Reshaping common sense: Management, power and the allure of medical leadership in England's NHS

Do left ideas on leadership have a role in debates on the NHS?

Although the concept of 'Medical Leadership' remains in many ways unclear, within the NHS it is widely seen as the solution to the service's second biggest problem (after funding) - the fragmentation of services and system inefficiencies that undermine high quality care. This belief is growing even though evidence for the critical importance of 'leadership' as a distinct, individual characteristic is thin, and the return on investment in leadership training programmes remains largely unmeasured.¹

Leadership in the NHS is deemed necessary because medical science (in its broadest sense, including the knowledge and expertise of a range of expert disciplines) has developed beyond the organisational and management capacities of a health service designed when Penicillin was not yet in widespread use. Attempts to overcome this contradiction by deploying a market-oriented system of general management (New Public Management) have largely failed. This article will outline the historic development of both the medical work that the NHS does, and the ways in which that work is managed. It will then describe the leadership function as it is currently promoted in the NHS, before going on to discuss and evaluate leadership from the perspective of Gramsci's ideas about the formation of a collective intellectual, and the transition by intellectuals from traditional to organic roles; and it will do so alongside a consideration of the characteristics of the 'cadre', as described by Göran Therborn.²

Medical work evolves

The growth and diversification of medical sciences during the second half of the twentieth century have created what could be broadly described as three different modes of working: repetitive; constrained problem-solving; and unconstrained, customised, problem-solving.³ Most of us have experience of the first two as patients - our childhood immunisations, for example, are examples of repetitive medicine. An example of constrained problem solving would be the distinguishing of a self-limiting virus infection - needing only symptom control - from a more serious bacterial one needing treatment. In the course of a lifetime we will almost all also experience the third category of medical work, unconstrained problem-solving - the puzzling out of worrying but hard to interpret symptoms, like a persistent cough or unexpected weight loss. This is historically the oldest form of medicine: the causes of illness are unclear but the symptoms demand a response. Theories of causation are needed to explain the illness, and ways of intervening are created to combat it. But what was once a matter of complex problem-solving can become more routine as the passage of time allows knowledge to accumulate. The expansion of scientific knowledge about illnesses has clarified some diseases to the point where the sick individual's problem is clearly understood, the most effective treatment is known and available, outcomes are predictable, and care is driven by protocols; in sum, as time passes, much medical care (in its broadest sense) tends to fall within the constrained problem-solving mode, or even the repetitive mode.

Repetitive medicine is not the stuff of TV dramas. It standardises practice into streamlined micro-systems based on logic trees. The practical tasks become ever more specialised, and are delegated to other disciplines (especially nursing, but also to technicians and paramedics). The Glaucoma clinic is an example: glaucoma is not common, but its consequences for eyesight are serious; it develops with few symptoms initially, and it is inheritable. Early identification of glaucoma in those with a genetic risk but who have no symptoms is possible by measuring the pressure within the eye, mapping the extent of visual fields and observing changes in the retina, allowing a production-line approach. It is this mode of care work that is the most open to mechanisation by robots and machine learning - and its privatisation, in terms of being contracted out to commercial companies or self-employed professionals, is commonplace in the UK.

At the opposite end of the work-mode spectrum - unconstrained and customised problem-solving - practitioners must clarify causes and work...