Management, People and Organisations - Nhs

1.1 Introduction to NHS

Statistics from the NHS Confederation (2007) reports a colossal number of employees and patients in the NHS. Managers and senior managers account for 2.8 per cent of the almost 1.3 million staff employed by the NHS. 27 per cent of NHS chief executives come from a clinical background and 50.2 per cent of NHS managers have a clinical background. The NHS deals with over 1 million patients every 36 hours.

There are many hospitals and infirmaries under the NHS management. From the Leighton Hospital and Victoria Infirmary, we can see the typical organisation chart of a hospital in the NHS. Figure 1.1 below is adapted from Mid Cheshire Hospitals NHS Trust (2007).

Figure 1.1 Organisation chart of Leighton Hospital and Victoria Infirmary

In the following sections, we are going to discuss the possible problems in management and organisation, what had caused them, and what would happen if the organisation had taken a different strategy.

1.2 Problems in NHS and Possible Causes

The NHS is set in an environment with ever-changing policies and crisis. The Department of Health (2007) is responsible for frequently changing and implementing policies affecting the NHS. The National Statistics (2006a, 2006b) reports of an ageing population caused by pandemic diseases and lower birth rates; hence the public is pressurising the NHS to improve these numbers. These problems are forcing the NHS to change to cope with the environment.

In Figure 1.1, we have seen the typical organisation chart of a single division of the NHS. The one we have seen is just the tip of the iceberg. According to NHS Confederation (2006), there are 152 primary care trusts and each overseeing many hospitals. With such a huge number of employees, the NHS inevitably created a tall scalar chain in the organisation. The organisation is also split into many divisions managed by the primary care trusts.

Tall scalar chains in the organisation were reported (Management, People and Organisation 2006, p. 3.6) to lower morale, slows decision making and worsen communications. A tall scalar chain is not advantageous; however, reducing the levels in the scalar chain will further increase the span of control.

Daft (2006 p. 353) defines span of control as the number of employees reporting to a supervisor. The higher the span of control, the more the number of employees the supervisor has under his charge. A high span of control is suitable for organisations where:

- Work is routine and repetitive

- Subordinates perform similar work tasks

- Subordinates specialises in a few tasks

- Rules and regulations are clear

- Little time is needed in non supervisory work like planning

High span of control is only desirable in an organisation where little interaction is needed. On the other hand, the NHS is unlike a production line where little communication is required, employees have changing job requirements and information to be passed along.

Daft (2006, p. 375) relates organisation structure to the environment. The following will happen in an uncertain environment:

- There would be increased differences occurring amongst departments. Each major department will only focus on their own responsibilities, and hence distinguishes themselves from the other departments. Departments work autonomously, creating "barriers".

- The organisation will need increased coordination to keep departments working together.

- The organisation must maintain the flexibility to change. Changes in policies or other factors require even more cooperation departments.

Therefore a vertical organisation structure is unsuitable in an uncertain environment like the NHS, where new policies are always implemented and crisis outbreak regularly. This structure will further worsen the communications and decision making process.

The NHS consists of many trusts, hospitals and infirmaries. These entities are spread across the United Kingdom. Each entity has the management of their own like the Leighton Hospital and Infirmary in Figure 1.1. This configuration is described as the divisional structure.

Mintzberg (1981) discussed that divisional structured organisations' top management often uses performance control systems over each divisions but leave the details to the division's management. This system adds extra paper work and slows communications. Tasks are duplicated across divisions, increasing costs and efficiency. These problems also lead to increasing the span of control of the managers. Problems associated with a divisional organisation structure are typically:

- Increased overheads

- Slower and ineffective communications

- Increase the distance between management and their subordinates

- Slow decision making

- Too many people managing a task

- Managers are overloaded because of the above mentioned reasons

Mintzberg (1981) added that centralisation tend to happen within the divisions as they hold the responsibility of their performances. However divisional structure is difficult to be dynamic because of the procedures and red tape they have to go though to make a change.

However, Daft (2006 p. 366) argues that in a divisional structure, the organisation has fast response, is flexible in an unstable environment, fosters concern for customer needs, and has excellent coordination across functional departments. This was supposed to be theoretically correct and NHS must have adopted this structure in the hope of gaining all these advantages. From the previous analysis, all these advantages are wiped out because of the sheer size of the NHS. Each division would at least have a few thousand employees, and each division would have a tall scalar chain to adhere to. That would remove the advantage of being flexible in a changing environment which was discussed in the previous section. NHS is only situated in one country, which is not overly large. NHS would not have benefited from having a divisional structure as it does not need to diversify to blend in with different geographical locations. The last advantage is easily overlapped by the