Anne McBride reflects on whether 20 years of change in healthcare management has really brought new ways of working.
The beginning of my career at Alliance MBS happened to coincide with the early years of the Blair government and New Labour, a time which saw a determined emphasis on the need to introduce new ways of working across the NHS.
Yet if you look back today at those once shiny New Labour plans from 20 years ago and compare them with the government’s latest interim NHS Plan from the summer of 2019, you will find a striking resemblance in the narrative.
Which begs the question, are we simply reinventing the wheel when it comes to healthcare management?
What is clear is that there has been a lot of change across the health service in terms of roles, responsibilities and management over the past 20 years. Waves of policymakers will often say ‘let’s get people working differently’, but any change needs to be managed carefully and understood in the context of how healthcare practitioners work closely together, whilst also working to different limits on their practice.
For example, a recent study of skill mix changes in general practice - conducted here with colleagues and funded by CLAHRC (Collaboration for Leadership in Applied Health Research and Care) Greater Manchester - revealed ambiguity about the purpose and place of newly introduced roles in general practice, and created tensions around role definition and professional boundaries.
A key challenge was preparing trainees and practitioners to work in a clinical setting characterised by a higher level of uncertainty, pace, and responsibility. The new practitioners needed to adjust to a more autonomous style of working and this required a greater level of active risk management.
Without carefully managing the long-term planning of the funding, training and integration of all associated workers, you risk undermining the spread and sustainability of that change. And this is one explanation for why policymakers might assume that nothing is changing.
As this example shows, a number of new practitioners are now sharing some of the responsibilities in healthcare, sometimes through delegation. But the supervision of non-regulated workers (i.e. workers who are not allowed to work independently and to whom tasks are delegated) remains a particular challenge. For instance, who carries out this supervision and what burden does it place on the supervisor? Or, does the supervision even take place at all?
Even the transfer (without delegation) of tasks to regulated workers (i.e. health workers whose training provides them with a legal framework for their autonomous working) by senior clinicians is not without its issues. For instance, our research has shown that sometimes changing who does the task can lead to increased costs.
One way of ensuring that these issues are not overlooked is developing an organisational-wide workforce development strategy, as opposed to looking at the introduction of isolated roles. Indeed, over the years attempts have been made to encourage staff in NHS (England) to actively step up the career ladder and seek new work opportunities, such as through New Labour’s ‘skills escalator’ drive in public services.
As well as focusing minds on developing new, intermediate roles that span the gap between regulated and non-regulated jobs, the escalator also supported a more inclusive approach to encouraging and developing latent talent outside and within organisations.
However, again the evidence here is that employers have shied away from taking a more holistic, longer-term view of workforce development. For instance research by myself and, among others, my colleague Stephen Mustchin into seven different case study organisations found that such an approach towards employee betterment and organisational development was only truly embedded in one organisation. The pressure to meet short-term targets was a component of this reticence.
Research into practice
The latter point shows the considerable challenges around translating health research into practice. But despite these challenges it is good to be able to point to a number of examples at Alliance MBS where this bridge has been crossed.
For instance working with my colleague Professor Helge Hoel and industry specialists, we made recommendations for a practical approach to diversity and inclusion in the workplace. We used examples, such as the Skills Escalator approach, to indicate how decisions about recruitment and promotion were made in the best organisations, and incorporated these findings into a new BSI workplace standard.
Another example has been the work of CLAHRC Greater Manchester, an excellent collaboration between providers and commissioners from the NHS, industry and the third sector, which has looked at specific programmes such as end-of-life care, wound care, and helping stroke survivors, their carers and families.
This collaboration has also enabled myself and colleagues to work with others across The University of Manchester, and is now being continued through the National Institute for Health Research Applied Research Collaboration for Greater Manchester.