End of management (long version)

A shorter crisp version (about 600 words) is published in the FMLM (blog http://www.fmlm.ac.uk/blog/makani-hemadri/end-management)  for which this topic was originally written. This is the rambling 1500 word extended narcissistic version. You are welcome to it ...  

It is important to read Alan Murray’s ‘The End of Management’ Corporate bureaucracy is becoming obsolete. Why managers should act like venture capitalists; in the WSJ. Here is the link: http://online.wsj.com/article/SB10001424052748704476104575439723695579664.html

Once you have read this blog post gets its context and then you can read this either as a commentary of the WSJ article as relevant to NHS or on its own. This blog is deliberately off-key, the topic is such, bear with me. Compared to many healthcare systems we do quite well in the NHS. Could we do better? Of course yes but how we do that will define our future.

We are the management and we will tell you how to end management!?!?!

At a broader level, in the NHS there are no examples that I can think of where corporate structure or management has been ‘ended’. The previous government did good work with top down waiting times and so on; the present government is attempting top down radical change in organisational structures. The government is trying to get us do differently. When individuals try to do something creative, the organisations and the NHS as a whole tries to look at 'where and how it fits in with the overall plan'. But in the public sector there is the government not just wanting us to do different but also telling us how precisely to do it; with organisations 'encouraging innovation and creativity' only if it fits in with pre-defined policies. But that is what modern business is trying not to do; modern thinking in management is not telling people what to do but to let people to do things first and the management to amplify the good ideas.

Thinking of me vs thinking of you

At the narrower level, trainees (I am talking about all trainees in the clinical areas- not just doctors) are taught to think of how they are learning and improving themselves; never to explicitly think about their contribution to the organisation. In fact, often people think that their contribution to healthcare as such starts only when they stop becoming trainees. By that time the mind set becomes so fixed in thinking inwardly about the self and not outwardly about others that it becomes very difficult for the rest of their lives. Careerism becomes the mantra for many people in healthcare; we always thought this was the case in the private sector - true but that trend is changing in some areas. 

Best with limits

This leads to people taking very defensive attitudes. Most people in healthcare management are either numerically shy or numerically illiterate. They are unwilling to make a personal numerical prediction on their or their department/division/directorate’s improvement based on a measurable internal parameter due to the fear that they may be unable to stand by it. In any case most of the numbers are geared towards predefined reporting parameters. People who work in the NHS also seem to think that they are somehow very altruistic and have a high sense of entitlement. That attitude is even more profound in the clinicians with clinicians tending to believe that they express their altruism by their very individualistic approaches to healthcare. It is also possible that there are certain kind of people who are drawn to public services (possibly risk averse, change shy, rule-bound, authority loving, service minded and so on) and it would be difficult to use the same methods as for instance in Google to achieve a new management approach.

At both the above levels, healthcare and NHS is thought to be too important and too costly to be creative or innovative; the phrase used is 'risk'. Healthcare especially in Europe and even more so in UK has innumerable external controllers and bodies telling people what to do and how to do it that it simply chokes off creativity even before it begins. In other industries there is an obligation to do some degree of statutory reporting with no real controls on how they do their business.

So, it seems like what the above WSJ article is saying is not possible in UK healthcare at all. There seems no space that is available or can be created for those concepts to happen without falling foul of something or someone. But there lies the opportunity as well to ‘end management’ and create self-sustaining systems.

Blue skies

Hence, I can now boldly enter the imaginary world to explore how the 'wisdom of the crowds' can be harnessed. I think the way to do it is to disengage from current conventions and demonstrate its success. That does not mean rebelling, non-cooperating, behaving illegally, not concentrating, becoming disenchanted or any such thing. It is using our own methods to satisfy our requirements and our clients’ requirement rather than using a method or doing a thing to satisfy an external definition. 

For instance when the roads around Birmingham were choking instead of building a new road, they opened the hard shoulder to traffic which in other roads is actually illegal; peak time traffic situation has improved since in that area. Compare that with an example of the situation in some hospitals where they buy yet another business intelligence interface/data-mining tool to provide information at service line specialty level when the managers and clinicians often feel that human connectivity was the issue that needed resolving to enable their older software to be used effectively. Often the tool is not really the problem, our thinking is.

Let us assume for example that one of our services is not accredited by some specialty society because we did not meet one or more of their requirements in the way they wanted. Normally the tendency would be either to stop that service or to work very hard to meet that accreditation standard. However, if our results in that particular specialty or aspect is better than anywhere else, would we as an organisation, anyone in the specialty society or the general society as a whole be unhappy? Certainly not. In this scenario the badge of not being accredited becomes a badge of honour. The problem is we do not think like that in the NHS. We probably should.

Like the Birmingham roads, what 'illegal' things could we do to make ourselves better?

Obviously we should disengage and develop only if it is beneficial to our hospital and patients and we are able to track it and prove it contemporaneously.

Is this an example of wisdom of the crowds in the real world of healthcare?

     Finally let me try a hypothetical yet hopefully practical proposition to disengage and demonstrate. There is a focus on Unplanned emergency re-admissions and we may not get paid for such re-admissions. I am aware of some of the things that we have started doing to tackle this issue. Let me put to you a potentially disruptive solution in the 'end of management' mode 

     

      a) not offering routine follow-ups for any patient who is discharged from the ward (medical, surgical, post-operative) 

and instead

b) Guaranteeing a clinic slot within a defined time (48 hours to one week as agreed) should the patient choose to contact us.

My hypothesis is, this approach will reduce unplanned emergency readmissions as the issue is often/mostly to with patient concerns on access (rather than real life-threatening matters); the 'routine' follow up itself is mostly to satisfy clinicians habit rather than a scientific finding that all complications in all patients happens precisely 3 months after seeing the doctor and hence patients need a 3 months appointment. This will also clear up the 'congestion' we have in our clinics. 

Okay, where is the 'wisdom of the crowd' here? The crowd in our example is the patient; and the wisdom is the patients’ knowledge about their own health on what is wrong with them and they should be able to access us when they find something wrong with them. This is of course one step further than the current thinking on 'crowd' which is usually the employees in a large organisation. We even need to change the definition of crowd to suit our requirement. 

Rambling ambiguity and the threads of new systems

We can predict that the conventional management methods will not work in the 21st century. End of management as we know it is not chaos as many would like us to believe. New models are not apparent or clear yet. Perhaps there may not be one new model; possibly there may not be a well defined model at all. There are emerging themes; democratisation of data, data mining, crowd sourcing, coping with anti-knowledge, cloud care and dumb-terminals, many more............ It is not these themes that are important; it is how we implement these themes that are relevant. We can be told how to do it thus not ‘ending management’ or we can show how we do it.

Thank you for getting to this sentence of the blog. If you thought this was rambling ambiguity, I am grateful for your attention and will do better next time. If there are some threads that we can build on then I have achieved my aim.

©M HEMADRI 

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