At the heart of any great team will be a central ethos and energy that connects with all members of the team and binds them together. It may help to think of this as the team’s identity.
This defines the team’s purpose for existing and is values driven. Take for instance Harley Davison.
Their team is all about the energy of exploring, which informs everything they do.
Another example would be the NHS in the UK, which has as its central ethos, the energy of the Caregiver.
When all is said and done, the NHS and its wonderful teams of Consultants, Doctors, Nurses, Carers and all its support staff, are about the energy of giving care.
This is what created the original NHS in England. The National Health Service Act of 1946 which came into effect on the 5th July 1948, had at its foundational roots, a carer system that was envisaged to provide support and care for the public.
It had, when it was created, a tripartite system that provided the services. Wikipedia summarises this as follows:
· Hospital services: Fourteen regional hospital boards were created in England and Wales to administer the majority of hospital services. Beneath these were 400 hospital management committees which administered hospitals. Teaching hospitals had different arrangements and were organised under boards of governors.
· Primary care: GPs were independent contractors (that is, they were not salaried employees) and would be paid for each person on their list. Dentists, opticians and pharmacists also generally provided services as independent contractors. Executive councils were formed and administered contracts and payments to the contractor professions as well as maintaining lists of local practitioners and dealing with patients.
Community services: Maternity and child welfare clinics, health visitors, midwives, health education, vaccination & immunisation services together with environmental health services were the responsibility of local authorities. This was a continuation of the role local government had held under the Poor Laws.
The NHS has changed and grown significantly since its formative years with additional legislation replacing the original Act, including the National Health Service Act 1977, which itself is now superseded by the National Health Service Act 2006 and the Health and Social Care Act 2012.
During this 72-year history there has been huge commercial pressure for the NHS to change and better manage itself both in terms of costs, value for money, systems and services.
There have been major attempts, to arguably re-direct the foundational energy, of the NHS, including the 1980’s review and creation of the NHS internal market in 1988. This followed on from a period that has been represented by Keynesian politics (support of the welfare state/public housing/nationalized industries and close regulation of the economy)
In the 1980s, as in now, the NHS was widely popular and whilst politics (particularly conservatism) moved away from post-war Keynesian policies, the National Health Service, was described in 1982, by Margaret Thatcher as being ‘safe in our hands’. It was financial pressure, often working in direct conflict, with the need to provide care, that created the need for a review of the NHS in 1988.
From this review in 1989, two white papers, working for Patients and Caring for People, were produced.
This is where the concept of an internal market was outlined, which has since shaped the structure and organisation of our health services.
At the time there was considerable opposition from the BMA (British Medical Association), who wanted a pilot study or the reforms in one region.
The Working for Patients white paper proposed significant reforms, to create this internal market, driven by two main objectives:
· to give patients better healthcare and greater choice
· to generate greater satisfaction and reward for those working in the NHS who managed to successfully respond to local needs and preferences.
The government wanted, to raise the performance of all hospitals and GP practices to that of the best, which was one of the driving forces behind the creation of an internal market. It seeked to address the question of how been to achieve that in the ever-growing NHS.
The paper set out that this could only ever be done by delegating responsibility as closely as possible to where healthcare is delivered to the patient – predominately to the GP and the local hospitals. It was stated that the best run services are those in which local staff are given responsibility for responding to local needs. (Working for patients 1989).
The white paper proposed a number of new key measures, including:
1. Functions were to be delegated to a local level.
2. Hospitals would be allowed to apply for self-governing status as NHS hospital trusts. Trusts would earn revenue from the services they provided thereby giving them a greater incentive to attract patients. Trusts would also be able to set the rates of pay for their own staff and borrow money to respond to demand.
3. Money would follow the patient across administrative boundaries, with health authorities being able to obtain services from NHS hospitals outside their area or from the private sector.
4. Large GP practices would be able to apply for their own budgets to procure services directly from hospitals.
5. Regional, district and family practitioner management bodies would be reduced in size and reformed into more business-like organisations with executive and non-executive directors.
6. There would be more rigorous audits of service quality and value for money.
The white paper was also positive about the role the private sector could play, citing its competitive tendering ability, which refers to the process whereby bids are invited from interested parties to carry out specific packages of work. The government suggested in the 1980’s that there was scope for wider use of competitive tendering beyond non-clinical services, and health authorities were expected to consider private providers as part of their purchasing role.
In 1989 Margaret Thatcher again stated:
‘’The National Health Service at its best is without equal … The National Health Service will continue to be available to all regardless of income, and to be financed mainly out of general taxation. But a major task now faces us: to bring all parts of the National Health Service up to the very high standard of the best, while maintaining the principles on which it was founded … We aim to extend patient choice, to delegate responsibility to where the services are provided and to secure the best value for money. All the proposals in this white paper put the needs of patients first.’ (Margaret Thatcher in the foreword to Working for patients 1989)’’
(Margaret Thatcher in the foreword to the 1989 white paper Working for Patients)
The provisions in the white paper were realised through the National Health Service and Community Care Act 1990.
However, by February 2020, thirty years later, despite a large increase in total budgetary spend, the National Audit Office wrote in its most recent review:
The NHS is treating more patients but has not yet achieved the fundamental transformation in services and finance regime needed to meet rising demand. The short‑term fixes that DHSC, NHS England and NHS Improvement put in place to manage resources in a constrained financial environment are not sustainable. The extra money brought in to stabilise the finances of NHS bodies has continued to drive volatility and variability among trusts, while patient waiting times continue to deteriorate and the number of people waiting for treatment continues to increase.
Years of short-term funding decisions for the health sector means that resources have moved away from areas of investment in the future, such as the workforce, public health and capital. This will need to be rebalanced to ensure that the ambitions set out in The NHS Long Term Plan are realised.
To bring about lasting stability, the NHS needs a financial restructuring programme not just a recovery programme. If integrated care systems are to be successful, funding mechanisms and incentives need to support collaborative behaviours. The delivery of long-term financial sustainability is at risk unless every organisation is on a realistic path to breaking even. Until the Department and NHSE&I have implemented more sustainable solutions and dispensed with short-term financial fixes, we cannot conclude that they have delivered value for money through their collective actions.
NHS FINANCIAL MANAGEMENT AND STABILITY
On a day to day basis, many of the great teams in the NHS feel this need to balance, effectively care with financial constraints.
Long term sustainable solutions and not just short-term financial fixes are clearly required.
Often the Doctors and Nurses feel conflicted in their teams, when for instance they must conduct an assessment, based on the existing structures and processes in place (driven by the internal market), on a patient.
They are required to do this to determine if the patient will receive the primary care support they may need. Decisions are made daily and weekly regarding the balance between care and finances, which can often lead to very difficult situations.
These structures can even lead to difficult decisions being parked by Senior Managers and Executives, when significant cost related matters arise.
In our E-book team mojo, the art of winning, we dedicate a whole chapter to the pathway on Structures. Even the best of teams and organisations, need the right structure set up, within the organisation, to be able to perform at their best.
This is a massive area that requires constructive dialogues, in the NHS and one that will need further thought going forward.
You can read more about team and organisational Structures, in our E-book, team mojo, the art of winning at:
Post the current global pandemic, there will no doubt be a review of the NHS and if it was properly funded and structured prior to the Corona Virus.
With so many organisations and teams now in the NHS, collective policy decisions can be slow to executive and costs can potentially increase, particularly in terms of support costs and infrastructure, as you have regional Board/Managers/support functions and so forth, within each organisation.
We certainly don’t have all the answer as to what to do next however clearly there is a balance between decentralising and centralisation.
What we do know is that you cannot change or challenge a team’s foundational roots.
At every turn and new chapter, the NHS and the amazing teams within it, will remind us, that whatever Structures we may wish to have in our future NHS, at their heart, they will need to deliver great patient care.
This will allow our wonderful NHS staff and teams to do what they do best; care for us and thereby continue to retain their foundational identity.