Changing Role of HRM: The NHS

The Changing Role of Human Resource Management within the National Health Service: Feeling at Home in an Increasingly Complex Environment.

Abstract

In the context of a widespread programme of reform of the English National Health Service (NHS) this paper considers the changing role of Human Resources Management (HRM) within the service, and reports a study of the changing role of HRM in a large teaching hospital. Empirical research suggests that whilst the perception of the role and effectiveness of the HRM function remains varied, if managed correctly it is potentially capable of having a direct and beneficial impact upon service delivery.

Introduction

The reforms and changes within the National Health Service (NHS) and its management of staff and services has clearly been well documented, however research into the evaluation of these initiatives remains a neglected area. Walshe suggests that the reason behind this is that researchers do not have time to ‘painstakingly' document and measure the progress and impacts of reform due to constant change caused by the initial ‘bright ideas' having been poorly thought out (2002:106). Empirical research can though attempt to offer an understanding into the ‘complex relationships that exist between individuals and how they interpret policies within a wider social and cultural organisational context' (Clarke 2006:202) and provide insight into the NHS managerial culture to examine how it ‘supports and facilitates the implementation of the recent wave of NHS reforms' (Merali 2003:550). Through incorporating a review of the literature that surrounds the changing role of HRM within the NHS and empirically based qualitative research, a comprehensive insight into the current context and position of Human Resource Management within an NHS Trust is given. Whilst such research will hopefully be of academic interest, perhaps more importantly in order for the NHS and other public services to be aware of the impact of reforms upon employees and thus on subsequent service delivery, an awareness of HRM practices and their implementation should be a necessity for practitioners (Edgar and Geare 2005).

The Current Context of the NHS

“…the NHS is unique. To name but a few of its characteristics, it is in the public sector, exceptionally large in terms of its resources, activities and numbers employed; domestic not international in its operations; its tasks are infinitely varied, complex and difficult; its goals are unclear; it is subject to an exceptionally wide range of political and economic influences; and it is an organisation uniquely and specially close to the hearts (metaphorically), minds and bodies (physically) of British people. It is run by ‘special' kinds of people too: dedicated, yet often ambitious, highly qualified and skilled, often bloody-minded and usually tough-minded, yet also caring and even tender.”(Glover and Leopold 1996:256)

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The NHS is the largest employer in Europe, employing over a million clinical, infrastructure and support personnel (The Information Centre 2006). Whilst remaining close to the people's heart in terms of its founding values of a universal and comprehensive health care with its service delivery freely and equally available to all in society (Rivett 1997; Talbot-Smith and Pollock 2006), it is also close to the people's pockets, with billions of pounds having been invested into the NHS in the last ten years (Appelby 2007). In addition to providing a health service to the population, it is also claimed that ‘health and healthcare play a key role in generating social cohesion, productive workforce, employment and hence economic growth' (Harrison 2005) and for this reason, as Bach notes, the means to reform health care systems effectively is an issue that confronts policy makers worldwide. (2001:1) As such, the challenges facing the NHS in terms of management, change and efficiency are important to an audience far wider than the UK and those who use and work within the organisation.

In consuming around £50 billion per annum it is no wonder that successive British governments have attempted throughout the history of the NHS to dictate from the centre the ‘minutia' of the NHS's activities. A key problem however is that due to the complexity of the organisation itself and the politics that surround it, the methods used are considered by many to consist merely of ‘a plethora of complicated targets and initiatives that confound those who are charged to implement them' (Bradshaw 2003:90). In recognising the obvious public concern over the management, and expenditure, of the NHS both the previous Conservative and Labour governments and current New Labour invest considerable time, and tax-payers' money, into attempting to improve the service. Yet it is considered increasingly apparent that in responding to health deficiencies ‘by throwing money at them to see the quick, comfortable resolution of the political conflict that these inevitably cause' (Duncan-Smith 2002), continual change ‘for change's sake' has become the focus at the expense of the ultimate ‘telos' that created the health service (Kelly and Glover 1996:31).

Changes in Management of the NHS

Since its conception, it is clear that the NHS has undergone many changes, both structurally and ideologically, but it is since the reforms of the early 1980s that the focus of NHS management has attempted to move away from obvious ‘command and control' techniques and towards local management with local responsibility and accountability not only to the government but to the public that ‘experience' the service. It was subsequent to these reforms and as a result of the Griffiths Report and policies such as ‘Promoting Better Health', that ‘Working for Patients'(1989) was introduced which further emphasised the NHS's aims of better health care, choice, complaints procedures, patient information, and overarching quality.

Currently a number of policy and management initiatives are transforming the structure and organisation of the NHS (Truss 2003). New Labour are heralding the benefits of ‘choice' within the public services as a whole and many of the recent initiatives focus upon the ‘customer' and the need for services to attract these customers and the money that they bring, to the extent that within the NHS ‘individual patient preference [is] determining where business will be placed' (Bradshaw 2003:87). The logic behind this is claimed to be one of providing a new incentive for ‘providers to improve customer responsiveness', for if money follows patients and patients have a choice of service the power is with the people rather than in the hands of a previous monopolistic service provider (ibid). Such market incentives are driving NHS hospital trusts to perform more like businesses, with a corporate focus based upon meeting the demands of all the various stakeholders, and thus requiring distinct business strategies which will account for all aspects of the organisation and services provided and ultimately ‘enhance their cash flow (Pollock 2004:218).

With the establishment of Foundation Trusts, NHS Trusts which are perceived as high performers can gain Foundation Status, thus becoming corporate bodies, free from the controls of the strategic health authorities and accountable only to those whom they represent - their own managers, staff, patients and local residents (Pollock 2004). The thinking behind this is seemingly one of moving away from what has been perceived as a ‘monolithic', inefficient bureaucracy to a system of individual services which are autonomous healthcare provider organisations that could be flexible, responsive and innovative' (Walshe 2002:109). As the Department of Health states:

“The Health and Social Care (Community Health and Standards) Act 2003 establishes NHS Foundation Trusts as independent public benefit corporations modelled on co-operative and mutual traditions. Public benefit corporations are a new type of organisation, specially developed to reflect the unique aims and responsibilities of NHS Foundation Trusts. NHS Foundation Trusts exist to provide and develop services for NHS patients according to NHS principles and standards and are subject to NHS systems of inspection. Transferring ownership and accountability from Whitehall to the local community means that NHS Foundation Trusts are able to tailor their services to best meet the needs of the local population and tackle health inequalities more effectively.”(DoH 2007)

Walshe considers the introduction of Foundation Trusts as providing organisational stability due to them reducing the ability of ‘future Secretaries of State for Health to reorganise the NHS every two or three years' and thus allowing ‘meaningful service improvements to take place (2002:109). However, it is also recognised that this in turn could potentially cause problems as there will be ‘no guarantee of good management and governance' resulting in the replacement of ‘one set of dysfunctional behaviours with another' (ibid).

Many interpret Foundation Trusts as forcing NHS trusts into having to respond flexibly to market forces similarly to private sector organisations, due to the public and political interest in the service it must also contend with the constant barrage of audits, inspections, monitoring, league tables and an increasingly demanding and knowledgeable public (Talbot-Smith and Pollock 2006). The NHS today can therefore be seen as remaining seemingly attached to the ideologies of the business world, and current government emphasis towards ‘modernisation' suggests that the premise remains dominantly that:

“…no organisational context is immune from the uncertainties of unrelenting change and that, as a result, all organisations - public, private and voluntary - need to develop similar norms and techniques of conduct: if they do not do so, they will not survive. Thus all organisations need to look to current ‘best practice'…Government services are brought forward using the best and most modern techniques, to match the best of the private sector.”(Du Gay 2003:676)

These government initiatives reflect notions that by improving management and employee satisfaction, the NHS could become both an efficient and effective business, able to satisfy these consumerist needs of the customer. For example, the policy ‘Improving Working Lives' aimed to encourage NHS employers to ‘develop a range of policies and practices which support personal and professional development and enable employees to achieve a healthy work-life balance' (DH 2000). These management strategies have been labelled within this sector as New Public Management (NPM) and are considered to mark a clear differentiation from the previous strategies of ‘an administered service to a managed service'(Bach, 2000:928). Flynn argues that NPM clearly incorporates all of the changes that have occurred within the NHS following the reorganisations and new rhetorics of the 1980 reforms and the essential components that NPM consists of are clearly visible:

“…more active and accountable management; explicit standards, targets and measures for performance; a stress on results, quality and outcomes; the break-up of large units into smaller decentralised agencies; more competition and a contract culture; more flexibility in the terms and conditions of employment; increased managerial control over the workforce and efficiency in resource allocation.”(1991:28)

With the introduction of this managerialist emphasis in the NHS it has been suggested that there has been an investment of ‘faith in managers'. This faith has been based on the supposition that the ‘language, techniques and values of managerialism' were, and are, ‘the only way actually to deliver change'; thus an ‘unparalleled' position of ‘power and authority' has been placed upon public managers (Exworthy and Halford 1999:5-6). Such managerialism, and its values and beliefs is based upon the assumption that ‘better management will prove an efficient solvent for a wide range of economic and social ills' (Pollitt 1993:1), and in the case of the NHS these ‘ills' are well documented in terms of a lack of capital and thus a shortage of resources yet with a need to provide an increasingly efficient and ‘quality' driven service.

However, the notion of managerialism must be used with caution. ‘Faith' in managers can be perceived as politicians having faith in their own management in that they have failed to ever relinquish control, instead taking even more tight control through the implementation of numerous health policies and operational procedures. Such a need to keep close reigns on the management of the NHS suggests a deep mistrust in the capabilities of the public servants within it rather than a desire to allow it its freedom.

Overall it is clear that the NHS is very complex for a range of reasons not least because of its complexity and variety of its duties, the range of skills it needs to draw on, the difficulty of reconciling competing priorities, the cost of healthcare, and the way the NHS has been stitched into the political fabric of England. From an organisational perspective too it is a hybrid mix of hierarchy, bureaucracy, market and network. To efficiently manage such an organisation is therefore a highly complex and unrelenting challenge.

HRM in the NHS

The role of HRM pre-reforms was mainly focused on administration and support with a lack of defined responsibility. Named Personnel rather than HR, the function was used to deal with general staffing issues of terms and conditions of employment, payment and holiday options, individual and local staffing issues and the well known ‘hiring and firing' that it remains renowned for. From Personnel Managers came HR professionals, HR departments, and increasingly HR directors with voting rights on the Executive Boards of NHS Trusts. This has been considered a result of the changes that stemmed from the Griffiths reforms and continue today, and due to a particular focus on corporate business ideals, from which a clear, but nonetheless controversial role was carved out for a function that dealt with the management of the increasingly important resource of people.

‘…the effect of the reforms was to stimulate management to review custom and practice and historical staffing patterns, with a view to achieving better value for money. In this context the HR function was caught up in the continuing tension between those health care professionals who focused primarily on patient care, and those managers responsible for cost-effective use of resources but constrained by a lack of clinical knowledge'(Buchan 2000:320).

The current role of HRM in the NHS, its status within the service, and its success as an effective function has become especially important at this time where ‘human resources' are considered the key to not only improved staff performance but also competitive advantage (Bach 2001; Clarke 2006). Despite the managerialist rhetoric that clearly surrounds the drive for increasing the role of HR, on a more simple note it is little wonder that such an emphasis has been placed upon the HR function considering the cost of staffing in the NHS - of the £19 billion cash increase in the NHS from 2004/5 to 2007/8 the increases in staff pay ‘swallowed up' around 34% (Appelby 2007). To add to this, the growing importance of the function is particularly clear in situations where individual NHS trusts are being granted greater financial and operational independence within the increasingly competitive, consumer driven market that the government is creating through such initiatives as Foundation Trust Status. Barnett et al's research demonstrated that the HR function within a Trust evolved through these changes in political and organisational focus and ‘generated a new focus on labour productivity and on value for money' from which ‘a new and strategic approach to the management of the workforce was required' and as a result they decided to ‘embrace the principles of human resource management'(1996:31).

So with the acknowledgement that service funding follows customers, customer satisfaction is linked to quality of service, and quality of service is linked to ‘the skills, motivation and commitment' of service staff, within such a ‘labour intensive human service industry' the role of HRM is imperative (Bach 2001:1; Pollock 2004).

The Changing Role of HRM in the NHS

Yet HRM's move from an administrative role to a function that potentially impacts upon corporate strategy has been my no means plain sailing. Ham succinctly locates a key basis for conflict within the NHS in his suggestion that ‘there is continuing tension between the role of doctors in deciding treatment…and the attempt by managers and politicians to influence priorities at a national and local level' (1996:96). There is much literature on the dominance of professionals and the conflict with managers within public sector organisations and in particular the NHS (Kember 1994; Skjorshammer 2001; Atun 2006; Hoggett 2006) and it is clear that their dominance remains not only because of their unique skills and knowledge but also because of their obvious importance within the service (Kelly and Glover 1996). However, within the changing NHS, the dominance of the professionals is subject to more and more management constraints, both on their resources and their autonomy and whilst some acceptance of management expertise is recognised by the professional groups their patience reaches a limit when this becomes encroachment on their ‘professional competence', resulting inevitably in conflict (Ackroyd 1996).

Managers within the NHS are marked by a poor image, often both within the organisation and by members of the public. Merali's study found that the ‘majority of the managers were convinced that the general public believed that doctors and nurses were the only professionals in the NHS who are motivated by a desire to serve/provide care to society' (2003:558) and similarly within this research the public perception of management within the NHS was consistently negative: ‘There's too many [managers] as it is', ‘The NHS should swap most of the managers for doctors and nurses, then there wouldn't be waiting lists', “If you can find out what the management do then that's an achievement in itself'. Overall it seems that management, especially in a context of attempting to rationalise the NHS and incorporate business ideals of value for money and efficiency which often results in cost-cutting through redundancies and closing services, are deemed by non-managers to hold an entirely different ideology that is a far cry from caring for people. Yet the function of ‘management' is well placed within the NHS, and its conflict with the medical professionals whilst often cited can appear over-emphasised.

However with HRM now shifting in its role from administration and support to management and strategy at the same time as organisational change that is producing a complex and uncertain environment for many within the NHS, the HRM function faces a hostile crowd. This symmetry between the focus upon business and private sector ideals and the rise in HR as a function in its own right, can begin to explain perhaps the antagonism that many within the NHS express towards the HR departments. Those within the NHS who hold close to their hearts the original ideals of the NHS and their role within it rather than fighting against government initiatives and the corporate business world influence instead could hold to account the one group which was ‘created' out of these initiatives - the HR function. Bryson et al in acknowledging both the power struggle between doctors and management and the increasing role of HRM note that, with a complex organisational strategy that seemingly has no clear direction and with few colleagues from the traditional management functions to align with, HRM are far from being seen as any part of the ‘NHS tribal club' (1996:53).

Through becoming part of the ‘Corporate Business Team' and gaining responsibility and a potential role of ‘power' within the new NHS environment the HRM function has run into conflict. Starting off on the wrong-foot, as Bach explains, HR within the NHS must struggle with the constant accusation that it is illegitimate as its role does ‘not obviously contribute to patient care'(Bach 2001:12). It would also be expected that any role within the NHS service that had the role of scrutinising staff and reviewing quality of care when they were not medically knowledgeable would come to blows with the medical professionals, especially when the latter has enjoyed far-reaching autonomy and control in the service since its beginning (Buchan 2000). However, to also find few compatriots within the rest of management due to its timely rise with organisational change which has rationalised and constrained many other departments, many HR departments have been left in a no-man's land.

There are few who would debate the continued dominance of the medical profession within the NHS, nor the importance of it remaining in such a position. However, their importance within the NHS as a business is becoming more complex. Management are increasingly holding the power to dictate for example the working patterns of doctors and they have the ability to withhold or reward resources depending upon clinicians abilities to achieve targets. And, with the introduction of Foundation Status, Trusts are running a competitive business within which all are dispensable, as Pollock describes:

“…in the past, doctors were free to speak out - in fact they were under a moral obligation to do so - if they felt it was in the interests of their patients. In a business culture, however, loyalty is said to be due above all to the shareholders. Where the survival of the hospitals depends on massaging the figures and performance ratings, doctors who expose the inadequacies in the system or rail against underfunding or lack of resources are seen to be criticising their own hospitals…”(2004:203)

With performance targets increasingly dominant in the NHS, to the extent that funding, resources and ‘Foundation Status' can be given or taken away accordingly, accountability not only for service provision but also initiatives such as ‘Improving Working Lives' have meant that HRM can also take a large piece of the managerial high-ground (Givan 2005). In addition, with the record investments in staffing and government focus upon improving service delivery through effective people management, HRM has been given legitimacy within the NHS through the Government's ‘HR in the NHS Plan' (DoH 2002) which represented the NHS's ‘first generic HR strategy'(Truss 2003:49) and more recently ‘NHS Foundation Trusts: A Guide to Developing HR arrangements' which highlighted the importance of the HRM function within Foundation Trusts (DoH 2006). With these initiatives in place the effective functioning of HRM is a measurable target - it matters not whether the medical professionals or other managers accept or value the role of HRM. This not only provides the HRM function with a place within the NHS, it gives it the opportunity to ‘adopt a more strategic role within the ‘new public management: ‘it is no longer consigned to a reactive and administrative role, interpreting and applying national rules, and can be proactive' (Corby 1996 cited in Truss 2003:49).

A number of commentators have assumed that changes in the role and status of HRM in the public sector merely follow orientations developed in the private sector (Buchan 2000; Thomason 1990). Just as the NHS as an organisation can be seen to have taken on private, corporate business strategies, so too it is considered that private sector HR management techniques were established (Buchan 2000:320). Distinct similarities can indeed be seen between the developments of HRM in the private sector and what is currently expected of the HRM function within the NHS as Begley and Boyd summarise:

“The declining relevance of the command-and-control approach to business has extended into the roles played by HRM. Many companies regard their employees' talents as providing a significant competitive advantage. they expect their HR professionals to formulate creative, flexible programs and policies to woo, develop, and retain that talent.”(2000:12)

This apparent mirroring of private sector HR techniques within the public sector environment has met with various hostile reactions, with accusations of public managers being forced to adopt private sector HRM styles with the possible ‘dangerous' result that such language will cause the public domains to ‘neglect their values' (Boyne, Jenkins et al. 1999:411).

Yet others, and especially some senior HR professionals within the NHS, take a different view. For them, the introduction of more efficient people management is an important and necessary development, one that is sorely needed in an environment where people are not only the service providers, but also the product and customer of healthcare services. The following empirical research and analysis demonstrates that far from being left out in the cold, the HRM function is capable of rising through an NHS Trust, effectively implementing government initiatives as well as producing its own, and finally reaching the position of designing and directing corporate strategy. Whilst the perceptions of HRM by other Trust members may vary, this is not necessarily a hindrance, but perhaps an organisational necessity that must be negotiated.

Methodology

The paper reports a research project that has followed the changing role of the HRM function within a large teaching NHS Trust (herein called ‘The Trust') in the UK. It reports on in-depth interviews and observations of a number of meetings involving staff from across the hospital hierarchy. The Trust is facing many changes, both in its financial governance and organisational practices. Recently it was granted “Foundation Trust” status and, as a result, a competitive drive for value for money and the need to develop efficient recruitment and retention practices have become key issues.

Despite only requiring access to staff, rather than patients, researching an NHS Trust proved more difficult than originally anticipated. Currently researchers wanting to interview NHS staff are required to gain NHS Ethics Committee approval to the same degree that clinical researchers must do when requesting clinical trials on patients. This can be seen as associated with the increased awareness of the importance and value of hospital staff and their working lives at all levels of the organisation, requiring the researcher to ensure that the research is valid and that staff will not be adversely affected. It could be suggested that by not distinguishing between staff and patients and the need for ethical approval in research the NHS has adopted the understanding that to ensure quality of service and patient care staff must also benefit from an improved working life.[1]

The empirical research took place over a period of nine months within the one NHS Trust and included in-depth interviews with twenty-two members of The Trust's staff and observations of key meetings with staff from across The Trust's hierarchy in attendance. A Trust Executive P.A. provided a list of thirty-five potential participants for the interviews, ranging from Assistant Service Managers, Junior Doctors, Ward Managers, Nurse Specialists and Senior Staff (including members of the Trust Executive) who were contacted via email communication. Assurances were given that these participants had not been ‘cherry picked' for their perceptions of HR or management initiatives (which was reflected in interview content at times).

The interviews were conducted either within an office provided by The Trust or at a location convenient to the interviewee, often a staff room or their office. Each interview was recorded, with the participants' consent, and transcribed in full, with all distinguishing information such as names, exact details of roles and personal information destroyed to ensure anonymity, in accordance with the Ethics Approval criteria. The Director of Workforce and Corporate Affairs was interviewed twice, before subsequent interviews took place and again once interviewing was completed.

The three meetings observed (Patient and Staff Experience Meeting; Executive Governance Committee for Clinical Effectiveness; and Strategy Advisory Group) were chosen through knowledge of the different staffing groups that would be in attendance in order to attempt to gather information as to how different groups interacted. By chance observation of the RCN Clinical Leadership Programme Presentation to the Patient and Staff Experience Group was also possible. Notes were taken during the meeting regarding staff interaction, comments about policies and Trust issues, though individual names and some meeting content was not recorded due to either anonymity or irrelevance.

Due to the highly qualitative nature of this research and in valuing the need to attempt to provide an accurate and indepth understanding into the perceptions of those interviewed and how these relate to the role of HRM and its effectiveness, the following presentation and discussion of the research will use direct quotations, some at length, to highlight issues. It is felt that it is important to allow these views to be expressed clearly and as distinct from over interpretation thus enabling as honest a reflection of the current context as possible. In order to ensure the anonymity of participants they will usually be identified only by their generic role within The Trust.

Discussion of Empirical Research

The research demonstrates that perceptions of HRM within The Trust remain varied, a stance that is not unknown to those within the role:

“I think lots of different people have lots of different perceptions. I think …a lot of managers are starting to see the value of HR and what HR can actually offer them…Other managers would probably just think we are only here to make their lives difficult and not let them get on with the job but those are the people who perhaps have never really had any involvement or used HR to its capacity...” (Human Resources Staff #1)

This suggests that HRM within the NHS remains in a similar situation to when Currie and Procter researched the role of personnel within the NHS and highlight the differing perceptions that the personnel department, and it's subsequent human resource strategies, had within a trust:

“Both executive directors and middle level managers see an advisory role as appropriate…They differ in their views as to whether the emphasis of the personnel department should lie with operational or strategic issues in an advisory role…middle managers view the personnel department unfavourably because it is distant from the operational aspects of health care…”(1998:383-384)

Indeed, many of the participants found it difficult to summarise the role of HRM and during the research the role was often described as ‘personnel' or ‘medical staffing'. This lack of clearly defined role for some within The Trust may, as suggested by the HR staff, stem from minimal contact with the HRM department, other than in specific situations such issues with recruitment and pay-role[2].

“…lower grade staff will still see the HR as a sort of mini police force within the organisation and if you do anything naughty you get disciplined and I guess a lot of the lower grade staff don't have a real idea of what the HR department does…”( Human Resources Staff2)

Perhaps another reason could be the constantly changing title of the head of the HR department. Initially The Trust employed a Director of HRM but as the Director developed and expanded the remit and function of the HR department's role his title developed to one of Director of Workfor