The dynamics of the purchaser/provider split
Tony McCaffrey
The NHS and Community Care Act has had an enormous impact on the health service, social services and voluntary organizations through the creation of a purchaser/provider split and the need for contracting arrangements. To quote Simon Biggs:
As one would expect from a method rooted in the free enterprise culture of the US and the project to turn the British Welfare State into a mixed economy, case management assumes a marketplace model of interpersonal relationships—that is to say a meeting of two equal individuals coming together to agree a bargain on the exchange of goods and services. This guiding principle is interesting from a psychodynamic point of view, largely because of the detail of interpersonal thought feeling and action it leaves out. It proposes a vision of single persons rationally in possession of relevant information and a cool grasp of their own motivation, finding an agreeable solution to a mutually agreed definition of need.
(Biggs, 1991:73; see also Chapter 6) So what are the consequences in terms of the services of the public sector? And in particular, how are the managers in the various organizations coping with and making sense of this new culture? My sense of some of the issues emerging for public sector managers can be illustrated by reference to an example drawn from some consultancy work that I undertook with a large NHS Trust.
Case study
I was commissioned by the directors of a large health trust to carry out a series of workshops with service managers, that tier of managers responsible for the service units that deliver the medical and mental health services of the trust.
They were worried that the service managers as a group seemed to be unable to meet the budgetary targets that each had been set, a failure that threatened the success of the purchasing/providing system that comprised the framework within which the trust operated. In essence the trust seemed to be faced with bankruptcy.
It was agreed that the work would be undertaken by myself as an external consultant, with an internal consultant as a partner.
The broad aim of the initial workshops was diagnostic. They were designed to try to understand what made the job of the service manager so stressful and difficult, in order that their development needs could then be addressed. But we also had in mind the question of ‘Why the service managers?’ What did their dissatisfaction and ‘failure’ mean in the context of the wider system?
Two groups of service managers each attended two afternoon workshops. In the first of the two afternoons, the focus was on exploring the managers’
experience of their task and identifying the issues that got in the way of effective working. In the second afternoon, the focus was on identifying the issues around the roles and responsibilities of the service managers. Attendance at these workshops was not compulsory. Some of the themes that emerged were as follows.
Stress
The service managers exhibited a high degree of stress. They linked this to the ambiguity of their tasks and roles, and the organizational structure in which they found themselves. They were not sure what to do, or how to do it in an organization that seemed to be constantly changing. They felt themselves constantly running just to stay in place. Crucially, they feared that they could lose their jobs at any moment. This made it difficult for them to commit themselves fully to the task of the workshops, and it manifested itself in a collective touchiness about what was felt to be the self-exposure demanded by the workshop task. They gave a sense of being at the end of their tethers. In other words, the workshops themselves added to the stress.
Mistrust
They exhibited a high degree of mistrust of and cynicism about managerial superiors. For example, there was considerable scepticism about the workshops themselves, and anger about what was perceived as a ‘three-line whip’ to ensure their attendance. Although attendance was ostensibly voluntary, in effect they felt coerced. There was hostility towards and suspicion of both consultants. We were seen as lackeys of the persecutory higher management. The in-coming new chief executive appeared to recognize that the service managers had been labouring in a culture of blame in which mistakes were punished, and in which the greatest sin was to be seen to be not coping. This climate produced herculean but unfocused efforts by the service managers, and involved them exhausting themselves by working an inordinate number of hours to try to keep their sinking ships afloat. A statement by the chief executive that was intended to be wholly positive, and to recognize the struggle that the service managers had had to deal with—‘I now want to see you managing, not just coping!’—was routinely given
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a negative connotation by the service managers: ‘He thinks we’re just not coping!’
Hopelessness
They described as a sense of powerlessness, of being nakedly exposed, under a spotlight, in the service manager role, to the critical and hostile scrutiny of both their superiors and their subordinates as if they were the meat in a hostile persecutory sandwich. They also experienced a sense of hopelessness and defeat.
This had two components. First, they described how they found it difficult to make sense of the bewildering present, there being too many variables to integrate in doing a task that seemed to them undo-able. But this was exacerbated by the second factor, the expectation of continual change, the sense that the next change in the future might render inapplicable all the work being done here and now.
Isolation
Perhaps most significantly, and the theme on which I propose to focus particularly in this chapter, the service managers exhibited a significant degree of disconnectedness, an almost purposeful isolation—from each other, from senior management, from their subordinates and from the patients. Some of this seemed structural: there were no peer group meetings in the normal working week, for example. But they also noted, with some chagrin, that there seemed to be few social or friendship ties among themselves either. Friendship was feared; it was felt that if you did not get together with your mates, then you would not be reminded of and would not have to think about and acknowledge the painful experience of the job. Thus social and structural isolation was identified as one way of defending themselves against the feeling of being overwhelmed by the surrounding turbulence.
Sources of anxiety
As a way of making sense of these feelings, the service managers were invited to consider, as an analogy, the electromagnetic spectrum. In the trust, the service managers could readily agree that there were ‘visible’ issues that could be identified by rational analysis in their situation. However, it was also possible to detect and to examine with them an ‘invisible’ set of forces, the ‘irrational’ or
‘unconscious’ forces that illuminated the whole picture. These were identified and linked to the extremes of feeling experienced by the service managers and were thought about as in Figure 8.1.
What became clear was that the service managers were having to cope, consciously and unconsciously, on a daily basis, with an inordinate amount of anxiety that constantly threatened to engulf them. Anxiety is probably the most
important unpleasant feeling that human beings experience. It is, in essence, a response to perceived danger. Human beings, like all higher animals, have developed two major responses to external danger—fight or flight. Evolutionary survival depended on a judicious admixture of these. The physical effects of anxiety can be seen as triggers, or warning signs, heralding danger. These effects are commonly experienced in similar ways by everyone. For example, we sweat, we feel a tightening of the muscles and a rapid beating of the heart. But the causes of anxiety are intensely subjective and depend on the way that each individual perceives and interprets a situation.
The sources of anxiety can be thought about in two ways. As well as the external dangers and threats discussed, anxiety can also have an internal origin in the individual mind. This happens when the current situation resonates with old, often forgotten losses and dangers. These feelings and memories can stir up intolerable anxieties which may seem out of proportion to the current event that has triggered it. However, whether anxiety is ‘objective’ (from without) or
‘neurotic’ (from within), it is experienced as the same painful emotional state, and in essence is dealt with in the same way by fight or flight. The internal equivalents of fight and flight are the psychological defence mechanisms, the ways in which we protect ourselves by the evasion of difficult feelings. Of key importance here are the defences of denial, splitting and projection, identified by Melanie Klein (Klein, 1946; see also Chapter 6).
Defending against anxiety
I suggest that the inability of these managers to cope was due to the impact of overwhelming anxiety in their organization, an anxiety that disabled them and caused them to defend themselves with what Menzies has called a ‘social defence system’ (Menzies, 1959).
In her classic study of stress in the nursing profession, Menzies showed how anxiety from both internal and external sources, working in tandem, can overwhelm the capacity to carry out professional tasks. She argued that, when faced with a sense of impending annihilation, nurses defend themselves by fight and flight mechanisms. The nature of the anxiety is as follows. In common with many jobs in the medical field, the jobs that the nurse has to perform are frequently frightening and disgusting. Human pain and suffering are omnipresent. Yet intimate contact with patients may also stir up libidinal desires.
Death can be a constant companion. Then, too, the response of patients and their Figure 8.1 The spectrum of rational and irrational forces
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relatives can be difficult to deal with due to the strong ambivalence that they feel towards the nurse. Gratitude for her care and attention jostles with hostility at the dependency that they feel towards her, and envy of her health and vitality.
According to Menzies, this confused and highly emotional situation confronting the nurse ‘bears a striking resemblance to the phantasy situations that exist in every individual in the deepest and most primitive levels of the mind’. This results in a confusion arising between internal and external dangers.
As adults, we are all susceptible to a stirring up of infantile anxiety. It can often be coped with by projecting it onto our work situation. Work can be used as a symbolic representation of the inner phantasy situation. By achieving and succeeding in our work task, the phantasy situation is conquered, leading to internal reassurance and a lessening of anxiety. However, when the inner phantasy and the outer reality are very similar, a confusion occurs. The deep resonance between the inner terrors and the outer horrors actually cranks up the experience of anxiety, and can be literally overwhelming. This is what happens with the nurse. It leads to the amplification of unconscious defences on an individual level, and to a ‘social defence system’ at the level of the group or organization, in which individual nurses collude with each other as they attempt to operate their own psychic defence mechanisms.
Menzies identifies a number of different defensive structures shared by the nurses. Of particular interest for our case is the way that they dealt with the anxieties surrounding the taking of responsibility. Each nurse experienced a powerful internal conflict between the responsibility demanded by her work, and her wishes to avoid this heavy and continuous burden by acting irresponsibly. This conflict was partially avoided by the processes of denial, splitting and projection, which converted this intra-personal struggle into an inter-personal conflict, each nurse tending to split off aspects of herself from her conscious personality and to project them into other nurses. The irresponsible impulses were projected down the hierarchy into subordinates, who were then treated with the severity which that part of the split-off self ‘deserved’. The stern and harsh aspects of herself were split off and projected up the hierarchy into her superiors, so that she expected (and often received) harsh disciplinary treatment from them.
Let us now consider the relevance of Menzies’ work to this case study. There are two strands that may be teased out:
1 What was most strikingly missing from the discourse of these service managers, as compared with Menzies’ nursing staff, was any sense of what might be called the ‘clinical’ task, the treatment function of their respective services. Instead, all their experiences seemed to be mediated solely through the lens of the ‘business’ perspective.
2 What was also striking was the ambivalence of the managers towards the consultants and the workshops, shown by good attendance and yet suspicion and hostility towards the consultants.
These factors seem to be particularly important, and I would like to explore each of them in some detail. But first I would like to describe an example that catches the flavour of both of these particular points.
The start of the second workshop was punctuated by the following vignette. It ensued from the late arrival of the manager of the accident and emergency service of the trust. The group had spent much of their first workshop exploring the burden of ‘balancing the books’, and the dilemma of trying to run a service when there is no money left. This particular manager, in explaining her latecoming, described a crisis that had occurred for her team. There had been a terrible road accident. The helicopter service, always a high-profile operation, had responded, and picked up a critically injured patient. In full public gaze, it transported the patient back to the Intensive Care Unit of the Accident and Emergency Department. ‘Luckily,’ she announced, with no trace of irony, ‘the patient was dead on arrival!’ ‘Nice one!’ murmured the other managers in response, again without a trace of irony.
What seemed to be to the fore in the managers’ minds was the realization that the Intensive Care Unit had run out of funds. But the simple human consideration (linked, after all, to the primary task of a hospital) of a human death was simply split off, as if it were not available for consideration. When this was pointed out to the group, it produced major discomfort and caused this particular group to refuse to participate in the rest of the workshop.
Splitting clinical and business anxiety
How might this be understood? Put rather simplistically, before the purchaser/
provider split, the anxiety in the system could be seen as being associated with the clinical task. This clinical task anxiety was generated by the ‘hands on’ work of dealing with death, pain and suffering of patients, and the associated distress of relatives, as described above. It was coped with by being dispersed throughout the structure, with different tiers of the hierarchy ‘containing’ different bits of the anxiety (Bion, 1959).
It is worth teasing out this theoretical idea of containment a little further. Bion argues that in order for anything to develop, there must be an appropriate apparatus or container to hold or contain the development. Bion described thought, which he considered ‘trial action’, in such a way. He argued that there must be an appropriate ‘container’ for thought to develop, which in the early stages of development is provided by the mother. Failure to provide such a container leads to a state of ‘nameless dread’ in the infant. These ideas are useful, for example, in conceptualizing the role of the consultant to an organization as trying to create a setting (container) in which difficult emotions can be safely explored or, as Bion might put it, where thought can emerge and develop.
Containment in an organization is provided by effective management. It is embodied in clearly defined tasks and clearly defined roles, and in the systematic
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provision of spaces in which reflection can occur and difficulties can be struggled with.
The advent of purchasing/providing can be thought of as introducing a radically new quantity and quality of anxiety into the system. This business anxiety is about balancing the books: business planning, ‘downsizing’, redundancies, cuts in services and trying to meet the increasing demands of the public with decreasing resources.
Furthermore, as Hinshelwood has argued:
[T]here is also another significant addition to the level of anxiety and this is deliberately introduced as policy. The rationale for the market system in the NHS is to create a stimulating sense of competitive insecurity—we should be energised by the anxiety that if we do not do well we will lose business and we shall be closed down. This is intended to keep people on their toes and thus to improve performance and productivity, etc. However the medical and nursing professions are beset by particularly high levels of anxiety already, just from the nature of the work. What happens if they bear extra anxiety? It is possible that, instead of increasing performance, it will increase the intensity and scope of defensive measures and collective phantasy-based attitudes.
(Hinshelwood, 1994:287) Thus, trusts have had to cope with a doubling up of anxiety, but without an increase in capacity to contain it. As the saying goes, you cannot fit a quart into a pint pot! This can be shown as follows in Figure 8.2.
For the purchasing/providing system to work, it would seem to be necessary for the two functions, the professional task and the business task, to be held in mind at once. That is, after all, the mission of a modern trust. But the double dose of anxiety associated with the two functions is so great that one or other gets lopped off, pushed out of mind as if it did not exist. Hence the focus of the service managers on ‘business’, and the absence in their discussions of the
‘clinical’ task. The service managers were seemingly being asked to carry the anxiety associated with ‘business’ on behalf of the whole trust, because it is they who had to operationalize the business framework and make it work. Thus, they were caught between the proverbial rock and a hard place.
Figure 8.2 The increase of anxiety with the advent of purchasing and providing
Some consequences of splitting the task
Hinshelwood shows that clinicians in a purchasing/providing regime ‘experience (managers) as extremely intruding and blindly jeopardising the clinical service’
(Hinshelwood, 1994:292). In reality, there is some truth in this perception. The business anxiety corresponds to the ‘visible’ part of the spectrum shown above in Figure 8.1. Managers do have the responsibility to ration scarce resources. They are responsible for increasingly intrusive decisions that affect clinical output, but also for balancing the budget, which can mean cutbacks and often redundancies of subordinate staff. They have to do this against the backdrop of the competition in which they themselves are involved—the competition for their own jobs. This also stirs up primitive or unconscious anxieties (the ‘ultraviolet’ part of the spectrum). I suggest that they deal with the pain of this responsibility in ways similar to those identified by Menzies-Lyth for the nurses. They split off that part of themselves that rations, that seems to be destructively intrusive, and project it up the hierarchy into the senior managers. Senior managers then are imbued with these negative characteristics, and the service managers can feel more
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