would have their job description analysed, to ascertain the degree of clinical and managerial responsibilities and as a result, managerial roles cut. Developing “HealthWatch” aims to ensure that patient complaints are dealt with independently, as opposed to in-house, by current PALS Teams and local complaints departments. Access to cancer drugs, outside of NICE guidance, will have an obvious impact on funding, as these drugs are extremely expensive and would need to be funded by Primary Care trusts, if the Conservative party are voted into power. As well of all that is mentioned above, the Conservative party want to allow for Direct Payments to be made to carers, for respite care, as well as introducing a scheme to ensure that an insurance premium, will protect your home, in the event of long-term care being required. Also, GP’s will be given the responsibility to commission care services for patients (currently the responsibility of PCT’s).
- With the Liberal Democratic party, who are currently deciding which party to develop a coalition with, (following the announcement of a hung party today) (7 th May 2010), the changes to the current structure of the NHS would be far reaching. Scrapping the Strategic Health Authorities is something that only the Liberal Democratic party have suggested. Instead of SHA’s, newly elected local Health Boards will be developed, therefore making an efficiency saving on the cost of Senior managers within the SHA and associated QUANGOS. The new Health Boards will be responsible for the commissioning of services by PCT’s. This is potentially a very significant change in practice and one that would affect BENPCT greatly, particularly at a time when 3 PCT’s are currently merging, to devise a single Commissioning Arm. As far as Social Care is concerned, the Liberal Democrats have made a commitment to cross-party commissioning on social care and how to fund it. As far as respite care is concerned, this will be offered to a million carers and health and Social Care will be integrated. As for the very expensive IT projects, introduced by Labour, these would be significantly reduced by the Liberal Democrats. Information Technology is of paramount importance in the NHS, with the introduction of patient Administration Systems and the Spine, Summary Care Records and Single Assessment Processes. Communication will be discussed throughout the presentation to highlight it’s importance in an ever changing NHS.
- As well as those initiatives mentioned, Labour have included in their manifesto that they too, will make efficiency savings; 20 billion pounds. There is a commitment to slashing the cost of IT projects in the NHS and a promise to retain Primary care Trusts and the over arching Strategic Health Authority. This is line with the Conservative manifesto. Labour have set out that any drugs required by patients, will first be assessed by the national Institute for Clinical Excellence and where deemed appropriate, available within 6 months. A major initiative that Labour proposes, is to make all hospitals Foundation Trusts and any under performing hospitals will be taken over by the better performing Trusts and the failing management teams replaced. The successful Foundation Trust will then will given the opportunity to provide both Primary and Community care. Labour remains committed to free personal care to those most at need and proposes to develop a National Care Service, bringing more funds into the Social care system.
- The model above is a System with Feedback Loop; a very important tool when an organisation is proposing to merge with other organisations. Some of the systems (organisations) outputs ( changes) are fed back as an input (information) in order to modify the system (decision making process). The feedback acts as a control mechanism to ensure that the decisions being made, are as a direct result (or consequence) of the opinions, comments and demands of the majority. This is a very unsteady and uncertain time for staff and service users alike, within BEN and the PCT must include everyone of it’s stakeholders in the decision making process. This can be done in a number of formats; Public and Staff consultations, Media coverage, information leaflets through door drops, public (outward) and staff (inward) facing websites....... Without a feedback loop, public consultations would not give the service users of BENPCT an opportunity to offer their opinion, Staff side and organisational members would not be aware of impending proposals for change and have the opportunity to ask questions and offer opinions. As an information system, the feedback loop is made up of people, data and procedures that work together to provide useful information and outcomes. The information being gathered by BENPCT currently ahead of the imminent merger, has included an Options Appraisal of services as well as Staff side and Public opinions. It is important to realise that the information being collected will have no relevance whatsoever, unless it is used appropriately and effectively. The decision making that comes out of the data collection is of paramount importance as collecting, collating, recording and handling information incurs costs. The merger of the 3 PCT’s mentioned throughout this presentation, will be costly and timely enough, so reducing the time and effort spent on gathering irrelevant information is important. Organisations often produce expensive and useless information that has no value in it atall. Lucey(1991) looked at the Cost and Value of Information Model, and these questions should be asked before collecting information or communicating information; What is the information being provided and what is it being used for; Who will be using the information and how often does the information need to be transmitted; Is it high quality information and what is being achieved by using it. What is the cost of gathering the information in the first placea secret that the NHS has spent phenomenal amounts of money on Information Technology projects, over the last decade. Under certain political parties, this would be reduced massively, having either a positive or negative impact on the NHS as a whole. That remains to be seen.
- Communication must be timely and appropriate. It must be given to the right person for the right reason or else collecting and disseminating it, is wasted. In the NHS, information is often given to the wrong level of management; it may be sent to senior managers who do not cascade it down, or sent to junior staff who do not know what to do with it. As managers in the NHS, it is imperative to know who needs what information, when and how often. Accuracy of the information and the delivery mode is important not forgetting that ALL of the information needed by the other person is available, so important decisions can be made, with a full set of facts. The information needs to be clear and easily understood as lack of clarity is one of the commonest causes of breakdown in communication and with an imminent merger of 3 PCT’s, good quality information is vital. You cannot expect to make the right decisions if the information provided is insufficient and of poor quality. In my role as a Team manager, I receive and impart information and data on a daily basis; this can include; off duty requests, annual leave reports, sickness records, patient notes, MRI scan results, histology and haematology reports, PAS data, salary turnaround documents, staff references, budget reports, invoices........ The list is endless. I need to have accurate information in front of me to make informed decisions, or else a decision will not be reached and deadlines missed. As far as changes in my services are concerned, I can consider adaptations to the service as a result of analysing accurate data and information, therefore aiming to improve the service. When major organisational change happens, 1 in 5 staff members resign. It is vital to maintain motivation, creation, innovation, teams working together, good interpersonal relationships and an attitude of openness. Cooke and Slach(1991), argue that “the idea of climate.......is a useful one in that it helps us to think of internal climate as part of an organisation’s reserves and assets, which can be built up or run down and which allow or prevent that organisation from achieving it’s objectives”.
- Looking at all the current and future lines of communication mentioned on the slide, these provide information and as a result, can be referred to as Information Systems. For information to be useful, it must reach the appropriate people at the appropriate time in an understandable format, for it to make a difference to the organisation. At a time in BENPCT, with so many imminent changes happening, an effective management information system is vital. Lucey(1991) defines a management information system as : a system to convert data from internal an d external sources into information and to communicate that information, in an appropriate form, to managers at all levels in all functions to enable them to make timely and effective decisions for planning, directing and controlling the activities for which they are responsible. The PCT have a massive responsibility to communicate with ALL staff members as well as the population of 440,000 service users we deliver health care to. This is a huge undertaking and one that must be managed effectively and timely. The internet has revolutionised our access to information and is used by the public, to engage with the NHS and communicate changes and developments. Because the NHS is a constantly changing organisation, the world wide web can be used to keep up to date with policy through government websites; access research materials and as a source for learning and personal development.
- Finally, at a time when political agendas have such a massive influence over the changes taking place in the NHS, the issues, problems and challenges of BENPCT must be identified and addressed in a timely and open culture. This allows managers and staff to operate as effectively as possible working together towards the same objectives and goals. At a time of major organisational change, it also offers managers an opportunity to improve communication, co-ordination and the flow of information throughout the whole of the organisation. As a manger, I have been heavily involved with the Options Appraisal and as a result, the service I manage will be transferred over to the new PCT. The service will need to be amalgamated with the Stroke and Rehabilitation services within HOB and South PCT, and as a result of this, my role will be “at risk” as the single service will only require one Clinical lead, as opposed to three. The role may need to be advertised and ring fenced to the current leads and this will be supported by Human Resources. To conclude, Using Quirke’s concept of macro and micro communication, I can improve my contribution to the changes within the organisation. As a transformational manager, I also feel that micro communication is as important as the macro concept. Using face to face contact to communicate messages can show the listener the feelings, values and opinions held by the person imparting the information. Albrecht and Boshear(1974) also suggest that social interactions also take place on another channel; facts. As a manager, I must take all of these into consideration, to support the values and beliefs of my staff; thus the structure and culture of BENPct. Remember the qualities of good communication; clarity sufficiently accurate right route sufficiently complete the user will have confidence timely relevant not excessive given to the right person cost is not excessive