Organizational Changes within the National Health Service Essay

1. Discuss and debate the organizational changes within the National Health Service and examine how these have influenced care delivery. At the start of the NHS, a mediation model of management subsisted where the role of the manager facilitated health care professionals to care for the patient. Medical staffs were extremely influential and controlling in determining the shape of the service, at the same time as managers were imprudent and focused on managing internal organizational issues (Harrison et al. 1992). After the 1979 general election, there was originally little change to the National Health Service (Klein 1983). Though, poor economic growth, together with growing public expenditure, slowly brought about changes. Influenced by the ‘New Right’ ideologies, a more interventionist, practical, style of management in the health service emerged. This efficiently changed the role of managers from one of imprudent scapegoats for existing problems, to agents of the government (Flynn 1992). Managers became the means by which government control over NHS spending was increased (Harrison and Pollitt 1994). The impulsion for this change arose from the 1983 Griffiths report (NHS Executive 1983), an assessment by the government health advisor, Sir Roy Griffiths. Within this report, four specific problem areas were recognized: the limited management influence over the clinical professions; a managerial stress on reactivity to problems; the significance placed on managing the status quo; and a culture of producer, not consumer, orientation (Harrison et al. 1992). The power of the Griffiths Report (op. cit.) was to challenge and limit medicine’s sovereignty in the health service, and over health care resources. certainly, nurses were simply referred to twice throughout the document. Through its attention on organizational dynamics and not structure, the Griffiths Report proposed main change to the health service. General Managers were initiated at all levels of the NHS. In spite of Griffiths’ original intention that it was simply cultural adjustment that was required, there were instantaneous and considerable structural and organizational changes in the health service (Robinson et al. 1989). Post-Griffiths there were escalating demands for value for money in the health service (DoH 1989). Efforts to extend managerial control over professional autonomy and behavior so continued throughout this intense period of change, and terminated with the NHS and Community Care Act (DoH 1990). From the re-organizations that taken place during this period, the NHS was rationalized to conform more intimately to the model of free enterprise in the private sector. This reformation was shaped by the belief that greater competence could be stimulated through the formation of an internal and competitive market. The belief that the health service was a distinguishing organization was disputed. The principles of economic rationality linked with business organizations were applied extensive to the operation of health service. The services requisite were determined, negotiated, and agreed by purchasers and providers through a funding and constricting mechanism. In this, trust hospitals and Directly Managed Units supplied health care provision for District and General Practitioner fund holders. There has since been a further shift in the purchaser base from health authorities to local commissioning through primary care groups and, more lately, through the Shifting the Balance of Power: The Next Steps policy document (DoH 2001b), to Primary Care Trusts. Through such recognized relationships, purchasers have turn out to be commissioners of services and the idea of the internal market has become the managed market that recognizes the more long-term planning of services that is required. Rhetoric of organization and health improvement underpins service agreements now made. The NHS is not simply a technical institution for the delivery of care, but as well a political institution where the practice of health care and the roles of health care practitioners imitate the authority base within society. The hospital organizational structure is an influential determinant of social identity, and thus affects health care roles and responsibilities. Though, through the health care reforms the medical staff and, to a lesser degree the managers, appeared to be defense from the introduction of general management into the health service. This has resulted in health service delivery remaining stoutly located within a medical model, and medical domination unchallenged (Mechanic 1991). It is the less authoritative occupational groups, including nursing, that have felt the major impact of such reforms. The NHS organizational changes aimed to convey leadership, value for money, and professional responsibility to managers at all level of the health service. These alterations were intended to reverse the organizational inertia that was limiting growth and efficiency in the system. Though originally aiming a positive impact on the service, these radical ideologies led to tension at the manager-health care professional boundary (Owens and Glennerster 1990). The prologue of the internal market in the NHS meant to present a more neutral and competent way of allocating resources, through rationalization and depersonalization. The new era of managerially claimed to be a changing force opposing customary health professional power (Newman and Clarke 1994), and persuasive professionals to offer to organizational objectives (Macara 1996). The contradictory models of health care held by managers and health care workers improved ambiguity over areas of responsibility and decision making, somewhat than clarity as anticipated (Owens and Glennerster 1990). The contending ideologies and tribalism between the health care groups were more unequivocally revealed. The introduction of markets to health care exposed a dichotomy for health care professionals. Medical and nursing staffs were requisite to report to better managerial officials, yet reveal professional commitment to a collegial peer group. This was challenging, mainly for medical staff that understood medical influence and the independence of medical practice, but did not recognize managerial ability. In many of the commentaries addressing this, the majority pragmatic resolution to addressing this situation was to distinguish that professional independence exists but together with, and limited, by managerial and decision-making control. The Griffiths Report (NHS Management Executive 1983) considered the doctor as the natural manager and endeavored to engage medicine with the general management culture through the resource management inventiveness. This requisite medicine to clinch the managerial values of collaboration, team work and collective attainment through the configuration of clinical management teams: the clinical directorate. On the contrary such working attitudes were in direct contrast to medicine’s principles of maximizing rather than optimizing, and of autonomy not interdependence. It is fascinating that even in today’s health care environment; there have been sustained observations that medical staffs do not supervise resources or clinical staff in an idealistic way. in spite of this, there has been little effort to undertake a methodical and broad review of the organization of medical work. This is in direct distinction to the experience of nurses, whose working practices and standards persist to be critiqued by all. Early on attempts made by managers to bound medical authority led to doctors adopting countervailing practices so as to remain independent and avoid organizational authority. Such practices, taken to keep their clinical independence, included unrestricted behaviors in admitting patients or deciding on explicit patient treatments (Harrison and Bruscini 1995). These behaviors rendered it hard for managers to intrude on medical practice, and therefore restricted the impact of the health care reforms. Immediately post-Griffiths there was some proof that introduction of general managers had, to a small extent, influenced medical practices. Green and Armstrong (1993) undertook a study on bed management in nine London hospitals. In this study, it was established how the work of managerial bed managers was capable to influence throughput of patients, admission and operating lists, thereby ultimately affecting the work of medicine. however, attempts made by managers to organize medicine were self-limiting. Health care managers were not a colossal, ideologically homogeneous group and lacked a strong consistent power base (Harrison and Pollitt 1994). Managers did not fulfill their remit of exigent the medical position in the health service and evade the responsibility for implementing repulsive and difficult decisions (Harrison and Pollitt op. cit.). The management capability of medicine persists to be challenged by government initiatives including the overture of clinical governance (DoH 1997). In this, the Chief Executives of trusts are held responsible for the quality of clinical care delivered by the whole workforce. An optimistic impact of this transform may be to provide opportunity for an incorporated organization with all team members, representing an interdependent admiration of health care (Marnoch and Ross 1998). on the other hand, it might be viewed as simply a structural change to increase the recognized ability of the Chief Executive over the traditional authority of medical staff: a further effort to make in-roads into the medical power base. Current years have demonstrated sustained commitment from the government towards modernizing health care (DoH 2000b). This has integrated challenging conventional working patterns and clinical roles across clinical specialties and disciplines. certainly medicine has received improved public and government scrutiny over current years. This has resulted in a shift of approach from within and outside the medical profession. The accomplishment of challenging the agenda for change in health care will be part-determined by medicine’s capability to further flex its own boundaries, and respond to the developing proficiency of others. 2. Identify and critically explore the changing role of the nurse, within the multi disciplinary team, examining legal, ethical and professional implications. The impact on nurses of the post-Griffiths health service configuration has not been so inconsequential. Empirical work has demonstrated that execution of the Griffiths recommendations led to the removal of the nursing management structure. This efficiently limited senior nurses to simply operational roles (Keen and Malby 1992). The implementation of the clinical directorate structure, with consultants having managerial accountability over nursing, further reduced nursing’s capability to effect change. Prior to 1984, budgetary control for nursing place with the profession. The 1984 reorganization distant nursing from nursing’s own control and placed it decisively under the new general managers’ (Robinson and Strong 1987, p. 5). As the notions of cost inhibition and erudite consumers were promoted, audit and accounting practices assumed a significant position in the health service. It was nurses who, encompassing a considerable percentage of the total workforce and linked staffing budget, found themselves targets for public and government analysis. Nursing maintained some strategic management functions within the new management structures, but these tasks were mostly limited to areas within the professional nursing domain. Nurses have been seen as pricey and potentially upsetting factors of production: channels through which costs can be lessened and administration functions can be absorbed (Ackroyd 1996). Caught in the crossfire of managerial changes that were originally targeted at medicine, nursing has been placed subordinate to management (Robinson and Strong 1987). In spite of debates on the impact of health care changes, there is consent on one issue. The structural and organizational changes in the NHS since 1991 have re-fashioned unit management teams and unit management responsibilities. This has resulted in the improved involvement of these teams in the stipulation of the service. It has required a diverse way of thinking about health care and new relationships between clinicians and managers to be developed (Owens and Glennerster 1990). The nineties are set to become a vital period in changing the ways in which health care is delivered, not just in terms of the potential re-demarcation of occupational boundaries between health care occupations, but as well in terms of the broader political, economic and organizational changes presently taking place in the NHS. It is asserted that traditional demarcations between doctors and nurses, seen as based on ever more unsustainable distinctions between ‘cure’ and ‘care’, are becoming blurred and that the new nursing causes a threat to the supremacy of the medical profession within health care (Beardshaw and Robinson 1990). though, there is an element of wishful thinking about this and, indeed, Beardshaw and Robinson (1990) rage their optimism with an identification of the continued reality of medical dominance. They see the threat to medical supremacy as one of the most problematical aspects of the new nursing, largely as claims to a unique therapeutic role for nursing must essentially involve a reassessment of patient care relative to cure. In Beardshaw and Robinson’s view, the degree to which doctors will be willing to exchange their conventional ‘handmaidens’ for true clinical partners, or even substitutes, is one of the most significant questions pos ed by the new nursing. In the wake of the Cumberlege Report on Community Nursing (DHSS 1986) and World Health Organization directions concerning precautionary health care, there appeared the very real view of the substitution of nurses for doctors in definite clinical areas-particularly primary care in the community, through nurses creating a central role in health encouragement, screening, counseling and routine treatment work in some GP practices (Beardshaw and Robinson 1990). Though, a current evaluation of the impact of present reforms in the NHS on the role of the nurse in primary care is more distrustful concerning the future shape of the community nursing role. If the way to determine the extent of nurses’ challenge to medicine is in terms of the conflict it provokes, then there positively is proof of medical resistance to recent developments in nursing. Doctors’ reaction to the Cumberlege Report on neighborhood nursing (DHSS 1986), which suggested the appointment of nurse practitioners, revealed that there were doctors who strongly resisted the initiative of nurses acting autonomously (Delamothe 1988). On the other hand, the General Medical Services Committee and the Royal College of Nursing agreed that ‘decisions concerning appropriate treatment are in practice not always made by the patient’s general practitioner’ and recognized that nurses working in the community are effectively prescribes of treatment (British Medical Journal 1988:226). Discussions relating to the proper arrangements desired to hold the prescription of drugs by nurses are taking place, on the grounds that nurse prescribing raises issues linking to the legal and professional status of both the nursing and the medical professions (British Medical Journal 1988:226). This suggests that renegotiations relating to the spheres of competence of doctors and nurses are on the agenda. None the less, the General Medical Council (1992) Guidelines remain indistinct on nurse prescribing and other forms of ‘delegation’ of tasks under medical privilege to nurses, stating that it has no desire to hold back delegation, but warning that doctors must be satisfied concerning the competence of the person to whom they are delegated, and insisting that doctors should retain eventual responsibility for the patients, as improper delegation renders a doctor liable to disciplinary proceedings. Renegotiations around the division of responsibilities between doctors and nurses are taking place very carefully and to a large extent on a rather extemporized basis, given the volume of letters requesting advice and clarification received from GPs by the General Medical Council. The focus in much of the nursing literature seems to be on the challenge of the ‘new’ nursing to the ‘old’ nursing posed by nursing reform, somewhat than on the challenge to medicine. One doctor (Mitchell 1984) has complained in the pages of the British Medical Journal that doctors have not been told what the nursing process is about. Paradoxically, the nursing process is in fact derived from the work of an American doctor, Lawrence Weed, who pioneered the ‘problem-oriented record’ for hospitals in 1969. This changed the way in which patient information was collected and stored by instituting one single record to which all health professionals given. Though the nursing process, which was part of this innovation, crossed the Atlantic to Britain, the problem-oriented record did not. Mitchell (1984) has argued that the medical profession must oppose the nursing process and give it a rough ride on the grounds that medical knowledge should precede nursing plans to remedy the deficiencies of living activities which are, he insists, consequential upon the cause and clinical course of disease. He also accuses nurses of enabling a pernicious dichotomy between ‘cure’ and ‘care’, relegating the doctor to disease and inspiring the nurse to the holistic care of the individual, and suspects that the nursing process is less a system of rationalizing the delivery of care than a means of elevating nurses’ status and securing autonomy from medical supremacy.