WK2 assignment due 313Assignment Analysis of a Pertinent H.docx
Between Two Worlds
1. SHORT DISSERTATION
NAMX3SDY
Commenced: 16th Aprill 2007
Submission deadline: 19th July 2007
University of East Anglia
School of Nursing and Midwifery, Institute of Health
BA (Hons) Policy, Planning and Leadership for Health Professionals
Between Two Worlds
An analysis of the dichotomous demands
on middle-managers in the modern NHS
and a proposal for a remedial model
by
Marcus Hayward
UEA Student No. 3034607
Word count: 4,995
First Submission
2. Acknowledgements
I am grateful to the teachers and staff at the School of Nursing
and Midwifery, University of East Anglia, for their support during
my undergraduate studies. I particularly thank Diana Lee, my
academic advisor during most of this time, for her encouragement.
I also extend my gratitude to staff based at the Dean of Students
Office, UEA, for the excellent and timely individualised support
they provided as I prepared to commence degree studies.
Thanks also go to senior staff at the NHS Trust within which I am
employed for their support of my post-registration studies over
the past 5 years. In particular I wish to thank John Warne for
supporting my application to commence this degree pathway and
for being instrumental in facilitating concurrent professional
development opportunities.
3. Abstract
This literature based study analyses the competing demands on middle-
managers in the modern NHS from the perspective of managing a Mental
Health NHS Trust’s Locality Community Service for older people. The
discussion is divided into three sections. Section One critically explores
the policies that are changing the way the NHS functions and demanding
the development of a business ethos with increased commercial
awareness. Consequently, middle-managers of clinical services are now
required to take on an expanded strategic and business focused role. After
defining the middle-manager, Section Two focuses on the middle-manager
of clinical services within the NHS and discusses the clinical and
professional leadership role also expected of them, particularly those from
a nursing background. Although previous studies have identified inherent
tensions in these competing demands, contemporary evidence suggests
that they are polarising into a, potentially untenable, serious dichotomy.
Section Three discusses the current national policy drivers underpinning
practice development in mental health care to support the proposal that
the dual responsibilities of the middle-manager need to be devolved. The
rationale supporting an alternative middle-management model is discussed.
One that advocates the practice development responsibilities of the middle-
manager are devolved, enabling the establishment of a robust and
adaptable matrix management structure. Although applied specifically to
4. a community mental health service for older people, this model is potentially
relevant to other services and has implications for many NHS providers.
The dissertation’s rationale suggests that such innovative approaches are
essential to enable NHS provider organisations to respond to the new
demands being made on them by the need for practice development and
the arrival of a competitive market. Failure to adapt threatens the demise
of established NHS providers, as independent sector health care
organisations offer commissioners more efficient and cost effective
services.
5. CONTENTS
Between Two Worlds
Introduction............................................................................. 1
Section One:
The changing NHS ................................................................. 4
Section Two:
The embattled middle-manager ............................................. 7
Section Three:
Devolution of the middle-manager’s dual roles .................... 13
Conclusion............................................................................ 19
References ........................................................................... 21
Appendices
Appendix I
Vertical organisational structure
detailing middle management level ...................................... 26
Appendix II
Matrix Management.............................................................. 27
Appendix III
Applied matrix management model ...................................... 28
Appendix IV
Vertical representation of proposed model ........................... 29
6. 1
Introduction
This literature based study analyses the changing role of National Health Service
(NHS) middle-managers in the context of changes to the NHS as a whole. Focusing
primarily on middle-managers from a nursing background, the discussion will explore
the apparent dichotomy between the demands of providing professional and clinical
leadership with those of functional and strategic management. Consideration will
then be given to an alternative model that the rationale suggests may be better able
to meet the multiple demands being made on NHS providers.
The literature has been drawn from various searches using: Journals at Ovid;
Cumulative Index to Nursing & Allied Health Literature Database (CINAHL); and The
Allied and Complementary Medicine Database (AMED). These searches used
combinations of at least two of the following keywords: NHS, management, manager,
change, leadership, nurse leader, clinician. Due to the very large number of articles,
the searches were limited to the last 10 years. This resulted in 557 titles, which were
all viewed over several sessions. Many articles were selected for closer scrutiny and
full text copies obtained of those with particular relevance. Searches, using the same
keywords, were also conducted using Google Scholar and resulted in further relevant
text being identified. Additional non-date limited literature has also been selected
from citations in articles resulting from the searches.
I selected this subject from the experience of taking on the role of Community Services
Manager (CSM) for a mental health NHS Trust’s Locality Community Service for
7. 2
older people, just over a year ago. Prior to this I was a senior Community Mental
Health Nurse (CMHN) in a specialist pan-locality Younger Persons Dementia Team
(YPDT). As the CSM, I provide a management and leadership function to three
multidisciplinary Community Mental Health Teams (CMHTs) for older people, a small
day hospital and the specialist YPDT. As a registered nurse, this includes my providing
a professional leadership role to nurses within the service. The CMHTs do not contain
the traditional team leader or manager role most commonly applied nationally (Burns,
2004), with these responsibilities assigned to the CSM. The CSM is also expected to
provide clinical leadership, particularly regarding issues that impact on the team as a
whole. However, as is frequently the case in CMHTs, the Consultant Psychiatrist has
an implicit clinical lead role (Burns, 2004), based on their ‘expert power’ (Mullins,
2002). Although the contribution of the Consultant is often essential, particularly in
services for older people due to the high incidence of co-morbidity (Royal College of
Psychiatrists, 2006), there is no explicit demarcation of clinical leadership
responsibilities. This creates ambiguity and the risk of conflict. I am directly
accountable to the Locality Manager – a general manager, who answers to the Trust’s
Executive Operational Team. The CSM role (see Appendix I) is therefore a prime
example of ‘middle-manager’ even if using the narrow definition applied by Currie
(2006) that I will discuss later. During the time I have been in post, I have become
aware of the growing strategic and business focused demands from senior
management. They, in turn, are driven by government targets and financial constraints
as preparation for entering a competitive market place (Pollack, 2004; Ham, 2004).
8. 3
This tension, between these business-focused developments and the need to provide
clinical leadership to front-line staff, demoralised by continued change (Wall, 2007),
inspired this dissertation and title.
The literature exploring the importance of leadership at all levels within the NHS is
extensive (DoH, 2007). Good leadership is integral to good management (Sullivan
and Decker, 2005). However, although frequently a distinction cannot be made
(Mullins, 2002), the focus of this study is on management rather than leadership.
Although issues related to clinical and professional leadership will be discussed within
the context of the middle management of clinical services, their further exploration is
beyond the scope of this dissertation.
The study is divided into three sections. Section One critically discusses the
government policies that are underpinning changes to the NHS, particularly over the
past seven years, and the consequences of these changes on the way health services
are managed particularly by middle-managers. Section Two analyses the literature
exploring the role of the middle-manager: progressing from middle-managers in
general to an analysis of those within the NHS; focussing on clinical staff, particularly
nurses, in middle management positions; and discussing inherent tensions in the
role that are leading to a serious dichotomy. Following a review of the latest Department
of Health (DoH) policies impacting on clinical practice, Section Three questions the
viability of combining clinical leadership with functional business management in the
middle-manager and concludes by considering whether an alternative model exists
9. 4
in which the dual role can be successfully devolved. The Conclusion considers the
implications of the findings for the NHS as a whole as well as for my own Trust and
the service I manage.
Section One:
The changing NHS
This section discusses the policy drivers that underpin the rapid changes to the way
the NHS operates, focussing on policies that impact on NHS management culture
and the consequences for middle-management.
The NHS has seen continued change since its inception (Ham, 2004). I have previously
explored the correlations between policy changes in health and social care and the
underlying political trends over the past 60 years (Hayward, 2006b). I argued that the
modernisation of the NHS, commencing with the arrival of the 1979 Thatcher
Government, was underpinned by monetarism and the free market economics of
Milton Friedman (Heywood, 2002). The underlying principles of maintaining tight
control of public spending, while at the same time deregulating to encourage market
growth, became part of the ‘third way’ approach adopted by the new Labour
government of 1997 (Heywood, 2002). This administration subsequently embarked
on a radical NHS restructuring and modernisation programme (Walshe and Smith,
2001; Ham, 2004).
10. 5
The period of particular interest to this dissertation is since the arrival of the NHS
Plan (DoH, 2000), which advocated the development of a service designed around
the patient with wide ranging reforms to increase capacity and ensure use of resources
to the best effect (Ham, 2004). The Plan included the setting of national standards
and targets. NHS organisations that performed well would gain increasing freedom
from central government control. However, Pollock (2004:63) argued that the Plan
would result in a “more radical marketisation of the NHS” – a road leading to increasing
privatisation.
The NHS Plan was followed by a series of further documents advocating the radical
reorganisation of regional and local NHS structures (Ham, 2004). Shifting the Balance
of Power (DoH, 2001a; 2002a) paved the way for devolving power to newly formed
Primary Care Trusts (PCTs), giving them responsibility for commissioning and service
delivery (Ham, 2004). However, Smith et al (2001:1262) considered that, although
advocating local control, these changes actually promoted a top-down style of
“unprecedented micromanagement from the centre” with “unrealistic targets and
objectives showered down on managers”. Despite the criticisms, the changes came
into effect during 2002 with the aim of giving local PCTs control of 75% of the NHS
budget by 2004 (Ham, 2004).
Delivering the NHS Plan (DoH, 2002b) maintained the pressure to reform and
introduced Foundation Trusts (FTs) that would enable NHS provider services that
performed well to gain relative autonomy from the DoH and Strategic HealthAuthorities
(Ham, 2004). Pollock (2004:71), however, argued that this actually represents “a
11. 6
drastic further step towards a fully marketised system” with FTs operating like
commercial companies. According to Pollock (2004:72), the focus will be on the
“balance sheets, not on meeting patient need”, which risks a reduction of less profitable
services, like those for mental health and older people.
The drive towards increasing commercialism and the growth of a business ethos
drawn from the private sector (Pollock, 2004; Ham, 2004), has continued with policies
(DoH, 2004a; 2005a; 2005b) that are transforming the NHS from a centrally controlled
monopoly to “devolved commissioners buying services from a mixed market of
providers” (Lewis and Dixon, 2005:1). Provider services, like FTs, are expected to
compete with others from the private, voluntary and statutory services to win contracts
and continue to provide a service (Timmins, 2005). Consequently, senior managers
are primarily focused on achieving government targets, while at the same time
developing cost efficiencies and commercial awareness within their organisations
(Forbes and Hallier, 2006; Bolton, 2003). This impacts on clinical staff in middle-
management positions, who, as Bolton (2003 cited by Faugier, 2004:20) pointed out,
are being asked to take on “the guise of new public management, and the moral
crusade of results, competition and efficiency that this entails”. However, these same
middle-managers are also expected to provide clinical leadership (Bolton, 2003;
Jasper, 2002) at a time when “strong clinical leadership is needed now more than
ever” (Wall, 2007:8).
These changes are coming when there is a general trend away from hierarchical
organisational systems towards flatter, more flexible structures (Floyd and Wooldridge,
12. 7
1997; Balogun, 2003). Currie (2006) and Balogun (2003) both cited numerous sources
to support their own arguments that this move towards horizontal structures has greatly
increased the strategic importance of middle-managers within modern organisations.
Within the NHS a major policy reform, Agenda for Change (AfC) (DoH, 2004b), has
contributed to creating a flatter system by changing the pay structure of non-medical
staff. I have previously explored the impact AfC has had on the structure of CMHTs
due to CMHNs previously on the Whitley grades, E, F and G all being assimilated
primarily onto the new AfC Band 6 (Hayward, 2006c). This effectively removed the
team leader role previously undertaken by senior G grade CMHNs, inadvertently
strengthening the Consultant Psychiatrist’s dominant position, contrary to the intention
of contemporary practice developments discussed in Section Three. This has also
emphasised the need for middle-managers to provide more explicit clinical leadership
to individual CMHTs. The combination of this heightened leadership role, together
with the need to contribute to strategic development and achieve government targets,
is putting increasing pressure on middle-managers (Hewison, 2006). However, before
considering this dual role further, it is necessary to understand what is meant by
middle-manager.
Section Two:
The embattled middle-manager
After defining middle-manager and discussing the role in general, this section focuses
on middle-managers within the NHS, particularly those from a nursing background.
13. 8
The discussion analyses the competing demands on these managers to ascertain
whether the inherent duality of the role constitutes a serious dichotomy.
Wooldridge and Floyd (1990 cited by Carney, 2006:24), defined a middle-manager
as someone who “reports to the chief executive officer, or who reports to a manager
who reports to the chief executive officer”. In their later seminal study involving 259
middle-managers, Floyd and Wooldridge (1997:466) concluded that they “perform a
coordinating role where they mediate, negotiate, and interpret connections between
the organisation’s institutional (strategic) and technical (operational) levels”. Replacing
‘technical’ with ‘clinical’ creates a description that is immediately applicable to health
care settings. Drawing heavily on the works of Floyd and Wooldridge, Currie (2006)
defined the middle-manager narrowly, arguing that some of the criticisms of the role
arise from studies that use too broad a definition, encompassing managers in junior
as well as more senior positions. This has resulted in middle-managers becoming
scapegoats for problems that often lie elsewhere within organisations. Currie’s narrow
definition identifies middle-managers within a health service context as those
responsible for a number of wards within a hospital or multidisciplinary teams within
a directorate (or locality) and with “at least two hierarchical levels under them” (Staehle
and Schirmer 1992 cited by Currie, 2006:6). The role of Community Services Manager
within a mental health NHS Trust’s locality is therefore a perfect example of Currie’s
narrow definition of middle-manager (see Appendix I).
Although traditionally a role with limited involvement at strategic level (Carney, 2006),
middle-manages are now increasingly recognised for their potential to make strategic
14. 9
contributions (Currie, 2006; Balogun, 2003; Dopson and Fitzgerald, 2006). Floyd
and Wooldridge (1997) considered them a vital link between levels within organisations.
Their strategic importance arises from the very fact they are in a boundary-spanning
role. They connect operational and strategic levels and mediate between both internal
and external environments. On the other hand, as a result of being in such a pivotal
position, both Currie (2006) and Balgoun (2003), citing numerous sources, pointed
out that middle-managers have been heavily criticised as the cause of many
organisational problems – “targets for the blame of contemporary decline in productivity
and competitiveness” (Currie, 2006:6).
The role of middle-managers in the NHS has been no less controversial and influenced
by the rise of new competitive realities (Dopson and Fitzgerald, 2006). In fact, Currie
(2006:8) suggested that, unlike the private sector, middle-managers in the NHS have
not enjoyed any form of “golden age”. On the contrary, they have continued to bear
the brunt of much criticism and are a target for the cutting of management costs.
Given such criticisms, the question must be asked: where do NHS middle-managers
come from?
There is a long tradition of clinical staff taking on management responsibilities within
the NHS. Nursing is the largest health care profession (Lewis and Urmston, 2000)
and invariably, therefore, more middle-managers come from the nursing profession
than from any other NHS staff group (Hewison, 2006). One important study identified
that around 50% of middle-managers were from a nursing background (Carney, 2006).
Not surprisingly therefore, the issue of nurses in middle management has been much
15. 10
explored in the literature (e.g. Currie, 2006; Bolton, 2003; Cameron, 2000; Lewis and
Urmston, 2000). The Salmon Report (1966 cited by Bolton, 2003) first officially
endorsed nurses as managers, recognising the importance of nurses managing and
leading nurses. But NHS middle management has changed significantly over the
last twenty years (Dopson and Fitzgerald, 2006). Following The Griffiths’ Inquiry
(1983 cited by Pollock, 2004) into NHS management, non-clinical general managers,
with responsibility for financial efficiency and performance, were introduced throughout
the NHS (Bolton, 2003). However, far from removing health professionals from
management, government reforms since the mid-1980s have actually sought to
increasingly include them in general management and in the strategic process within
the NHS (Carney, 2006; Forbes and Hallier, 2006; DoH, 1999a). Focusing on the
implication for nurses, Faugier (2004:20) argued that this “effectively swept aside the
existing system of nursing leadership and layers of nursing management”.
Nevertheless, middle-managers from clinical backgrounds are still expected to provide
professional leadership (Bolton, 2003; Jasper, 2002). However, with the growth of
multidisciplinary teams, this role is becoming inter-professional (Burns and Lloyd,
2004; Norman and Peck, 1999). Consequently, these managers, particularly from
the nursing profession with a forty year history of providing uni-professional leaderhsip,
face unique challenges as they seek to reconcile traditional professional and clinical
leadership roles with the demands of modern management (Jasper, 2002).
Carney (2006) suggested that health professionals taking on a management role do
so in addition to their clinical duties. However, Forbes and Hallier (2006) argued that
16. 11
only those middle-managers from the medical profession tend to be able to maintain
clinical practice. Nurses on the other hand, on becoming managers, find they must,
“leave behind their clinical role, whilst conversely, maintaining responsibility and
accountability for others clinical practise” (Jasper, 2002:63). Joss and Kogan (1995
cited by Savage and Scott, 2004:425) cautioned “against putting middle-managers in
situations where their corporate management responsibilities clashed with their
professional values”. Causer and Exworthy (1999 cited by Hewison, 2006:1) used
the term “hybrid management” to represent a dichotomy that exists between the
complex demands of middle management along with the “professional responsibilities
which come from being a nurse”. Bolton’s opinion (2003:123) that the dual roles of
the nurse manager are not “diametrically opposed or a simple dichotomy”, is countered
by others, such as Forbes and Hallier (2005:123), who highlighted an “inherent tension”
between a nurse manager’s clinical values and increasing management demands
for improved efficiency and cost effectiveness. Hewison (2006:1) went further, arguing
that “fundamental conflicts” can result for managers balancing “the demands and
needs of the organisation with those of the patient”.
My own experience as a Community Services Manager has reflected these issues. I
soon became aware of the tension between the demands of the organisation for
increasing commercial awareness and cost improvements, and the clinical leadership
needs of staff within the service. In fact the strategic drive for increasing efficiency
while reducing costs, in preparation for entering a competitive market place, are primary
objectives of the management team of which I am now a part. Although this strategic
17. 12
and commercial awareness is developed and nurtured collectively within the
management team, the clinical leadership responsibilities expected of my role are
left to my own interpretation and resources. Forbes and Hallier (2006) pointed out
that, on becoming managers, nurses are seen by their nursing colleagues as being
associated with management rather than the nursing profession. They argued that a
nurse manager’s lack of clinical practice results in erosion of core nursing skills,
leading to a “de-skilling process” and a “loss of credibility by nursing colleagues”
(Forbes and Hallier 2006:41). Bolton (2003) concluded that subordinate staff may
not only see managers, collectively, in derogatory terms, but attach less social value
to the role. I consequently found myself, as Bolton (2003:127) described it, “between
a rock and a hard place” – a recipient of staff resentment over the business ethos
inherent in the new management philosophy with which I was now identified. In
response to such pressures, Jasper (2002:64) suggested that managers “need to re-
evaluate their clinical roles” if clinical leadership credibility is to be regained.
This section provides compelling evidence that a potentially serious dichotomy does
indeed exist in the dual role expected of clinical staff, particularly nurses, in middle
management positions. They are caught in the “tension between the need to change
and the continuity of traditional values and systems” (Hewison, 2006:1). But is there
a workable solution?
18. 13
Section Three:
Devolution of the middle-manager’s dual roles
After a brief consideration of organisational management and leadership pressures
in the modern NHS this section reviews the latest policy developments impacting on
practices within mental health services. The discussion then considers whether the
devolution of the middle-manager’s clinical responsibilities are not only possible, but
essential to resolve the identified dichotomy in the role and enable the successful
implementation of clinical practice developments.
In a previous essay I explored the importance of leaders within the NHS being able to
motivate staff (Hayward, 2006a). Although concluding that motivating others is
essential to successful leadership, I also argued that nurses and other health
professionals frequently enter a career in health care for the intrinsic rewards that
come from providing a service to others. Such a workforce performs best with a neo-
human relations management approach (Mullins, 2002) or what Flynn (1992 cited by
Bolton, 2003:125) referred to as “new wave management”, which advocates “worker
empowerment and commitment”. However, Bolton (2003:125) argued that the
increasing emphasis on budgetary controls, improved efficiency, and “performance-
conscious management” in the modern NHS is leading to a return to classic
management (Mullins, 2002), or what Pollitt (1993 cited by Bolton, 2003:125) called
“neo-Taylorism”. The resultant tension contributes largely to the low morale that Wall
(2007:8) identified as being endemic in the “new-look NHS”.
19. 14
The DoH has attempted to reconcile these competing demands by advocating the
establishment of dedicated clinical leadership roles like that of Nurse Consultant and
Modern Matron (DoH, 2002b; 2000;1999a). The DoH has been careful to avoid the
use of management language when describing the new clinical roles (Bolton, 2003).
On the other hand, Savage and Scott (2004:419) considered that they actually fit the
“hybrid management” model previously discussed, and are exposed to the same
conflicting demands as middle-managers. Importantly, however, they conclude that
those modern matrons who work from the bottom-up and remain “firmly rooted in the
clinical domain” are “powerful agents of change” (Savage and Scott, 2004:425). In
contrast, those with a top-down agenda, expected to meet externally imposed targets,
face considerable role tension.
So, nurse leaders in clinically focused roles can be effective agents of change. On
the other hand, as already identified, if the clinical leadership role also demands the
implementation of commercially driven budgetary controls and the achieving of
performance management targets, serious tensions arise. This suggests the need,
not only to devolve the clinical leadership role from the middle-manager of clinical
services, but also to ensure that the focus of the new role remains on clinical practice.
Before considering a possible model, applicable to a community mental health service
for older people, it is essential to consider some of the policy drivers underpinning
practice developments within such services.
National Service Frameworks (NSF) have underpinned service development in virtually
every area of health care. The NSF for Mental Health (DoH, 1999b) and the NSF for
20. 15
Older People, Standard Seven (DoH, 2001b) have ensured the continuing refocus of
mental health care from hospitals to the community. Multidisciplinary CMHTs have,
therefore, an increasing and vital role to play in the current and future provision of
mental health care (Burns, 2004). The traditional dominance of the medical model in
mental health is being challenged by the ongoing development of psycho-social holistic
approaches (Kendler, 2005; Carr, 1996). The dominant role of Consultant Psychiatrists
in clinical decision making is also undergoing review (DoH, 2005c; 2007). The medical
profession has traditionally enjoyed a high degree of “clinical autonomy” (Forbes and
Hallier, 2006:34) as well as the implicit lead role within CMHTs previously discussed.
This leads to tension between medical staff and management, particularly when
management-driven changes threaten this autonomy (Forbes and Hallier, 2006). The
DoH, recognising the need for fundamental cultural change, has instigated a multi-
stakeholder initiative called New Ways of Working (NWW). Initially targeted at
Consultant Psychiatrists (DoH, 2005c), NWW is now commencing the second wave
involving all members of multidisciplinary teams (DoH, 2007). In essence it aims to
promote “a model where responsibility is distributed amongst team members rather
than delegated by a single professional, such as the consultant” (DoH, 2007:14).
This will require a major cultural change in the way services are managed and
delivered.
It is unrealistic to expect the middle-manager of clinical services, no matter how
experienced as clinician, manager or leader, to project manage successfully the cultural
changes and practice developments demanded by NWW. This is asking too much of
a role that has already expanded to embrace new commercial and strategic demands
21. 16
(Carney, 2006; Balogun, 2003; Floyd and Wooldridge, 1997). While the middle-
manager remains focused on the need to meet the performance targets of the new
market driven NHS (Pollack, 2004; Ham 2004; Smith et al, 2001), there is clearly a
need to devolve the clinical leadership role for the purpose of practice development.
This would not completely remove middle-management’s clinical responsibilities, but
would acknowledge that management and clinical leadership are “two different facets
of the coin” (Jasper, 2002:64). Professional leadership is a separate issue, particularly
in regard to multidisciplinary teams, the further consideration of which is not possible
in this study.
Practice development (PD) has been used to describe the process of modernisation
in health care delivery (McCormack et al, 2006). McSherry (2004) considered a
primary role of PD is to promote innovative practices, leading to improved quality and
excellence through supporting individuals in clinical practice. Arobust structure better
able to implement and sustain NWW would be created by establishing Practice
Development Lead (PDL) roles, dedicated to project managing practice developments,
along with middle-managers maintaining functional, budgetary and operational
management responsibilities. For example, NWW will inevitably create tensions
between consultants and management (NCCSDO, 2006); shared responsibilities and
tripartite discussions, enabled through the establishment of a PDL, would mitigate
the risk of polarised conflict developing. This division of responsibility into a functional
manager and project manager creates a grid-like organisational structure known as
‘matrix management’ (Gunn, 2001; Ford and Randolph, 1992). (See Appendix II.)
Although many organisations are adopting a matrix approach to deal with the
22. 17
increasingly complex business world in which they must operate (Sy and D’Annunzio,
2005), there is little evidence this has occurred in the NHS. Why is this?
Large public sector organisations continue to be underpinned by bureaucratic principles
(Tappen, 2001), which requires a hierarchical top-down authority structure with clear
lines of accountability (Cole, 1996). Matrix management, on the other hand, violates
these bureaucratic principles of responsibility equating to authority and every
subordinate being line-managed by a single superior (Sy and D’Annunzio, 2005).
Power is typically shared by two or more managers performing different functions.
Bureaucracies are considered essential to enable complex organisations, like the
NHS, to function smoothly (Tappen, 2001). However, they also create a culture that
has difficulty adapting to change (Mullins, 2002). But, as already discussed, the NHS
is currently undergoing fundamental change. Sy and D’Annunzio (2005) pointed out
that the ability to adapt to innovation and change is one of the major strengths of
matrix management. So, although the cultural change required to embrace matrix
management systems within the NHS may appear too great a paradigm shift to be
viable, failure to do so may prevent the ability to adapt to inevitable change, with
disastrous consequences. Private commercially driven companies are poised to
compete for contracts in the new health care market (Lewis and Dixon, 2005; Pollack,
2004). NHS providers unable to adapt to this changing world by improving efficiency,
cost effectiveness, and market responsiveness, will not survive.
The use of matrix management principles, at least in part, would therefore appear
essential – not only to implement NWW, but also to ensure the very survival of existing
23. 18
NHS providers. For example, a matrix system could be established at a service
delivery level within the traditional hierarchical organisational structure. The resultant
model would enable matrix-based units to function within the parent NHS Trust, each
responding rapidly to the demands of their own service sector. Appendix III illustrates
such a structure applied to a community mental health service for older people. The
clinical leadership role is devolved to the PDL, working alongside the CSM to provide
a two-dimensional focus typical of matrix management (Sy and D’Annunzio, 2005).
Appendix IV illustrates how this two-dimensional structure fits with the traditional
hierarchical flow of control within the NHS and also provides a useful comparison
with Appendix I.
The PDL role must remain distinct from that of the CSM. The PDL’s focus being on
meeting national quality standards and the development of clinical practice, while the
CSM maintains responsibility for the functional management of budgets, human
resources, meeting organisational performance targets and so on. It is essential that
neither role is expected to deputise for the other as this would create ambiguity and
confusion, particularly for members of the clinical teams – a known risk of matrix
structures (Sy and D’Annunzio, 2005). Staff appraisals would be used to identify
senior clinical staff with the aptitude to deputise as part of their own professional
development. Conflict between the two-dimensional roles is also an acknowledged
risk of matrix management (Sy and D’Annunzio, 2005). However, harmony can be
maintained through the establishment of common goals and objectives. This would
be facilitated through the line-management of both the PDL and CSM being with the
24. 19
senior general manager of the locality and their joint membership of the locality
management team. The resultant structure not only resolves the identified dichotomy
inherent in the existing role of the middle-manager, but actually facilitates “the dynamic
exchange between two individuals” that Dopson and Fitzgerald (2006:49) consider
vital for the successful implementation of change in health care.
Matrix systems often require extra resources (Sy and D’Annunzio, 2005). It is
acknowledged that in this model, resources are required for the establishment of a
new PDL post. However, as already discussed, in the existing community service
structure (see Appendix I), the traditional role of Team Leader is absent, with the
CSM expected to provide this function alone for multiple CMHTs. In the proposed
matrix management model, team leadership is provided by the PDL and CSM working
together across all teams and services creating a more robust structure with greater
capacity to manage risk during the process of service development and change.
This model is, therefore, more cost effective than the traditional hierarchical team
leader structure, and will ultimately facilitate greater cost effectiveness as NWW
become established.
Conclusion
NHS policy development has been largely incremental, building on what has gone
before (Hill, 2005). This has led over time to unwieldy structures that are unbalanced,
inflexible and unable to adapt to changing demands of a 21st
Century world (Smith et
al, 2001). Traditional methods of public sector management have steered the NHS
25. 20
through the last 60 years, but are clearly no longer fit for purpose. The dichotomy
created by the increasing demands made on NHS middle-managers of clinical services
exemplifies the inherent weaknesses of the leviathan bureaucracy that is traditional
NHS management.
Innovation is needed at all levels. As we have seen, Government policy is driving this
innovation from the top, albeit controversially (Smith et al, 2001). But if NHS Trusts,
freed from central control, are to become truly learning organisations, transformation
is also needed from the bottom-up. This is achievable, but only with the major and
far reaching cultural change already alluded to. A new paradigm is needed in which
adaptation to changing demands is integral to the ongoing delivery of quality health
care. Failure to do this will see the demise of many NHS providers. The delivery of
their services and their human resources being transferred to commercially aware
independent sector companies able to provide commissioners with greater value for
money (Pollack, 2004; Smith et al, 2001). My own organisation and the community
service for older people that I currently manage must not succumb to such a fate, but
must make the transition into a service capable of thriving in an open market.
Faugier (2004) advocated that we should avoid ambivalence about management
and leadership roles, and actually seek to define them for ourselves. This is ultimately
what this study has attempted to do. I firmly believe the model advocated here, in
which the dual role of the clinical middle-manager is devolved, creating a two-
dimensional matrix management structure, is not only achievable within my own
service, but essential to enable it to survive and prosper into the future. n
26. 21
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30. Appendices
Appendix I
Vertical organisational structure
detailing middle management level ...................................... 26
Appendix II
Matrix Management.............................................................. 27
Appendix III
Applied matrix management model ...................................... 28
Appendix IV
Vertical representation of proposed model ........................... 29
32. 8
" $
8
" $
8
" $
8
" $
9
9
9
9
FunctionalResponsibility
CROSS-FUNCTIONALPROCESSES
FUNCTIONS
*
27
Appendix II
A matrix management structure
(Gunn, 2001; Ford and Randolph, 1992)
33. **
: **
;
2
,
%
28
Appendix III
Matrix management
Example of functional (vertical) and cross-functional (horizontal) elements
applied to a community mental health service of older people.
34. Middle
Management
Level
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! "# $
** "#$
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Clinical staff
Non-Clinical
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29
Appendix IV
Vertical representation of proposed organisational structure below
Executive Management level, for a Locality community service for older people
(for comparison with Appendix I – medical structure remains unchanged).
