The Scalpel's Blog


The training plans of Ronald McDonald

Source: NHE Jan/Feb 2019

From McDonalds to eBay, Paul Conroy, chief executive of the Institute of Healthcare Management, discusses the various business styles which have influenced NHS training throughout the years, and how this all fits into the long-term plan.

Whatever the 10-year plan says, whatever the headlines on cash for the NHS – we all know the reality. Demand and expectations will continue unabated, resources will be constrained, and politicians will not have the courage to say we can only do so much with what we have.

Technology is much vaunted as the panacea, and superhuman efficiency savings are the foundation of many of the plans we see. But for those without the belief that either of these will solve all our problems in the immediate term, there are some rather more stark options. These are particularly so when the workforce plan remains a craggy IOU in the 10-year landscape.

The American sociologist Professor George Ritzer coined the term ‘McDonaldisation’ in his 1993 book ‘The McDonaldisation of Society,’ in which he describes how rational and scientific management through predictability, calculability, efficiency, and control become mechanisms for the standardisation of output.

In healthcare, this has manifested in the belief that what we do is all science, without the art of human interpretation, and the use of targets to incentivise and control behaviour.

The criticisms of Ritzer’s theory carry into healthcare as well, with the burnout of workers exposed to a system so rationalised it becomes devoid of personality and humanity.

We also see the deskilling of workers as machines or lower-cost staff take over what were formerly professional roles. The shift towards consumers as workers was also identified in the McDonaldisation model, with customers clearing their own tables. We increasingly see this with self-booking, self-check-in, and online care.

As we think of the £700m cost savings from ‘back-office’ functions in the NHS promised in the 10-year plan, there is a significant danger that the perils of outsourcing demonstrated so powerfully by the failures of the Primary Care Support England contract are writ even larger and more dangerously in other key areas of the service. Standardisation is a noble aim in itself, but its outcome is only as good as the knowledge, rigour, and understanding of those implementing it. Otherwise, we risk simply adopting the lowest common denominator in a robotic and dehumanised offering, devoid of care.

Tasks which were previously medical only have become nursing tasks, and increasingly are passing further down the ladder to non-clinical associates. We must be careful that as we train future cohorts of broad-skilled staff teams, we are clear of the implications of this for capacity, safety and quality. It has often been said that you can only have two of the triumvirate of convenience, quality, and efficiency.

Subsequent writers have played on Ritzer’s work to talk about the chaos of an ‘eBayisation’ in society, where the results are unpredictable, with variety and surprise being both positive and negative.

In recent years, manufacturing and consumer retail brands have sought to differentiate themselves through variations and combinations of personalisation, customisation, and mass-automated variation. Experts in the field differ in their use of these terms, with often diametrically opposed meanings to the same words, but we’ll adopt a working definition for the purpose of this article. 

We will characterise ‘personalisation’ by the use of variants in stylistic characteristics, which have little or no effect on the fundamental structure of a product or service, but which merely change its outward appearance. An example would be the choice of colour, or the addition of stripes or chrome to your new car, which have no performance or comfort utility beyond aesthetics. In contrast, ‘customisation’ we will use to mean the fundamental change of core products or services to improve fit or utility to the end user.

Many have dismissed personal health budgets as mere personalisation, without the intended utility that customisation entails.

In contrast, we’ve heard the incredible story of surgeons 3D printing a rib. This, to me, is customisation at its very best: personal, bespoke, and a cost-effective way of radically changing the way of doing something to make it better.

It must be done at the frontline, by people who are given the trust to innovate, and who are enjoined in the change they make – not having it done to them by the Time and Motion Man. That’s why we’ve partnered with the University of Coventry to deliver a master’s programme in Global Healthcare Management funded by the apprenticeship levy, that equips our members for the challenges that lie ahead.

Developing the staff and leaders of the future will require more than just regurgitating what has been done elsewhere in other sectors. Leaders must not only learn from other industries, but develop the skills to adapt and translate concepts with nuance and insight to appropriately fit into the complex healthcare landscape. The alternative is a staffing strategy that resembles something more akin to Ronald McDonald than the NHS.


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