how the ‘customer’ influences the skills of the front-line worker

HUMAN RESOURCE MANAGEMENT JOURNAL, VOL 15 NO 2, 2005 35

How the ‘customer’ influences the skills ofthe front-line worker

Anne McBride, Paula Hyde, Ruth Young and Kieran WalsheManchester Business School, University of ManchesterHuman Resource Management Journal, Vol 15, no 2, 2005, pages 35-49

Previous research illustrates how managers use the ‘customer’ in the service sector todevelop roles and determine requisite skill sets. This article uses the evaluation of arecent workforce modernisation initiative in the NHS to provide insights into themanner in which the patient has played an increasing role in the construction ofskills in healthcare. It indicates how public-funded healthcare in the NHS containssimilar tensions and contradictions to service work in consumer capitalism.Although the patient is not in a position of authority, the desire of some workers toaddress fully the physical and psychological needs of the patient (or embodiedcustomer) leads them to develop skills and roles that management may find hard toresource within current budgets.Contact: Anne McBride, Manchester Business School, University ofManchester, PO Box 88, Manchester, M60 1QD. Email: a.mcbride@ manchester.ac.uk

Adistinctive feature of the service sector is the perception that the quality of thesocial interaction between workers and customers is a key factor in thesuccess of the service firm (Fuller and Smith, 1991). Taylor (1998: 87)

distinguishes two types of quality in terms of this worker-customer interaction. Thefirst is ‘technical’ (or hard) which includes product knowledge and knowledge ofoperational systems. The second is ‘functional’ (or soft) which refers to staffbehaviour, attitude and appearance. Research discussed in articles such as Fuller andSmith (1991), Taylor (1998) and Korczynski et al (2000) illustrate how managers haveinvoked perceptions of customer needs and wants, or used customer questionnaires,to develop the functional part of service quality delivered by their employees. In thismanner, customers have been indirectly involved in the development of new skills –namely, in the management of their own feelings and the projection of desiredcharacteristics to the customer.

The new, modern NHS is committed in numerous documents to being patient-centred (Department of Health, 2000a). Korczynski (2002: 96) notes how patients havebeen ‘re-labelled and reinvented as consumers of health’. Since the NHS in the UK is apublic-funded body which employs more than one million workers, has a high uniondensity and a predominance of professional staff groups, it is important to seewhether the patient/customer is invoked and involved in similar ways as in otherservice sector organisations and how this leads to the development of different skillsets among the workforce.

A Department of Health-commissioned evaluation of the NHS Changing WorkforceProgramme by the authors (Hyde et al, 2004) provides insights into the manner in whichpatient-centred concerns – and sometimes the patient – have played an increasing role

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How the ‘customer’ influences the skills of the front-line worker

in the construction of skills in healthcare. The article begins by noting the triangle ofinterests between consumers, workers and management. It then introduces the model ofthe customer-oriented bureaucracy (Korczynski, 2002: 97) which captures the tensionsraised by introducing customers to the worker management relationship. This model isthen used to dissect the policy of customer orientation within UK health services andhighlight the questions it raises for the development of skills. Following a brief outline ofthe research methods, we indicate how patients have been directly and indirectlyinvolved in skill development, and highlight some tensions and contradictions thisraises in a publicly funded bureaucracy. In this respect, public-funded healthcare in theNHS has similar characteristics to service work in consumer capitalism. Although thepatient is not in a position of authority, the desire of some healthcare workers to addressfully the physical and psychological needs of the patient (or the embodied customer)leads them to develop skills and roles that management will find hard to sustain. Thearticle also considers the implications of the research for the customer-orientedbureaucracy framework.

THE WORK EXPERIENCES OF FRONT-LINE STAFF

Front-line workers form part of a triangle of interests which also includes managementand customers (Frenkel et al, 1999). There are two literature streams to guide us as to theexperience, characteristics and management of such workers (Korczynski, 2001, 2002).The first, underpinned by unitarist assumptions, provides an optimistic image of thecustomer, workers and management working together in a ‘win:win:win’ scenario. Thesecond, more critical, approach indicates how each of the three parties can formalliances with one other party to exploit the third (Frenkel et al, 1999; Sturdy, 2001). Forexample, management can join with employees to manipulate customers or, equally,join with customers to supervise employees. Likewise, workers and customers can jointogether to influence and over-ride management decisions. This dynamic can beexplained through the use of Korczynski’s ideal model of the ‘customer-orientedbureaucracy’ which illustrates how service organisations are infused with two logics.The first logic demands that the organisation should be geared around the needs of thecustomer (the customer orientation). The second logic demands that the organisation begeared around the need for rationality and efficiency. These logics are frequently incontradiction to each other and contrast with the earlier imagery of the win:win:winscenario for customers, workers and management. Although Korczynski et al (2000)attribute these dual logics to consumer capitalism, Korczynski’s later work (2002)illustrates how this model can capture the contradictions of healthcare work regardlessof source of funding.

The customer-orientation bureaucracy model contains five organisationaldimensions – each of which contains two competing logics. One derived from the needfor rationality, the other from the needs of the customer. The first dimension of‘dominant organisational principle’ includes a logic in which organisations need to beorganised for efficiency and a logic that requires work to be organised aroundcustomers. The second dimension (division of labour) requires staff groups to be basedon efficient task completion at the same time as the creation and maintenance ofcustomer relationships. Dimensions three and four relate to the basis of authority andcontrol, and refer to it being exercised by management through output and behaviourmeasures at the same time as needing to be supplemented by cultural forms of control‘in which norms are based around the customer’ (Korczynski, 2001: 89). The fifthelement (affectivity) relates to the need for workers to rationalise the emotional labour

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they provide to the customer. Korczynski believes his ideal model captures ‘the keyelements in the organisation of contemporary service work’ (2002: 195), irrespective ofsector – but what does it tell us about skill development?

Skills are socially constructed from the power of workers to consent to, or resist, the(re)definition of skills around the needs of the job and the qualifications andcompetencies held by the workers (Cockburn, 1983). In short, skill definition is acontested terrain (Rainbird, 2000). The dual logics of a customer-oriented bureaucracy,and the triangular nature of the customer, worker and management relationship,present an interesting terrain for such a contest. The combination of these dynamicswould imply that skill development for the purpose of meeting customer needs will beencouraged, by management, at the same time as being constrained, by management,for reasons of rationality. The model also implies that workers will be organised (andappropriately skilled) into staff groups that will enable the creation of a customerrelationship, but that these skills, and the size of the staff group, will be curtailed by theneed to complete tasks efficiently. Mapping the definition of skills against thedimensions highlighted in the customer-oriented bureaucracy model raises thefollowing questions:

● around which skill sets is work organised? ● who gets trained in which skills? ● who has authority to define skills? ● who is in control of skill definition? ● what skills are developed in the area of affectivity?

These questions will now be addressed within the healthcare sector.

DEVELOPING CUSTOMER-ORIENTED HEALTHCARE

For the past couple of decades management has been restructuring healthcare, and thishas been conceptualised as being about changing to meet the needs of the patients,rather than the needs of dominant staff groups (Korczynski, 2002). In the UK this wasstarted in the 1990s by the Conservative government. Providing patient-centred carewas purported to be an effective means of improving quality, cutting costs andchallenging the priorities and practices of professional groups (Kendall and Lissauer,2003: 9). However, work by Thornley (1996: 165) illustrates how ‘the state was able toplay on the nebulous character of “skill” in nursing’ and substitute cheaper labour formore expensive grades in a process she calls ‘grade dilution’. At this point, althoughthe patient was invoked as the rationale for grade dilution in the 1990s, these debateswere not informed either by patients themselves or by patient-centred research.Latterly, however, there have been two drivers for bringing the patient into the socialconstruction of skills. First, the new priorities of the Labour governments elected in1997 and 2001; and, secondly, recent qualitative research into what patients want fromtheir healthcare services (Kendall and Lissauer, 2003).

Since its election in 1997, the government has indicated its intent to modernise thehealth service with its 10-year programme of investment in the NHS contained in TheNHS Plan (Department of Health, 2000a; Bach, 2002). The focus of this modernisationis to provide a health service ‘designed around the patient’ which entails that ‘step bystep over the next 10 years the NHS must be redesigned to be patient centred – to offera personalised service’ (Department of Health, 2000a: 17). The NHS Plan also laid out

Anne McBride, Paula Hyde, Ruth Young and Kieran Walshe

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two key objectives for the workforce: (1) specified increases in staff numbers, and (2)major redesign of roles for NHS staff which were followed up in the HR in the NHSPlan (Department of Health, 2002). The perceived connections between deliveringpatient-centred care and workforce changes are explicit in the policy documentation,and echo the positive image of patient, worker, management working together in awin:win:win scenario:

Developing the skills and potential of NHS staff is a fundamental part ofthis plan. The Government is committed to giving them the support theyneed in order to make the most of their contribution to patient-centredcare. By liberating the potential of staff the NHS can shape its servicesaround the needs of the patient. Department of Health, 2000a: 87

The second driver for including the patient in the social construction of healthcareskills is recent research into the nature of individual patients’ interactions withhealthcare practitioners and what patients want from their health services. Kendall andLissauer (2003) argue that this research (see Williams and Calnan, 1991, for an example)indicates that patient-centred practitioners are those who work to the patient’s agenda;listen and respond to what patients say; provide patients with high-quality, relevantinformation; and develop relationships that treat patients as partners in the process ofcare. In a publication for the Institute of Public Policy Research (IPPR), a centre-leftthink tank, Kendall and Lissauer (2003: iii) argue for patient-centred care that is safeand effective, integrated and seamless, informing and empowering, timely andconvenient, and which promotes health and wellbeing. Each of these characteristics hasimplications for changing occupational professions within the workforce andredefining skills. For example, the desire for services to be integrated and seamless maybe met by ‘an intermediate care practitioner’ who combines elements of nursing,occupational therapy, social work and home support in a new profession focusing onproviding services for older people (Vaughan, 2002).

The customer-oriented bureaucracy model explains how management can usecustomer needs to determine how work and workers are organised, and theseconnections are explicit within A Health Service of all the Talents, which argues for anemphasis on ‘maximising the contribution of all staff to patient care, doing away withbarriers which say only doctors or nurses can provide particular types of care’ (originalitalics) (Department of Health, 2000b: 5). This document also specifies that roleredesign, among other activities, should offer: greater integration and more flexibility ofworkers; better training, education and regulation of staff; and better managementownership through clearer roles and responsibilities of managers.

In particular, professional staff groups are being challenged to change traditionalroles, conventional team structures and hierarchies and existing care processes.Professional groups have distinctive characteristics which include a commitment to adistinct body of knowledge, restrictive entry, and peer group evaluation, control andpromotion (Dawson, 1992: 32). The NHS Plan (Department of Health, 2000a) andsubsequent materials imply that there is a greater scope for overlappingresponsibilities, flexibility, multi-skilling and generic work – none of which fits easilywith the aforementioned characteristics of professionals. Adjustments may involve asignificant redrawing of, or challenge to, the boundaries between existing professionalgroups and established job roles. This, in turn, is a major test for organisationalmanagement with professional groups questioning whether, and how, to maintain theirprofessionalism and identity (Doyal and Cameron, 2000) and many stakeholders



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needing to be convinced of the need for change (Leverment et al, 1998; Adams et al,2000; Halliwell et al, 2000; Read et al, 2002).

One of the key mechanisms employed to move towards a patient-centred healthservice is The NHS Modernisation Agency, established in 2001. (At the time of goingto press, the government announced that the work of the Modernisation Agency wasto be absorbed into a new NHS Institute for Learning, Skills and Innovation to beestablished in July 2005.) At the time of this research, the Modernisation Agency’sNew Ways of Working team was given a remit that involved the revision of pay andstaffing structures and the introduction of new and redesigned roles (ModernisationAgency, undated). Introducing the latter has been the responsibility of the ChangingWorkforce Programme (CWP) which set out to test new ways of working, such astransferring tasks to other professional groups, increasing the number of tasksperformed by staff, expanding the autonomy and responsibility within particularroles, and the creation of wholly new jobs. CWP came out of the aforementioned twodocuments: The NHS Plan (Department of Health, 2000a) and A Health Service of allthe Talents: Developing the NHS Workforce (Department of Health, 2000b), and sitsalongside other initiatives in the Modernisation Agency such as pay modernisation(known as Agenda for Change) and the implementation of the European WorkingTime Directive.

Beginning in 2001, 13 CWP pilot sites were established in NHS organisations orhealth economies around England. Each site was supported by two CWP personnelwho worked with local staff actively to develop and test new roles in healthcare (and,in some cases, social care) services. CWP provided funding for roles while they werebeing developed and tested, and for some training and development of local staff.CWP techniques ranged from analysing staff tasks to the use of daily diaries andgroup discussion (Buchan et al, 2001). The intention was that roles would be designedlocally under the guidance of CWP and spread throughout the NHS after successfultesting. The decision to adopt tested roles permanently, however, remained with thelocal organisation.

The positive win:win:win image of the initiative can be seen in its aim ofdeveloping ‘new ways of working which can improve both patient care and staffsatisfaction through the best use of skills’ (CWP, 2001). However, given that these roleredesigns were intended to challenge professional role demarcations, conventionalteam structures and hierarchies, existing care processes and established health/socialcare divides, such activity was likely to cause tension in the patient/worker/management relationship. In addition, some professional staff groups have morepower to resist some forms of change than others (Manley, 2001), adding anothertension to the terrain. Figure 1 uses Korczynski’s (2002) model of the customer-oriented bureaucracy to indicate the tensions that are likely to arise in thedevelopment of new roles and skills in healthcare. The authors’ 12-month evaluationof CWP provides evidence of these tensions arising from introducing an explicitcustomer orientation into the health service and confirms Korczynski’s (2002)argument that the model can capture the contradictions of healthcare work.

RESEARCH METHODS

The evaluation of CWP began in 2003. A realistic evaluation design was used whichseeks to answer questions such as what works, for whom, in which circumstances, inwhat respects and why (Pawson and Tilley, 1997). Over three phases of research thestudy aimed to analyse the development of CWP pilot sites, assess outcomes and



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perceived impact, and understand the characteristics of successful CWP initiatives.The first phase of the evaluation involved 30 interviews across the 13 pilot sites, andthe review of documents such as progress reports and steering group minutes. Phasetwo of the evaluation employed a case study design of four pilot sites. Two sitesfocused on the redesign of roles usually performed by senior house officers and alliedhealth professionals, respectively. Two sites focused on work performed by a varietyof occupational groups within older people’s services and mental health services,respectively. A fifth case study was of the CWP team itself, which enabled a wideroverview of the programme. The criteria for case study selection included varyingdegrees of progress in relation to individual roles, variation in type of role redesignattempted, and replicability and relevance to the wider NHS and other care sectors.Information sources included interviews, observations, attendance at meetings andsteering groups, and documentary analysis. The interviewees included CWP staff,senior management team members, clinical ‘champions’ of the project, role holders,HR managers and service user representatives. In total there were 64 interviewsacross the five case studies. All interviews were subsequently analysed thematically,together with documentation and notes of meeting observations and role shadowing.Case study summaries were sent to pilot sites for comment/verification purposes.Phase 3 involved two surveys – one of HR leads in NHS organisations in England,the other of people who attended a CWP training event. The survey of HR leadssought the extent of their involvement in role redesign activity in general, and withCWP in particular. The response rate for this survey was 29 per cent. It proveddifficult to reach attendees of the training event, and the final response to this surveywas 26 (37 per cent). The bulk of this article is based on the material collected in thecase studies.



Dimension Skill question Rationality logic Customer-orientedlogic

Dominant Around which skill Those that deliver Those that the organising principle sets is work organised? outcomes economically patient values

and efficiently

Division of labour Who gets trained in Only those who Anyone who maywhich skills? need them come into contact

with patient

Basis of authority Who has authority Only those in charge Patient groups/to define skills? of budget advocates

Basis of control Who is in control of Only those in charge Patient groups/skill definition? of budget advocates

Affectivity What skills are Keep to a minimum Exercise to extentdeveloped in this area? of patient need

Adapted from Korczynski, 2002: 83

FIGURE 1 Developing skills in a customer-oriented bureaucracy in healthcare

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DEVELOPING CUSTOMER-ORIENTED SKILLS IN HEALTHCARE

As noted in Figure 1, Korczynski’s customer-oriented bureaucracy model suggests thatthere will be a tension around which skills sets and which groups of workers areidentified for skill development. In accordance with the customer-oriented logic, roleredesigns were encouraged around the needs of the patient. CWP trained facilitators touse a ‘Role Redesign Workshop’, a set of materials aimed at supporting local staff inimplementing role redesign. Instructions were for workshop participants to ‘generateideas to improve the service through new ways of working... pick a small number (sayfour or five) of areas which are priorities in terms of high risk or greatest potential forbenefit, and concentrate on these’. By requiring staff to look at particular patientpathways (eg care of stroke survivors), the Role Redesign Workshop events indirectlyinvolved patients in role redesign.

Between April 2001 and the end of 2003, CWP’s work at the 13 pilot sites generated137 roles that had developed beyond the initial ideas phase. While the remit wasostensibly open to the development of skills for any occupational group that couldcontribute to better patient care, the largest proportion of redesigned roles in the CWPpilot sites involved nursing staff (32 per cent) and unregistered health or social careworkers (38 per cent). The survey of role redesign activity in the wider NHScommunity revealed that 71 per cent of all organisations responding had role redesignprojects that involved changes in the roles of nurses, and 61 per cent were redesigningroles for healthcare assistants and non-registered care staff. Given past tendencies forgrade dilution between registered and non-registered nursing staff (Thornley, 1996,2003), at first sight these figures suggest that the dominant organising principle anddivision of labour could be driven by the need to be more efficient and economical.However, qualitative findings discussed later indicate the autonomy of staff to developroles and skills around patient needs.

The dual logics for rationality and customer orientation (Korczynski, 2002) areevident in the guideline documentation produced for pilot sites (CWP, 2001). Thecustomer-oriented logic is seen in the note that ‘there will be a strong patient/carerinput to the design of new pathways and job roles’. The document also suggested that‘patient and carer representatives should be invited to participate as local stakeholders,and representatives from patient associations, associated with particular clinicalconditions, should be included as national stakeholders’. The rationality logic thenappears in a note that ‘changes to roles will be based on the use of care systems,pathways and protocols to ensure clarity, accountability and safety’. Protocols aredetailed descriptions of the steps to be taken – by whom, where and when – to delivercare or treatment to a patient, and infer replicability of care rather than uniqueness.However, while such documents can be analysed as containing contradictory logics,they are written to be read as win:win:win scenarios. As noted in a ModernisationAgency publication, ‘the development of protocol-based care is a key part of this visionof a health service run by a workforce that puts the needs of patients first’(Modernisation Agency, 2004a: 6). This set of documents also argues that protocol-based care can help patients because it ‘promotes high-quality, clinically effective care’and can help the workforce because it ‘improves team working across professionalboundaries and helps to do away with artificial barriers’.

The research indicated that there were two main ways in which the customer, or inthis case the patient, was an instigator in the development of roles and development ofskills. The first was through the direct involvement of patients, and the second wastheir indirect involvement through patient-centred discussions among the workforce.



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Both indicate the manner in which the CWP methodology engages front-line staff inchanging working practices, encourages them to transfer tasks and skills sets anddeliver and undertake training.

However, although managers were encouraging workers to engage with thecustomer, it was not the patient/consumer who had the authority and control overwhat skill sets were developed. Although the guidelines encouraged patientrepresentation on the project steering groups, approximately one year into the CWPinitiative only seven of the 13 pilot sites indicated having user/patient representation.(Even fewer had trade union and staff representation.) However, patients did have anindirect impact on skill development through roleholders taking the rhetoric ofcustomer orientation very seriously and developing their jobs around patient needsover time. This phenomenon echoes that seen in call-centre workers (Korczynski, 2001).It is illustrated in the following four examples.

Patient carer support worker

This role was designed to help older people get back home and maintain theirindependence by supporting them both physically and mentally over a potentially longstay in hospital. It requires the holder to follow a care plan developed for the clients bytherapists and to work closely with social care regarding hospital discharge (CWP, 2003:22). Two nursing auxiliaries working at the bottom of the grading structure tested thisrole on a half-day basis. The role has now become permanent and, when undertaken (ie50 per cent of their working time), the roleholders are paid at a higher grade. Althoughthis role started through the identification of need by nurses, its content hassubsequently grown around patient needs identified through focus groups. Theinterview transcript from one of the roleholders illustrates the evolutionary nature ofthe role redesign and the ongoing development of skills and personal satisfaction withthe change.

The interviewee notes how “there was nothing there originally” and how the job“just seemed to snowball and go into different areas, and different people becameinvolved, social services, older people and advocacy, homehelps”, and that it is stilldeveloping. A core part of the job is giving patients one-to-one attention both on theward and in a patient’s home on return from the hospital. The roleholders aresupported in their development through Level 3 NVQ training and other in-housetraining sessions. The roleholders have found it enjoyable and “hard at times”.

Stroke support worker

This role was designed to enable a healthcare assistant to deliver aspects of therapeuticcare to stroke survivors. The role was tested by a healthcare assistant who described herprevious role as “wash and dress them and help with the toileting”. The roleholderindicates the new therapeutic focus of her job, the closeness between perceived patientneed and job content, and a certain level of autonomy in the determination of the roleredesign. She notes how she is “devising little ways to see if they are seeing thingscorrectly”, how she liaises with the therapists and plans patient care. She believes she is“the ears and eyes of the patient – I fight the patient’s corner”. This skill developmentwas supported with a month’s training course covering all therapies, one-to-one tuitionwith the senior stroke nurse, and an eagerly awaited NVQ Level 3 course in the future.

Trauma co-ordinator

This role was designed to provide a more structured approach to the management ofpatients requiring trauma orthopaedic surgery. It requires the holder to work closely



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with anaesthetists and surgeons (CWP, 2003: 66), and was tested by a senior nurse.Although patients were not directly involved in the shaping of this role, they wereindirectly involved through the use of patient surveys, patient pathways and thedevelopment of protocol-based care. The role requires the transfer of responsibility formanaging the theatre list from the most senior grade of training doctors (registrars) tothe trauma co-ordinator, and could be interpreted as the appropriation by the nursingprofession of a key part of the doctor’s work organisation. This transfer met with littleresistance, however, as the roleholder indicated that “the consultants were super. Theywere very supportive”.

In addition to what could be described as a technical role, the trauma co-ordinatoralso wanted to develop the functional (soft) side of her interaction with patients. Inparticular, she noted that their “patient experience day” had indicated that somedoctors were not communicating with patients properly and she wanted to improve onthis. This desire to improve the softer side of the worker-patient interaction, whiletaking on a new technical task, was also an important feature in the following role.

Nurse-gained consent

This role requires the transfer of responsibility for gaining patient consent to clinicalinterventions from doctors to nurses (CWP, 2003: 66). The role was tested by two seniornurses who drew up protocols for nurse consenting and criteria for excluding patientsfrom nurse consenting. The roleholders argued that it was a task that the doctors hatedand did not “want to do because it is mundane and something that they can pass on tothe likes of ourselves”. They also noted that the consultants wanted them to do itbecause it reduced the workload of junior doctors. However, for nurses it was a“quality thing”, and “it is for the patient”.

These examples show that even when patients were not directly involved, they wereinvoked as a means of marking out what staff were prepared to do. Indeed, thetranscripts echo the observations of Wicks (1998), who noted the pleasure gained fromthe relational nature of nursing. However, the perceived needs of the patient were alsoinvoked when healthcare groups resisted the transfer of tasks to others. In particular,concerns about the proposed changes were often articulated through debates aboutpatient safety. This is not an incidental concern given the responsibility of all healthcareorganisations to engage with risk assessment and management (known more generallyas clinical governance (Scally and Donaldson, 1998). As noted earlier, ‘safe and effectivecare’ is also one of the five broad characteristics of ‘high-quality, patient-centred care’identified by IPPR. A clinical senior management team member at one pilot siteprovided several examples of role redesigns being stalled because of safety andaccountability issues. One case concerned pharmacists and nurses who objected toextending the role of an ophthalmic technician to include the injection of a fluid into apatient’s eye. In these circumstances, CWP facilitators were encouraged to ‘find out ifthe ‘rule’ really exists and what it really says’, since ‘most national rules are not nearlyas restrictive as people think they are’ (Modernisation Agency, 2004b: 19).

THE RATIONALISATION OF CUSTOMER-ORIENTED SKILLS

The Modernisation Agency was keen to stress that ‘role redesign is not a way of gettingstaff to do more for less, nor is it a cost-cutting exercise’ (Modernisation Agency, 2004b:10). However, it was also circumspect about the potential cost of role redesign, andappears to follow the mantra of quality initiatives industry-wide that ‘quality saves’,rather than ‘quality costs’. Indeed, it was noted at a national CWP presentation that



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‘most of these [new ways of working] are cost neutral’. Notwithstanding this belief, anumber of CWP roles were stalled awaiting finance (Hyde et al, 2004). Although theauthors found an example of a user/carer conference putting pressure on the localcommissioning body to fund two new nursing roles for people with dementia (Hyde etal, 2004), management were completely in authority and control and not releasingmonies for redesigned roles, even when roles were appreciated by patients. In addition,60 per cent of organisations responding to the Phase 3 surveys noted that the mainbarrier to role design projects was a lack of finances/resources. The authors’ researchindicates at least four funding issues that contradict the customer-oriented, or patient-centred, skill developments in the NHS – each of which is illustrated below.

Rewarding skill developments

Not all roleholders were rewarded for the extra skills that they developed as part oftheir role redesign activities. When asked whether they got a pay rise, one supportworker roleholder responded, “Do you mind if I ask you what planet you are on?... Ihave been doing this job now for just one year but no, I have not had a pay rise. We aretalking NHS, aren’t we?” Another roleholder (registered practitioner) noted thatalthough they had been in a new post and had taken on the extra responsibility for thepast year, they were not getting paid any differently but assumed that “Agenda forChange will probably sort those issues out, once we renew our job descriptions”. Tworoleholders who had received a pay increase noted, “We still do not think we are paidat the right scale for what we do. We have had all this extra training so we would hopethat it was a way to progress”. A clinical manager at another pilot site admitted thatalthough a redesigned role had “gone up one grade... it could even go up furtherbecause, depending on all the changes and looking at different ways of working, theyare responsible for more than they are actually paid for but... it is difficult to measureand say why”. The NHS is currently piloting a new pay system (Agenda for Change, seeDepartment of Health, 1999) which is designed to recognise and reward the ‘skills andcompetencies staff acquire throughout their career’ (Modernisation Agency, undated).These examples from a range of roleholders at different pilot sites indicate the futurefinancial implications of rewarding newly acquired skills.

Expansion in volume of proven roles

The research team collected data on 137 new or redesigned roles across the 13 pilotsites, of which a quarter had been fully implemented. Most of these involved one ortwo people, which in a 24/7 working environment meant that traditional practicesresumed in their absence. So, for example, the stroke support worker after a couple ofdays off work, found that patients who were washing themselves under her care werenow being washed by healthcare assistants. The specialist nurse in haematology andoncology noted that because no one person could cover her role in her absence,“different people have to pick up different parts of it” and “it will take you two daysto work out where everything is again”. In addition, when a number of new roleswere piloted, they were funded as ‘one-off’ posts on top of the maximum staffinglevels allocated to establishments. This meant that once the pilot (and the attendantfunding) had finished, the roles could continue only if new funding was found, orchanges could be made within the existing staff levels to accommodate the new roleor tasks.

During 2002, CWP established Accelerated Development Programmes (ADPs) tosupport speedier implementation of new roles in areas where the benefits had beentested and proven models were available to guide implementation. This different



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approach has ensured that a total of 247 sites (43 per cent of NHS organisations inEngland) are now formally involved in some aspect of CWP. The ADPs, however, werenot the subject of the Department of Health-commissioned evaluation by the authorsso it is not possible to comment on their content and effectiveness. However, thecomment that it “came out of the question about ‘can’t you go faster?’” suggests thestrong pull of rationalisation and goes against the bottom–up approach of manyredesigned roles in the original pilot sites.

Expansion of softer and therapeutic aspects

Several earlier quotations illustrated how role redesign had led to an expansion of thesofter aspect of quality in the worker-patient interaction. Although such patient-centred care is likely to be more beneficial to the patient, there needs to be a recognitionthat it takes more time. Talking through the implications of operations in the mannerthat the trauma co-ordinator and nurses taking consent wished is likely to take longerthan if conducted by junior doctors who do not have the time to look at the process inthe same way. Indeed, although the development of nurse-gained consent was viewedas a successful role, it was stalled at the time of research due to lack of funding tobackfill for the time spent by the nurses on the new task.

Likewise, the therapeutic work undertaken by the support workers takes more time.The stroke support worker recognised that she had “the luxury of time in my job wherehealthcare assistants do not... they have got a lot more than that to do so they will goalong and say, ‘I will just wash you’, because it is the time aspect on their side”.Likewise, a clinical manager noted, “It takes an awful lot longer... dressing somebody ...they [roleholders] are starting to learn that they have got to sit on their hands a bit andencourage and educate but only stepping in where the patient absolutely needs help”.Although such therapeutic activities might lead to shorter hospital stays and fewer re-admissions, it would be difficult to capture that saving and thereby justify fullyresourcing the softer aspect of the worker-patient interaction.

Cost of training, assessment and supervision

Training support workers to take on new therapeutic work, or nurses to take on workformally undertaken by a doctor, bears a cost, too. Although specific costs were borneby the CWP for the purpose of the pilots, and additional time was provided throughthe goodwill of participants, clinical managers raised concerns about the sustainabilityof such training and the attendant assessment and supervision required. One clinicalmanager noted how assistants to therapists “get caseload supervision weekly andformal supervision monthly but you couldn’t do that level of support and supervisionfor a whole ward full of unqualified staff”. Another noted how the increasing relianceon competency-based training would lead to the need for the assessment of “vastamounts of competencies which the teaching institutions are cheering about”.

DISCUSSION AND CONCLUSIONS

This article has examined the workforce modernisation strategy of the NHS, focusingon its implementation within one initiative, the Changing Workforce Programme.Although the healthcare service user has been explicitly identified in public policy as anecessary factor in the determination of service needs since the introduction of thePatients’ Charter (Department of Health, 1991), the authors believe that it is only sincethe development of The NHS Plan, associated National Service Frameworks andactivities of the Modernisation Agency that considerations of the end user have become



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more of a feature in the definition of roles and skills. Previous works (Cockburn, 1983;Rainbird, 2000) remind us of the contested terrain of skills development. That thecustomer in the healthcare sector is a patient adds different dimensions to customerinvolvement in this contested terrain. Some experiences are different to other servicesectors, others confirm what has been observed elsewhere. One difference relates to theinter-worker tensions which exist in the development of skills.

This study has identified the tensions of a professional logic that seeks to retain itscommitment to a distinct body of knowledge and peer group control. Managerialstrategies have been introduced to curtail this in the past and now customer-orientedlogics have been introduced with the same aim. Although Korczynski (2001) notesthese distinct logics, they are discussed under one of the organisational dimensions(division of labour) in his later work (2002). In contrast, we would suggest that it is alogic that stands alongside the rationality and customer-oriented logic, thereby runningthrough each of the five organisational dimensions, rather than residing in one. Thatthe communication skills of doctors were supplemented, rather than challenged, bynurses when they were taking on some of the doctors’ tasks echoes Manley’s (2001)observation of the differential power of some healthcare professions. We believe thatthe interplay of the logics of rationality, customer-orientation and professionalism isworthy of further reflection.

The customer-oriented bureaucracy model has been a useful tool to determine if thephysical presence of the embodied customer in a public service can dampen the pull ofthe rationality logic. The model of the customer-oriented bureaucracy asks which skillsets will be prioritised and which workers will be developed. By being open to all thoseworking on a particular patient pathway, the Role Redesign Workshop events capturedthe interest and commitment of workers. New roles stressed on-the-job learning andeffective communication, and caring aspects were acknowledged and encouraged inone-to-one work. There was an explicit focus on a task-based ethos, rather than on apractitioner-based ethos, and there were flexible task borderlines with doctors, nurses,allied health professionals and ancillary staff. This was in spite of the consumer notbeing in a position of control or authority over skill definition.

The Framework for Lifelong Learning for the NHS contains words of willingness to makesure ‘our staff, the teams and organisations they relate to, and work in, can acquire newknowledge and skills, both to realise their potential and to help shape and changethings for the better’ (Department of Health, 2001: i). The roleholder who told us that “Icouldn’t go back to being a care assistant because I know so much, I have all thisknowledge” engages directly with the sentiments in the lifelong learning framework.All staff taking on new roles who were interviewed reported high levels of jobsatisfaction and a greater commitment to the organisation.

At this point, an optimist would declare sight of a win:win:win: scenario. However,delivering the necessary finance to enable this systematically across the NHS is anotherissue and this is where the rationality logic comes to the fore, and also exposes theextent to which the customer is not a basis of authority and control in the determinationof skill development. This CWP research provides some specific references to resourceissues that need to be addressed within the NHS. Can it afford to:

● reward all skill developments with higher wages? ● develop more people in the proven roles?● develop the softer aspects of quality in the worker-customer interaction which somemight construe as ‘non-productive’?



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● develop NVQ training, assessment and increased supervision of non-registered staffwho are undertaking work delegated by non-registered healthcare workers?

If patient groups were in authority and control, they would be able to argue stronglyfor those aspects of care that patients valued and which contributed to their long-termhealth. It would also be possible for alliances to be forged with workers who gainimmense job satisfaction from working in these new ways.

A number of the roleholders discussed above were delivering the patient-centredcare that Kendall and Lissauer (2003) applaud, and they gained much satisfaction fromit. However, it is precisely these roleholders whose caring and communicating will becurtailed through rationalisation. Korczynski et al’s observations of call-centre workindicate that front-line workers are ‘more likely to identify with embodied individualcustomers, for interactions with specific customers may be an important arena formeaning and satisfaction within the work’. This contrasts with management whowould prefer workers to ‘identify with a collective, disembodied concept of thecustomer’ (2000: 671). This tension is exemplified by the role redesign example of thenurses taking consent. We know from the interview extracts that the nurses explicitlydo not want to identify this task with anonymous patients. They do not want “to besomeone who is just bleeped to consent”. They want to spend time with the patientcommensurate with patient need, not productivity concerns. Their satisfaction derivesfrom knowing that their patients feel better about impending operations and are not“so frightened”, but this could not be implemented beyond the pilot because thebudget did not allow for this. Thus, we see the phenomenon identified by Korczynskiet al that “the definition of the customer as the focus for normative commitment is acontested terrain” with significant differences existing between front-line workers andmanagement. In this respect, public-funded healthcare in the NHS has similarcharacteristics to service work in consumer capitalism.

Acknowledgements

This article is based on research gathered during an evaluation of CWP commissionedby the Department of Health, Research Policy Programme. The authors would like tothank the interviewees for their time and the Project Advisory Group for their support.This article represents the views of the authors and not the Department of Health. Theauthors would also like to thank Carole Thornley and the anonymous reviewers fortheir very constructive comments on this article.

REFERENCES

Adams, A., Lugsden, E., Chase, J. and Bond, S. (2000). ‘Skill-mix changes and workintensification in nursing’. Work, Employment & Society, 14: 3, 541–55.

Bach, S. (2002). ‘Public-sector employment relations reforms under Labour: muddlingthrough on modernization?’. British Journal of Industrial Relations, 40: 2, 319–39.

Buchan, J., Ball, J., O’May, F. (2001) ‘If changing skill mix is the answer, what is thequestion?’. Journal of Health Services Research and Policy, 6: 4, 233–238.

Cockburn, C. (1983). Brothers: Male Dominance and Technological Change, London: Pluto.CWP (2001). Guidelines for Pilot Sites, London: Changing Workforce Programme.CWP (2003). Changing Workforce Programme – Pilot Sites Progress Report, London:

Changing Workforce Programme.Dawson, S. (1992). Analysing Organisations, London: Macmillan.Department of Health (1991). The Patient’s Charter, London: Department of Health.



35-49 mcbride 5/4/05 11:39 am Page 47

Department of Health (1999). Agenda for Change, London: Department of Health.Department of Health (2000a). The NHS Plan, London: HMSO.Department of Health (2000b). A Health Service of all the Talents: Developing the NHS

Workforce. Consultation Document on the Review of Workforce Planning, London:Department of Health.

Department of Health (2001). Working Together – Learning Together: a Framework forLifelong Learning for the NHS, London: Department of Health.

Department of Health (2002). HR in the NHS Plan: More Staff Working Differently,London: Department of Health.

Doyal, L. and Cameron, A. (2000). ‘Reshaping the NHS workforce’. British MedicalJournal, 320, 1023–4.

Frenkel, S. J., Korczynski, K., Shire, K. A. and Tam, M. (1999). On the Front Line,Organization of Work in the Information Economy, Ithaca: Cornell University Press.

Fuller, L. and Smith, V. (1991). ‘Consumers’ reports: management by customers in achanging economy’. Work, Employment & Society, 5: 1, 1-16.

Halliwell, S., Sibbald, B., Rose, S. (2000). A Bibliography of Skill Mix in Primary Care – theSequel, Manchester: NPCRDC, University of Manchester.

Hyde, P., McBride, A., Young, R. and Walshe, K. (2004). A Catalyst for Change? A NationalEvaluation of the Changing Workforce Programme, Manchester: MCHM, University ofManchester.

Kendall, L. and Lissauer, R. (2003). The Future Health Worker, London: IPPR.Korczynski, M. (2001). ‘The contradictions of service work: call centre as customer-

oriented bureaucracy’, in A. Sturdy, I. Grugulis and H. Willmott (eds), CustomerService – Empowerment and Entrapment, Basingstoke: Palgrave.

Korczynski, M. (2002). Human Resource Management in Service Work, Basingstoke:Palgrave Macmillan.

Korczynski, M., Shire, K., Frenkel, S. and Tam, M. (2000). ‘Service work in consumercapitalism: customers, control and contradictions’. Work, Employment & Society, 14: 4,669-87.

Leverment, Y., Ackers, P., Preston, D. (1998). ‘Professionals in the NHS – a case study ofbusiness process re-engineering’. New Technology Work and Employment, 13: 2, 129-39.

Manley, J. E. (2001). ‘The customer is always right? Customer satisfaction surveys asemployee control mechanisms in professional service work’, in A. Sturdy, I. Grugulis andH. Willmott (eds), Customer Service – Empowerment and Entrapment, Basingstoke: Palgrave.

Modernisation Agency (2004a). Protocol-Based Care…Underpinning Improvement,London: Department of Health.

Modernisation Agency (2004b). Improvement Leaders’ Guide to Redesigning Roles, Series 3,London: Department of Health.

Modernisation Agency (undated). New Ways of Working. Investing in Staff is Investing inCare, London: Department of Health.

Pawson, R. and Tilley, N. (1997). Realistic Evaluation, London: Sage.Rainbird, H. (2000). ‘Training in the workplace and workplace learning: introduction’,

in H. Rainbird, Training in the Workplace, Basingstoke: Macmillan.Read, S., Lloyd Jones, M., Collins, K. (2002). Exploring New Roles in Practice, Sheffield:

SCHARR, University of Sheffield.Scally, G. and Donaldson, L. J. (1998). ‘Clinical governance and the drive for quality

improvement in the new NHS in England’. British Medical Journal, 317, 61-65Sturdy, A. (2001). ‘Servicing societies? – Colonisation, control, contradiction and

contestation’, in A. Sturdy, I. Grugulis and H. Willmott (eds), Customer Service –Empowerment and Entrapment, Basingstoke: Palgrave.



35-49 mcbride 5/4/05 11:39 am Page 48

Taylor, S. (1998). ‘Emotional labour and the new workplace’, in P. Thompson and C.Warhurst (eds), Workplaces of the Future, Basingstoke: Macmillan.

Thornley, C. (1996). ‘Segmentation and inequality in the nursing workforce’, in R.Crompton, D. Gallie and K. Purcell (eds), Changing Forms of Employment:Organisations, Skills and Gender, London: Routledge.

Thornley, C. (2003). ‘What future for healthcare assistants: high road or low road’, in C.Davies (ed), The Future Health Workforce, Basingstoke: Palgrave Macmillan.

Vaughan, B. (2002). ‘The intermediate care practitioner’, in R. Lissauer and L. Kendall(eds), New Practitioners in the Future Health Service: Exploring Roles for Practitioners inPrimary and Intermediate Care, London: IPPR.

Wicks, D. (1998). Nurses and Doctors at Work, Rethinking Professional Boundaries,Buckingham: Open University Press.

Williams, S. and Calnan, M. (1991). ‘Key determinants of consumer satisfaction withgeneral practice’. Family Practice 8.



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how the ‘customer’ influences the skills of the front-line worker

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