anew rung on the

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The author is Area Nursing Officerfor Newcastle.

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Many administrators want chief executives at each level of the NHS. Tony Carr,SRN, NDN,Cert, Queen's Nurse, FRSH, FHA, MBIM, calls it the creation of asupreme commander - the wrong style for the NHS. He says power must be shared:a corporate team must make the decisions.

THE IDEA of a chief executive ateach level in the NHS has beensuggested by various groups from

time to time - and Health Service ad-ministrators have always been to thefore among these groups. No doubttheRoyal Commission on the NationalHeaith Service has been, or is, givingsome attention and time to clarifying itsposition on this matter. There is, to mymind, one serious reservation to the pro-posal which needs mentioning right now.

In industry, the board of directorswith its chief executive, whatever histitle, spends money - but produces it 'first. They are essentially wealth cre-ating organisations. A profit, eithermedium- or long-term, must be shownon production and investment. A manor a woman with a good subordinateteam who creates wealth, perhaps whenacting within the policy of that companyand within the Companies Acts, has aright to be the ultimate decision maker.Generally, his contract can be ended ifthe performance does not match expec-tations and promises. But today, even inthe cut and thrust of business, the ideaof one man or woman holding the des-tiny of a company single-handed is de-clining.

Sharing powerMany believe corporate management

decision taking is the' better way, ofmanaging the business affairs of a com-pany.Not all the expertise is necessarilyin the hands of one man. Whatever thereasons, the power and authority inpractice, even if not in name, are beingshared.

There are many functions connectedwith the wealth-creating aspects of acompany that do not apply necessarilyto the Health Service. Proper invest-ment, for instance, is vital for the organi-sation's survival. Its marketing functionis also critical. I include ,in that, ofcourse, the packaging of the particularproduct and its sales promotion. Theproduct can be superb - but if it will notsell, the business will fail.

It should not be assumed that manag-ing an enterprise in the private sector issimple. The ultimate product may beeasy for the public to understand: an

electric light bulb, a tin of grease or amotor car. But the management skill inobtaining co-operation and co-ordina-tion from production and supportdepartments is immense. I say thisbecause many Health Service workers,and perhaps in particular nurses, maythink that when comparing their organi-sation with industry, the NHS is verymuch more complex. That may be so.But industry is not a simple organisationto manage.

Wrong styleI do not believe, however, that the

chief executive is an appropriate man-agement organisational style for theNHS. Many supporting the chief execu-tive idea would use the local authority asan example of how it could work in thepublic services. It is forgotten that localauthorities do, in part, create their own,wealth by the raising of taxes, and canuse it for what the councils wish. But Ihave also seen, even in local authorityorganisation, that when professions areinvolved - for example, in social services- then that department seems to oper-ate, in some sense, as apart from the restTony Carr

of the organisation. I believe it is thislarge professional input of caring forpeople which creates this difficulty. Itspolicy is influenced far more, to my'mind, by the professionals in the socialservices organisation and the councillorsin the major social services committee,rather than direct non-professionalsenior management intervention.

Turning to the NHS, we have a com-plex organisation very different from theindustrial model. The wealth is createdby the country as a whole through taxesallocated by Parliament. The amount ofdepartmental moneys for each financialyear, allocated to the NHS, depends toa large extent on the prosperity of theproduction: the performance of industryand the results of investment.

The NHS contributes indirectly tothis wealth by returning to the com-munity able-bodied people who will inturn contribute to the nation's produc-tivity. This is counteracted to someextent by elderly and long-term psychi-atric patients. So the NHS managementteam concentrates its time on the 98 percent recurring revenue, not on how tochange its production capacity to createmore money - well, not very often!

PQwer problemAnother major difficulty in the cre-

ation of a supreme commander, is whatwould he or she command or control?In American hospitals, where there is achief executive model, the complaint isthat the chief executives have no realcontrol over the way most' money isspent. Doctors and nurses, according toone source, spend 84 cents in every dol-lar. It should be noted, too, that gener-ally this type of administrator has toraise the finance and also has a majormarketing function in a very competitivemarket.

The chief executive cannot, by thevery nature of the hospital, control or in-fluence the day-to-day work or output ofthe ward or department to any realextent. Certainly, I have not seen verymuch resulting from concentrating oneperson's' energies on altering the workperformance of a ward or a departmentsuch as an operating theatre. The chiefexecutive could only attempt to controlthe secondary resources. This, amongother things, can take the form of a re-striction of service, closure of a ward or

Nursing Mirror, May 24 1979

adderdepartment and reduction of supportingancillary staff.

Reducing the yearly budget to adepartment is just fraught with diffi-culty. A pharmacist can be asked to cutcosts, but the medical staff are just aslikely to use an effective, expensive drugissued on general release during thatyear, and this money, unbudgeted for, isspent. The treatment is so effective thatthe patient turnover increases and/ withit, the total cost for each bed. A delightto the caring staff - a nightmare to theperson trying to control the situation.

I really do question the validity ofplacing one person in overall charge inthis situation, even if that person hasmedical training and background.

Prime purposeMany industries are complex organi-

sations, but a review of a hospital showsjust how difficult it is to manage in theHealth Service sector. A hospital'sprime purpose is to diagnose and treatpatients. This is followed closely byteaching students in a variety of the pro-fessions and, third, by engaging inresearch.

The doctor' in this situation is theprime member of staff. The organisa-tional chart is vastly different to that ofother organisations. Most people willappreciate that this senior, articulateand highly qualified person relates moredirectly with a first-line manager in thenursing services than anybody else.

The relationship between a ward sis-ter and a medical consultant has to beclose and clearly understood on bothsides. The ward sister, in turn, will relateto her own profession through a hier-archy of nursing officer, senior nursingofficer, divisional nursing officer and thedistrict or area nursing officer.

The medical consultant, on the otherhand, relates to his peers through con-sultative and staff committees and is re-sponsible either to the regional healthauthority for his employment contract,or to the area health authority in ateaching area. I think no-one can breakinto the working relationship betweendoctor and ward sister and succeed inchanging working arrangements, alterthe way they work or influence greatlyhow the work is conducted.

Group pressureA greater influence will come from

peer group pressure on consultants - orthrough the management structure asaffecting nurses. A decision made by achief executive could be challenged on

Nursing Mirror, May 24 1979

professional grounds by doctors, nursesand paramedical professionals. Theycould even call in professional statutorybodies to support their view. It would bevery difficult for a chief executive tochallenge much of the work of the pro-fessionals. So what authority would heor she have? Very little, I suspect.

Many have criticised the reorganisedHealth Service. But what really is thealternative? At present, we have nursingrepresented at the highest levels of man-agement, with administration, financeand medicine. This truly is a partnershipthat needs many years' practice before'the relationships can be effective. I

'If a review is to takeplace . . . J believe it has tostart at the bedside. Theproblems we have run intoover the past few yearsare because the reviewstarts at the top and worksdown. But the vital part ofany organisation should beat the patient's bedside, tosee what sort of structurethose working at the pa-.tient care area need. Itwould soon be found thatsome of the managementstructures do not producean efficient service ,

believe that with all its faults, it is onlynow coming into its own.

Starting pointIs there really any other way than

through general agreement with themajor professions and the administra-tive support services? I have not seen anappropriate model yet, even from thecritics of the reorganised Health Service.If we are talking of changing the man-agement structure below team level, thenI think this is a different subject - andchange may well be necessary in thenext few years,

If a review is to take place, and nodoubt the Royal Commission may giveits views on this, I believe it hasto startat the bedside. The problems we haverun into over the past few years arebecause the review starts at the top andworks down. But the vital part of anyorganisation should be at the patient'sbedside, to .see what sort of structure

those working at the patient care areaneed. It would soon be found that someof the management structures do notproduce an efficient service. For in-stance, the domestic working on a wardis managed by the ward sister, domesticsupervisor, assistant hospital secretaryor who else? I do believe a reappraisal ofmanagement structures from the bottomup, across all the disciplines, would bebeneficial for all staff.

A full circle may turn so that all theimmediate services are managed by theone profession, nursing. Look at theadvantages .. Nursing has a highlyorganised management structure at eachlevel of management. That structure isin operation 24 hours of the day allthrough the year, including Bank Holi-days. It is represented at ward level,where most staff are nurses or auxiliarynurses, and at district and area level.What more natural arrangement than tomake accountable to the most seniornurse, the heads of those support ser-vices such as domestic services, cateringservices, laundry and so on?

Time for reviewI know the cry over the past 10 years'

has been: "Relieve nurses of non-nurs-ing duties." In retrospect, I think manynurses would now say it is time toreview this concept. They see servicesoften having different aims to that of theward team, because the particularmanager of, say, the domestic services,has developed concepts of management .in a different way. Another advantage isthat nurses are there all the time. Therewould be continuity of service andsupervision.

It must be seen that caring for the pa-tient involves more than the basic cen-tral nursing function, that it embracesmany, if not all, of those other necessaryservices a patient and the nursing teamhave to rely on before effective care cantake place. And the nurse knows theneeds of the patient far more readilythan any other officer. She writes aboutthose needs and changing demandsseveral times a day and she has regularcontact with the public through visitorsand by telephone.

I suppose I could continue on theselines until a point is reached where astrong case is made for the nurse to bethe 'chief executive. I resist that temp-tation because it must be a corporateteam making the appropriate decisions.But if there is a single profession capableof making a bid for the chief position,who better than the nurse? 0

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