Really Managing Health Care - 2nd Edition
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Really managing
health care
2nd edition
Valerie Iles
Open University Press
Open University Press
McGraw-Hill Education
McGraw-Hill House
Shoppenhangers Road
Maidenhead
Berkshire
England
SL6 2QL
email: [email protected]
world wide web: www.openup.co.uk
and Two Penn Plaza, New York, NY 10121-2289, USA
First published 2005
Copyright © Valerie Iles 2006
All rights reserved. Except for the quotation of short passages for the purpose of
criticism and review, no part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without the prior written
permission of the publisher or a licence from the Copyright Licensing Agency
Limited. Details of such licences (for reprographic reproduction) may be obtained
from the Copyright Licensing Agency Ltd of 90 Tottenham Court Road, London
W1T 4LP.
A catalogue record of this book is available from the British Library
ISBN-10: 0335 21009 0 (pb) 0335 21010 4 (hb)
ISBN-13: 978 0335 21009 1 (pb) 978 0335 21010 7 (hb)
Library of Congress Cataloging-in-Publication Data
CIP data applied for
Typeset by RefineCatch Limited, Bungay, Suffolk
Printed in the UK by Bell & Bain Ltd, Glasgow
To Eleanor
Contents
Acknowledgements xi
Introduction 1
1 Really managing people: working through others 5
The art of getting things done 5
Three basic rules for managing people 7
Principles and practice of giving feedback 12
Management by walking about 16
Helping your manager to help you 20
Applying the three rules in different settings 20
Managing teams 21
Motivation and personality 24
Concluding thoughts 35
2 Really managing people: working with others 37
Professions in health care 38
Sharing responsibility 38
What makes a profession a profession? 40
Defining health and care 42
Differences in status between professions 44
Other ways of thinking about the dynamics within and between
professions 47
Causes of misunderstanding between professionals 55
Working effectively with other professions 63
Concluding thoughts: synergy 68
3 Really managing people: working for others 72
Are my aims congruent with those of my organization? 73
Are my values and beliefs in harmony with those of my
organization? 74
Where does the power lie in this organization? 78
Who is likely to succeed in this organization? 79
Are there other ways of achieving my aims? 83
Do I want to stay? 85
Concluding thoughts: staying on 86
viii CONTENTS
4 Really managing resources 89
Making the most of resources 89
Efficiency 90
Quality management 91
Understanding money 105
Concluding thoughts: using resources effectively and efficiently 116
5 Really managing change 119
Three schools of thinking about change 120
Leading a service through change 126
When something goes wrong 142
Testing new ideas 144
Exploiting a good opportunity 145
Implementing a mandated change 145
Concluding thoughts 148
6 Really managing yourself 152
Managing time 153
Increasing confidence 155
Approaches for dealing with stress 159
REBT 160
TA 163
Developing awareness 170
Preparation 175
Circumstances beyond our control 177
7 Really managing organizations 182
Health care at the heart 182
Roles of the real manager 182
Additional roles of the real manager 183
Changing roles, changing behaviours 197
Changing cultures 206
Where does this leave the board? 210
Concluding thoughts 212
8 Case studies 215
Hillside Hospital 215
Community mental health services 230
Combining practice with management 242
9 Concluding thoughts 258
Real management is about what you do 258
Real management is fundamentally different 259
CONTENTS ix
Real management engages with the wider system 261
Really managing – anywhere, any time 262
Appendix 1 How not to be ‘nice’ 265
Appendix 2 Clinical practice and real management 269
Appendix 3 Further reading 273
Index 277
Acknowledgements
Many people have contributed concepts that I use in this book, and stimulated
my thinking in different directions, and I am very grateful to them all. First
among these is Derek Cramp, an indefatigable provider of ideas and debate.
Annie Cushing and John Harries have both lent me more books and papers
than I have returned, all of them thought-provoking. Julia Vaughan Smith,
too, has introduced me to areas of thinking that I may have rejected from a less
credible source, and without Gordon Best Chapter 5 would look significantly
different and much less useful. Nigel Edwards, too, has been, as he often is, a
catalyst for ideas. There are so many others that it is invidious to include some
and not all but Jay Bevington, Nancy Craven, Peter Gill, Annabel Scarfe and
Linda Smith have all been more influential than I have told them.
However, the person who first prompted my realization that a new
model of management in health care is needed was my partner Colin Smith.
As a highly effective manager in the private sector who now ‘turns around’
ailing companies in the manufacturing and service industries, his behaviour
and approach to the management task is very different from that which I
observe in senior managers in health care organizations. There are reasons for
that, some of which are discussed in the introduction, but this proximity to
alternative behaviours has undoubtedly influenced my thinking.
If all these have helped to shape the model I propose here, the people who
have tested it out, increased its robustness and challenged me to make it as
usable and practical as possible are the students and clients I have worked
with. In different universities, learning sets, service teams and organizations, I
have learned hugely about what will work and what won’t. If I single out my
years with the Masters in Health Management at City University, one particu-
lar cohort of the MSc in Primary Care and my students at the London School of
Hygiene and Tropical Medicine, that is only because they reflect the steepness
of my learning curve and the exhilaration that always accompanies that.
Several have participated in this book, in giving information for case studies,
by reading drafts or debating points, and I will thank them personally rather
than here.
Without the two Chrises – Heginbotham and Ham – I would never have
written this book. Their confidence in my ability to do so was vitally important
for the first edition, and they have both encouraged the second. Chris Hegin-
botham has been generous in his ongoing support, while Chris Ham has been
very tolerant of a book that is a policy-free zone!
xii ACKNOWLEDGEMENTS
The person who has had the greatest impact on the way the ideas here are
presented (and hence made accessible to the reader) is its managing editor
Steve Cranfield. Steve and I have collaborated now on three publications and
each time I have found it a highly productive and enjoyable experience. Not
only does Steve have years of editing experience, I find it immensely helpful
that he tolerates tasks I hate, and that he is a living database of concepts,
related ideas and their history. We have also been very fortunate in having a
valuable ‘critical friend’ in Jonathan Richards.
None of these people, however, can be held responsible for my interpret-
ation of the facts or concepts, or guidance they have provided; any criticisms
must be directed at me.
Introduction
Not enough people are managing health care. And that is not because there are
not excellent people running health care organizations. It is because that is
what they are doing, concentrating on running their organizations. As a result
there is a lot of measuring and monitoring, a lot of ‘performance management’
and, ironically, a lot of health care professionals (HCPs)1 feeling over-managed.
It’s time for the focus to shift to managing health care itself, and this is a book
for people who want to improve services, to regain the goodwill of HCPs and
to help them deliver the kind of care we can all be proud of.
Why, when health care is such an important issue for so many people, do
we not pay enough attention to management at the level that matters? Why
do people called managers manage not health care but something else? In part
it is because the job we are currently asking them to do is the wrong one, in
part it is because they are tempted to concentrate on the wrong things and
in part it is because we want to believe in magic. Let’s look at these in turn.
First, the wrong job? Instead of defining the role of the health care
manager by considering the health care task and what management can add to
it, there has been an emphasis on translating the management role from other
settings. Modifying it certainly, to take into account some of the differences
between health care organizations and others, but not going as far as defining it
using the distinctiveness of the health care task as the starting point. When we
do this, when we aim to add to the contribution of those providing health care,
and see it as essential to try to avoid wasting their time and good will, we see
that the role we need is different, and requires particular skills, behaviours and
attitudes of the people fulfilling it.
Second, the wrong things? Joe Batten, in his book Tough Minded Leader-
ship,2 draws a distinction between the ‘simple hard’ and the ‘complicated
easy’. The former could be something as simple, and as hard, as being trust-
worthy; the latter, drawing up complicated plans or redesigning organiza-
tional structures. Today’s health care managers are concentrating on the
complicated easy at the expense of the simple hard. This is understandable.
The increasing specialization of health care has led to a culture in which there
is an unspoken assumption that if we could just find an expert with a definitive
answer, we would be able to solve any problem. While this belief may be
well founded for many clinical problems where the constituent elements are
cells and organs, in management problems those constituent parts are people
and the richness of personality ensures that there is no definitive solution,
2 INTRODUCTION
however complicated. Whenever we interact with other people, we cannot
succeed unless we heed the simple hard.
Much of the complicated easy is, of course, necessary. Without it, managers
do not have the tools with which to manage. However, without the simple
hard the complicated easy does not work. Worse, it can actually impede the
individuals and organizations it is supposed to be rendering more effective,
and be perceived as unnecessary bureaucracy and constraint.
Third, magic? There has been a tendency over the past few years to iden-
tify ‘leadership’ as different from (and rather superior to) ‘management’. But,
surely, this is a false dichotomy, on both the practical and theoretical
levels. The territories now claimed for leadership and management are not
dissimilar from those linked previously to management and administration,
respectively, and this suggests that in a little while the term ‘leadership’
too will have become demoted. This is because people are seeking something
that can’t exist; what they are looking for is the ability to win hearts
and minds, to persuade people to do something they don’t want to do, to take
on groups who are being difficult and persuade them to work together for
the greater good. Heroes and heroines who can do all that may exist in
fairy tales and undemanding novels but not in real life. At least not in the
quantities we seem to require! It is time to reinvigorate the neglected term
‘management’.
What I offer here, then, is an argument that seeks to enrich, extend and
indeed challenge current understandings of the word ‘management’. In this
book I outline a style of management I call real management. It is a style built
up from tools, behaviours and attitudes I have observed that people working in
health care find genuinely useful, find can help them to offer better services,
find can help them to help others to work more effectively. Real management
straddles the divide drawn between management and leadership, it takes
account of the special circumstances of the health care task, it errs on the side
of the simple hard, but it draws attention, too, to areas where it is important
that the complicated easy is undertaken with rigour and discipline. Because it
highlights the simple hard it will be dismissed by some, since the aspects that
are simple and hard are indeed conceptually simple, so simple that in practice
they often fail to receive the attention they warrant. For some people (particu-
larly those whose intellect is only tickled by the complicated easy) it will prove
irritating, simplistic and misguided. I very much hope that others will find it
useful, practical, challenging and even transforming.
Is it evidence based? Well, it depends on what is meant by evidence, and I
have discussed this in some detail elsewhere.3 It is rooted in reflection, theory,
action and experience – my own and that of others. Above all, it has been tested
out by generations of HCPs taking on management roles; I have worked with
these people on university courses, training programmes and in their own
organizations. For all that, it is a subjective and personal account of the kind of
INTRODUCTION 3
management I believe is needed, so it is perhaps necessary that you know a
little of where I am coming from.
For the first fifteen years of my working life I worked as a pharmacist, in
the bowels of health care organizations of all sorts, experiencing the dynamics
of working within a large complex organization of interdependent professions
and departments. After completing an MBA at the London Business School, I
moved into management roles just at the time when general management was
being established and the old district management teams of district medical
and nursing officers with district administrator were being disbanded. In 1990
I moved to City University to establish the Health Management Group there
and led the masters degree in health management for nearly nine years. And
for the past five years I have worked with a number of different universities
and NHS organizations, individuals and teams on all levels, exploring different
management challenges and ways of addressing them.
All my observations lead me to conclude that it is vital that the people
who directly manage front-line services are allowed and encouraged to flourish,
and that organizations where that is the case are those offering the best health
care, yet this is the tier of management receiving the least support and devel-
opment. This book is written for them, for those first line managers (most of
whom will be clinicians), for the people who manage them and for those who
in turn manage them. In other words, this is a book that assumes that the task
of senior managers is to support the clinical front line and the people directly
managing that. It is also for a group of people I have had the pleasure of
working with recently: non-executive directors in health care organizations.
These passionate, able people are often inhibited from making a more valuable
contribution because of their lack of understanding of the dynamics of health
care. I hope this book will give insight that will help them bring fresh energy to
the management task. And it is for a group of people who are becoming
increasingly important, people in so-called ‘hybrid roles’: those clinicians who
take on formal organizational management roles in addition to their clinical
management ones.
It is always difficult to know where to start in a text about management. I
have chosen to start with aspects of managing people, because this is where
most anxiety is expressed, and most troubles begin. In Chapter 1 we look at
how to work through other people, in Chapter 2 at working with other people,
and here we look closely at what happens when those other people are mem-
bers of different professions. In Chapter 3 we consider working for other
people, how to work effectively in large organizations and how to decide
whether your organization is the right one for you. Chapters 4 and 5 could
easily have been presented in reverse order. In Chapter 4 we think about how
to make the most of the resources available to a service, while Chapter 5
explores ways of managing change. Chapter 6 is more personal, and is about
how to manage yourself, your time and your stress levels. You may be tempted
4 INTRODUCTION
to read this first but I think you will find it more valuable having read some of
the others first. Chapter 7 is about managing organizations or, more accur-
ately, about the role of the manager in health care organizations, and while it
refers more to large organizations than small the principles are similar. Next,
we come to the case studies. In the first edition readers seemed to enjoy these.
Their purpose is to explore how some of the principles can be put into practice
while also seeing the world from the perspectives of people in different health
care settings. One has been updated from the first edition and two new ones
have been added. As you will see, they are not prescriptive, but look more at
how than what must or can be done, and they are set in circumstances that I
hope feel real to you, although they are compilations of incidents and people
rather than an account of an actual scenario. The concluding thoughts are just
that, a résumé of what I see as the most important points, and I hope you will
want not only to read them but also to let me know your own thoughts. Every
end is a beginning, as the saying goes, and I hope you will want to take what’s
written here as the start of your own role as a real manager. If you do, then I
have included a selection of further reading that I think you will find useful.
If you do, or if you don’t, I would welcome your views on what has been
said here, so do please write or contact me via the Really Learning website at
www.reallylearning.com.
Notes
1 I use the term ‘health care professional’, abbreviated to HCP, throughout the
book. It is used to refer to members of all the clinical and clinical support
professions.
2 Batten, J. (1991) Tough Minded Leadership (New York: Amacom). In this book,
Batten contrasts the complex easy with the simple tough and draws a further
distinction between tough and hard – the former resilient, the latter brittle.
However, for a British audience, the terms ‘hard’ and ‘complicated’ more
accurately convey the sense he intends.
3 See Iles, V. and Sutherland, K. (2001) Managing Change in the NHS: Organisa-
tional Change (London: NCC SDO).
