Change that leads to better lives

Maslow and the Health Select Committee

The Health Select Committee has created headlines today by pronouncing that the energy, attention and demands of the Health Bill (and the associated changes that are already being implemented prior to the passage of the Bill into law), are damaging the NHS’s ability to get on with the job of delivering high quality, cost effective healthcare. Should this come as news?

We already know that significant organisational change impacts on the ability to deliver the organisational mission. For example, over ten years ago, I was involved in a DH-funded project to support the then-emerging Primary Care Groups (remember them? They were remarkably similar to the proposed CCGs) to address the unmet health needs of people with learning disabilities. It was an uphill struggle – in part because in those pre Valuing People days, there was no policy requirement for this to be done. At least as significant was the inability of the PCGs to focus on that agenda. By the end of the three-year project, the early PCG developers were just starting to get engaged. Those that were late PCG starters were still doing little or nothing. The clear reason, articulated to us by those PCGs, was that for up to two years their energies went on addressing organisational change and its consequences. A focus on innovative service development was not achievable.

Any organisational change textbook will give you the theory behind this. Most readers of this blog will be familiar with Maslow’s Hierarchy of needs. Written about individual people, it describes how first of all we aim to achieve our basic survival requirements – food, security, warmth etc. Only once those things have been achieved do we progress onto addressing other needs, eventually working our way up to the snappily titled ‘self-actualisation’, where we aim for those things that fulfill our inner moral and personal development aspirations.

Organisations (the text books tell us) are no different. If the organisation is under threat or is being asked to do things that are not fully understood, and the people do not know if they will have a job in the future, then the organisation and its employees are focusing on the lower tiers of Maslow’s hierarchy. Survival, security and day-to-day existence become the overwhelming preoccupation. Self-actualisation – in the form of driving forward progressive service improvement, particularly for those people most at the margins of services and society, remains a distant dream that cannot get time and attention.

As the Health Select Committee and others have pointed out, simultaneously seeking to achieve the triple objectives of fundamental organisational change, service improvement and major financial cuts is simply flying in the face of reality. Three examples of how this plays out on the ‘front line’:

From a staff perspective - a friend of mine who is an experienced senior NHS clinician has been told that she and a colleague are to be downgraded as part of ‘efficiency savings’. There has been no consideration of clinical or service delivery implications. The driver is simply that those in authority, conscious that they are being judged on delivering cuts prior to likely ‘market testing’ of the service under new competition expectations, have responded without wider thought. The immediate staff are demoralised after years of commitment; their colleagues worry they will be next. Beyond service delivery impact, it will probably take years to achieve real savings, given that employment law has been largely ignored and it will end up in a tribunal.

From a patient or user perspective, an elderly relative of mine has long-term mental health problems, They hear and experience people conspiring against them and seeking to make their life a misery. At least partly because of this, they lead a socially and physically isolated life. All this is told to the Community Mental Health Team who have just decided to discharge my relative back to GP care following newly imposed staff cuts. The GP in the past has always said he does not have the skills to support my relative.

From a staff perspective, an NHS commissioner we at NDTi have been working with is about to be moved into her fourth job in two years. In her own words “I just begin to work out what I’m doing and I’m moved on”.

Sometimes financial reductions have to happen. For reasons we won’t go into here (but I still blame the banks) our economy is in a mess. At such times, it is more important than ever that those leading the commissioning and delivery of services know and understand how to manage finances whilst still holding onto the vision and the principles (what we in the NDTi call “Austerity with Integrity”). You don’t achieve that by coinciding the cuts with national policy change that creates personal and organisational uncertainty. Just ask Maslow (or the Select Committee).

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