Who or what shapes management thinking in the NHS?
Alternative Management Knowledge(s) in the English health care sector: Ewan Ferlie, Professor of Public Services Management at King’s Business School explores how much success the movement to introduce evidence-based approaches to management has had.
‘Put the clinicians in charge of the NHS and cut the bloated bureaucracy,’ is a perennial political rallying cry, which seemingly pits clinical and scientific expertise and experience against managers armed only with the latest theory. Exaggerated as this picture of two tribes might be, there may be some truth in the notion that knowledge about clinical practice in the NHS, and knowledge about management practice, are not based on the same foundations.
My new book, with co-authors Sue Dopson (University of Oxford), Chris Bennett (Independent research psychologist), Michael Fischer (Australian Catholic University), Jean Ledger (University College London) and Gerry McGivern (University of Warwick) explores what forms of management knowledge have influence in the field of health care.
Our findings are based on intensive case studies of six major health care organizations in England, across public and private sectors. We investigated whether, and how, management knowledge was used to complement the organisation’s clinical/scientific knowledge in improving organisational performance and service delivery. In particular, we asked whether NHS management thinking and knowledge follows the same conventions of peer reviewed science based on the observable outcomes of experiments that informs clinical practice.
The healthcare sector: a natural home for Evidence Based Management?
This is an especially interesting question for the health care sector. The growth of Evidence Based Medicine guidelines proven to a high scientific standard and their influence on clinical decision making has been influential and is now well explored. However, it is unclear whether a parallel Evidence Based Management movement, drawing on published, peer-reviewed research evidence and judgement and experience from contextual management practice, has gained traction and influence in everyday health care practice.
Given its strong scientific knowledge base and the legacy of Evidence Based Medicine in translating research into (clinical) practice, the health care sector is a critical test case. If Evidence Based Management fails to progress in healthcare, will it flourish anywhere?
We found that the Evidence Based Management movement was only weakly apparent in the health settings we researched. There were no Evidence Based Medicine style ‘knowledge products’ (such as evidence based guidelines, systematic reviews, meta analyses and Randomised Control Trials) found in practice in our sites.
However, some management texts and institutions were visible and influential. Health care organizations were therefore by no means management knowledge free zones. But the knowledge ‘products’ health care leaders, clinicians and managers accessed and used in practice were very often written in a very different style from the Evidence Based Medicine / Evidence Based Management tradition, and displayed a very different approach and thinking.
Who shapes healthcare management thinking?
A succession of national service improvement and transformation agencies have been a key influencer on UK healthcare management thinking. These agencies drew from generic improvement and management texts to map out tools and techniques which they then sought to diffuse into the NHS field. Most recently, the improvement and transformation agencies’ strongest emphasis has been on applying the theory of ‘Lean’ management to deliver productivity enhancements.
A second influencer has been health care think tanks, whose typical output is pamphlets or short reports. One think tank studied produced a pamphlet on health policy and productivity from an economics perspective, while others offered knowledge ‘consumers’ timely knowledge in response to developments within the policy world.
Globalised management consultants are a third highly active player. In one regional NHS body studied they were brought in to support a drive for major savings and productivity improvements at a time of major national pressures to find efficiency savings, and growing financial austerity in public sector spending. The consultancy produced its own change model and associated tools and techniques to guide the intervention.
Finally, and fourthly, we identified the use of certain major Business School academics and their high-profile books. The Balanced Scorecard text by Kaplan and Norton (1996), for example, strongly informed a developing performance management system in one health care provider. As with management consultancies, the work of the Business School academics had often originally been developed in a US private-sector context, and only later crossed into the UK and into health care.
The wider UK political economy, notably the sudden arrival of a pro austerity policy (2009-2019) after a period of buoyant financial growth under New Labour (2000-2009), exerted an effect on preferred management knowledges found locally. The move away from ‘softer’ knowledges associated with quality, organisational development and systems working reflected the new preference for ‘harder’ tools to support ambitious productivity objectives.
Future healthcare management knowledge: Some Questions
We concluded that Evidence-Based Management has failed (so far) to progress in the English health care sector, while alternative management knowledge producers have. But what does this mean for those with an interest in ensuring that health care management draws on the most effective, most appropriate and best-value thinking and methodologies?
There are plenty of questions that merit further exploration. Will the Evidence Based Management movement develop more traction over time? Or will alternative knowledge producers (think tanks, improvement agencies, management consultancies and management gurus) continue to retain greater practical influence? If alternative knowledge producers continue to hold sway, how should we rightly assess the quality of their work? In which circumstances might the knowledge products they typically produce be appropriate or inappropriate?
A major unknown is the political and policy environment, which determines what kind of management knowledge healthcare managers will find most useful in future. Austerity thinking appears to be easing its pinch, given the recent announcement of a government commitment to longer-term funding. However, workforce, efficiency and public demands on services will continue to make management of the service extremely challenging. In the coming years, will healthcare management thinking continue to focus on productivity enhancement, or will it rebalance back towards notions of quality and system co-ordination?
Ewan Ferlie, Professor of Public Services Management
Ferlie, E. Dopson. S., Bennett, C., Fischer. M.D., Ledger, J. and McGivern, G. (2018) ‘The Politics of Management Knowledge in Times of Austerity’ Oxford: Oxford University Press
Kaplan, R.S. and Norton, D.P. 1996. The balanced scorecard: translating strategy into action. Cambridge, MA: Harvard Business Press.