Memorandum by the Institute of Healthcare
Management (PSR 19)
The Institute of Healthcare Management would
like to take the opportunity to respond to the PASC Issues and
Questions Paper. It does so under the broad headings requested
although not necessarily in direct response to the sequence of
questions therein. The Institutes comments must be taken as relating
primarily to Health, unless otherwise indicated, since this is
of course its area of interest.
The Institute's purpose is to enhance and promote
high standards of professional healthcare management in order
to improve health and healthcare for the benefit of the public.
Its major objectives are:
To create, sustain and represent
a professional community of healthcare managers
To provide an independent voice for
healthcare managers, and to protect and promote the status, interests
and welfare of the members by ensuring that their contribution
to good health and healthcare is recognised
To influence policy, operations and
culture in UK healthcare
To provide strong local networks
and support for members, especially in times of professional difficulty
To promote professional standard-setting
To promote good practice and professional
To advance the study of and research
in healthcare management
To provide/support the education
of healthcare managers
The Institute is committed to support its members
with a personal and professional development framework.
1. Was reform unavoidable?
The need to reform the public services seems
to have been taken as a given and with this the underlying assumption
that they no longer fit for purpose for the 21st Century. Although
intuitively the Institute accepts this notion little has been
done to demonstrate that there are fundamental failings in the
concept or that reform rather than investment will resolve these
There does not seem to be the high level of
corruption that other countries seem to have. Outputs for cost
generally seem to compare well. The new District General Hospitals
say built during the 60s/70s and 80s did not seem to require PFI
initiatives to fund and the economy is supposedly much more sound
than at that period.
Perhaps more needs to be done to convince people
and organisations that the reform programme was inescapable.
2. How have the areas to reform been selected?
The reform programme is not evenly applied across
all the public servicesfor instance whilst there have been
cost constraints in the armed services there has been relatively
little structural or managerial change. Hierarchies still prevail
when many other employers have found greater employee favour from
other forms of management style. The change programme largely
unchallenges professional groupings or the basic principles of
a Parliament served by civil servants.
The change programme shows that democratic deficits
will still remain in some areas whilst others seem to be heavily
burdened with over representation. Quangos rather than elected
representatives still predominately govern many of our institutions.
However, which service is managed by which form of oversight remains
difficult to understand. Social Services is accountable to elected
representatives Health to a Quango except in Northern Ireland
3. Is reform UK wide?
The impact of devolution on this scenario is
also clear. If public service needs reform will it be UK wide
or simply country specific. The starting point was similar for
all the countries so one might reasonably have supposed if the
case for reform were self-evident all countries would be pursuing
the same agendas. This seems not to be the case and highlights
the dangers of true devolution and the problems of reform if for
instance there were to be Regional Government in England. In such
circumstances centrally driven and directed reform to standard
patterns is impossible but the alternative of local reform and
change leads to post code prescribing which seems to be unacceptable
to the electorate.
4. Is there a need for explanation?
These may all be appropriate differences, challenges
and anomalies and be more about priority and pace of change than
about concepts of the need for change and reform but perhaps more
needs to be done to explain and justify that this is the case.
For all its faults the NHS is based on the science of medicine
and as a science based organisation it likes to understand cause
and effect. What has caused the need for reform what will be the
effect of the changes? What seems evident from the short analysis
above is that reform is not universal.
We would suggest that all structural change
is largely irrelevant to the consumer/customer/client/patient
and that all that really matters is the standard of service they
receive at the point of need. It is likely that certain structures
are more likely to produce a better end product than others but
which and in what circumstances remains to a large extent a political
view rather than a researched one.
It seems popular to suggest that the public
service ethic is a thing of the past. There is certainly anecdotal
evidence that the motivators for many of the great professions
of the past have shifted. Junior doctors finishing shifts on time
irrespective of the fact that there are still patients to see.
Patients more willing to criticise failures than praise successes.
Nurses more willing to sell their extra hours back to the NHS
through an agency than directly to their employer. Managers given
hours to clear their desks as a new Chairman arrives. These are
wounds certainly in the concept of public service but all the
evidence to us here at the Institute suggests that these remain
the minority position. Surveys of consultants finds them working
well in excess of their paid hours. Graduate trainees still express
particular desires on entering the NHS to do good for others.
Many senior managers work in the NHS despite knowing personal
rewards are higher outside. These are very positive indicators.
However, the assumption we make is that this is not a public/private
issue and that many of the same values do apply just as strongly
in the commercial or private sector.
This point leads nicely into the next set of
questions posed in the consultation document. The Institute of
Healthcare Management has developed for its members a code of
behaviour and at the request of its members made it compulsory
as a part of membership. A copy of the shortened version is enclosed
with this submission for completeness.
The significance of this can be found when one relooks at the
membership of the Institute and the large numbers working in sectors
of health outside the NHS. These managers have had no difficulty
in signing up to values that embody all that one would expect
to see at the heart of the public service ethoshonesty
openness etc. This would seem to us to indicate that it is overt
standards that should be the issue not the employment base of
those exercising those standards. The medical profession have
the same core values wherever they are employed this should be
able to be applied to other areas. Lawyers work in the public
and private sectors so do qualified accountants. Moreover a lot
of services provided within the public service are provided by
outside contractors and have been for years. There should be much
greater clarity about the boundaries of that provision if it were
really that important.
It has to be accepted though that involvement
of the private sector brings a set of players to the table whose
interest in outcomes may be very different to that required in
the greater good. Shareholders and investors need to see returns
and this means that non-profitable lines have to be avoided or
discontinued. This inevitably means the pursuit of goals which
at best improve the lot of a sub set of the population rather
than the overall population. Health has many potential non-profitable
lines particularly as it veers towards chronic conditions and
social care. Moreover the argument goes that if the private companies
can provide and make a profit then the public sector should be
able to provide and convert the profit into more services on the
ground. These are difficult arguments to overcome since the implicit
assumption is that the private sector management teams are stronger
than those in public sector. If this is the case there needs to
be a stronger evidence base to confirm it.
It is clear from most international comparisons
that the potential exists for Health needs to outstrip the ability
of the public purse to meet those needs. This must be true in
several other public services especially those with strong reliance
on family and carers free input to provision as families disintegrate
in divorce and distance. (As an aside do carers automatically
espouse public service ethos and standards or are they private
sector providers?) Many countries have recognised that the challenge
for them is how to devote more resources to health and other underfunded
public sectors. It is more usual to find non-public sector sources
of funds to meet the gap elsewhere in the world. this could be
from individuals self-insuring or employers collectively contributing.
The point here then becomes whether it is moral
to have mixed economy fund raising but only public sector spending.
Many would argue that we need a lot more investment in Health
in the UK. This must at some point mean alternative funding sources
or much higher taxes in this sector also. If the former route
is chosen the argument for purely public sector provision based
on a notion of a public service ethic is impossible to sustain.
If old people in England have to give up their savings and property
to fund their care in the later stages of their life it cannot
be acceptable to suggest that the money has to be spent in the
public sector. Indeed if we are unable to fund care for our elderly
from the public purse is the concept of a provider being bound
to such an ethic a little hypocritical. There must be choice.
This may imply that the discussion is all too late and putting
the clock back is not possible.
These are extremely difficult issues but we
would argue the issue is again not a conflict about expenditure
in the public or the private sector but of standards protocols
and procedures governing all investment decisions. It proved difficult
in the early 90s during the conservative experiments with self
governing Trusts for elected representatives to say that they
were unable to answer the national questions since the local Trust
had made their own decisions. It is difficult to see that this
has or could reasonably change unless and until there was a very
local democratic process for the allocation of money and accountability
for its spending. This would mean much greater local government
or regional government or elected members of all public service
spending bodies. In saying this it also has to be recognised that
those structures that serve democracy and public accountability
well like committees, working parties, audit trails, paper records,
bureaucratic processes and so on are not necessarily the same
structures that ensure innovative and imaginative service delivery.
In other words the very consequence of a highly accountable structure
is one that is not customer focused. It spends too much time looking
up to the accountable body and its external monitors and not enough
delivering the public the service it wants. If these dilemmas
are genuine ones then it would be normal to suggest a compromisea
balance between ability to act be responsive deliver modern services
and the ability to account for ones actions. Solutions based on
compromise need very careful thought and perhaps this has to remain
in the less than ideal box.
So far as the NHS is concerned there is a massive
monitoring industry running to scores of bodies with a remit to
inspect and comment? If this is part of the compromise it is burdensome
and inhibits good managers from developing their organisations
and diverts valuable time from doing to answering monitors questions
about the doing. It is difficult to see the accountability argument
is stronger than the wasted effort argument.
It is unfashionable to suggest that the pendulum
is swinging too far the other way and in the age of consumerism
that there is a danger in too much power going to the consumer.
We will not suggest this but we will point to the dangers. It
is popular to suggest there are none that all public involvement
is good and good at whatever the cost in terms of time as well
The GMC has in the view of the Institute made
remarkable strides to modernise its public involvement but it
now sits somewhat uneasily between a public who may feel it has
not gone far enough and a profession that thinks it may have gone
too far. There should be universal praise for the model it has
produced but it has been mainly criticism. The public is not always
the reasonable person that attends committees and advises. Some
attack public servants in increasing numbers. Some vandalise public
buildings. Those involved with complaints in the public service
have noticed an increasing use of litigation. The fault for this
is often laid at the door of an unresponsive public sector who
only respond to the law but it is possible that there are elements
of anger, greed and revenge creeping into the public's view of
its public services.. A no blame culture is not one that all public
sector employees would recognise as existing where they work.
Stuart Marples FIHM
Institute of Healthcare Management
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