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thirteen - Setting the workers free? Managers in the (once again) reformed NHS
- Edited by Mark Exworthy, University of Birmingham, Russell Mannion, University of Birmingham, Martin Powell
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- Book:
- Dismantling the NHS?
- Published by:
- Bristol University Press
- Published online:
- 05 April 2022
- Print publication:
- 28 July 2016, pp 257-278
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Summary
Introduction
Despite repeated reorganisations, the NHS continues to be under severe pressure as it faces profound challenges in terms of growing patient demand, shrinking resources and a rise in external competition. More than ever, it depends upon the effort, knowledge and expertise of its workers. Managing the healthcare workforce was a central focus for Coalition government reforms and it continues to present several challenges; not least that demand for workers often exceeds supply and workforce is often the single most expensive budget item. Thus, it attracts (political, media and public) attention during times of recession and budget constraints (Hyde and McBride, 2011).
The NHS is regularly described by the size of its workforce – often erroneously as the third largest in the world (after the Chinese army and the Indian railways). In fact, it is the fifth largest employer after the US Department of Defense (3.2m), the Chinese military (2.3m), the US supermarket chain, Walmart (2.1m) and McDonald's (1.9m) (Alexander, 2012). In 2015, the NHS workforce amounted to 1.3 million (Health Education England, nd). Together with a further 1.6 million working in social care, the health and social care workforce accounts for 1 in 10 jobs in the UK (Imison, 2015, 20).
The NHS wage bill is £45 billion (DDRB, 2016, 7), accounting for about 40% of the total NHS budget (Kings Fund, 2010) and the majority of health expenditure across all health systems. For NHS providers in England, this amounts to ‘about two thirds’ of their total expenditure (Lafond, 2015, 11). Moreover, the NHS is marked by the diversity of employment, with over 300 occupations and over 1,000 employing organisations (Health Education England, nd). Although managerial decision-making can go some way towards mitigating shortages and containing costs (through training and development, for example), workforce planning and establishing new ways of working are sophisticated procedures that require strategic and operational coordination if they are to improve organisational performance (Hyde and McBride, 2011). Therefore, managers matter (King's Fund, 2011).
Over the past 30 years or so, a series of health reforms have affected the NHS workforce. As a result of these and combined with the more recent austerity policies, there has been a growing impact upon pay, skill mix, morale and motivation of all staff. While not discounting the effect of reforms upon all staff (especially clinical staff), we focus, in this chapter, upon NHS managers.
Knights and Knaves in the English Medical Profession: the Case of Clinical Excellence Awards
- MARK EXWORTHY, PAULA HYDE, PAMELA MCDONALD-KUHNE
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- Journal:
- Journal of Social Policy / Volume 45 / Issue 1 / January 2016
- Published online by Cambridge University Press:
- 02 October 2015, pp. 83-99
- Print publication:
- January 2016
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We elaborate Le Grand's thesis of ‘knights and knaves’ in terms of clinical excellence awards (CEAs), the ‘financial bonuses’ which are paid to over half of all English hospital specialists and which can be as much as £75,000 (€92,000) per year in addition to an NHS (National Health Service) salary. Knights are ‘individuals who are motivated to help others for no private reward’ while knaves are ‘self-interested individuals who are motivated to help others only if by doing so they will serve their private interests.’ Doctors (individually and collectively) exhibit both traits but the work of explanation of the inter-relationship between them has remained neglected. Through a textual analysis of written responses to a recent review of CEAs, we examine the ‘knightly’ and ‘knavish’ arguments used by medical professional stakeholders in defending these CEAs. While doctors promote their knightly claims, they are also knavish in shaping the preferences of, and options for, policy-makers. Policy-makers continue to support CEAs but have introduced revised criteria for CEAs, putting pressure on the medical profession to accept reforms. CEAs illustrate the enduring and flexible power of the medical profession in the UK in colonising reforms to their pay, and also the subtle inter-relationship between knights and knaves in health policy.
Looking Backward, Looking Forward: MLA Members Speak
- April Alliston, Elizabeth Ammons, Jean Arnold, Nina Baym, Sandra L. Beckett, Peter G. Beidler, Roger A. Berger, Sandra Bermann, J.J. Wilson, Troy Boone, Alison Booth, Wayne C. Booth, James Phelan, Marie Borroff, Ihab Hassan, Ulrich Weisstein, Zack Bowen, Jill Campbell, Dan Campion, Jay Caplan, Maurice Charney, Beverly Lyon Clark, Robert A. Colby, Thomas C. Coleman III, Nicole Cooley, Richard Dellamora, Morris Dickstein, Terrell Dixon, Emory Elliott, Caryl Emerson, Ann W. Engar, Lars Engle, Kai Hammermeister, N. N. Feltes, Mary Anne Ferguson, Annie Finch, Shelley Fisher Fishkin, Jerry Aline Flieger, Norman Friedman, Rosemarie Garland-Thomson, Sandra M. Gilbert, Laurie Grobman, George Guida, Liselotte Gumpel, R. K. Gupta, Florence Howe, Cathy L. Jrade, Richard A. Kaye, Calhoun Winton, Murray Krieger, Robert Langbaum, Richard A. Lanham, Marilee Lindemann, Paul Michael Lützeler, Thomas J. Lynn, Juliet Flower MacCannell, Michelle A. Massé, Irving Massey, Georges May, Christian W. Hallstein, Gita May, Lucy McDiarmid, Ellen Messer-Davidow, Koritha Mitchell, Robin Smiles, Kenyatta Albeny, George Monteiro, Joel Myerson, Alan Nadel, Ashton Nichols, Jeffrey Nishimura, Neal Oxenhandler, David Palumbo-Liu, Vincent P. Pecora, David Porter, Nancy Potter, Ronald C. Rosbottom, Elias L. Rivers, Gerhard F. Strasser, J. L. Styan, Marianna De Marco Torgovnick, Gary Totten, David van Leer, Asha Varadharajan, Orrin N. C. Wang, Sharon Willis, Louise E. Wright, Donald A. Yates, Takayuki Yokota-Murakami, Richard E. Zeikowitz, Angelika Bammer, Dale Bauer, Karl Beckson, Betsy A. Bowen, Stacey Donohue, Sheila Emerson, Gwendolyn Audrey Foster, Jay L. Halio, Karl Kroeber, Terence Hawkes, William B. Hunter, Mary Jambus, Willard F. King, Nancy K. Miller, Jody Norton, Ann Pellegrini, S. P. Rosenbaum, Lorie Roth, Robert Scholes, Joanne Shattock, Rosemary T. VanArsdel, Alfred Bendixen, Alarma Kathleen Brown, Michael J. Kiskis, Debra A. Castillo, Rey Chow, John F. Crossen, Robert F. Fleissner, Regenia Gagnier, Nicholas Howe, M. Thomas Inge, Frank Mehring, Hyungji Park, Jahan Ramazani, Kenneth M. Roemer, Deborah D. Rogers, A. LaVonne Brown Ruoff, Regina M. Schwartz, John T. Shawcross, Brenda R. Silver, Andrew von Hendy, Virginia Wright Wexman, Britta Zangen, A. Owen Aldridge, Paula R. Backscheider, Roland Bartel, E. M. Forster, Milton Birnbaum, Jonathan Bishop, Crystal Downing, Frank H. Ellis, Roberto Forns-Broggi, James R. Giles, Mary E. Giles, Susan Blair Green, Madelyn Gutwirth, Constance B. Hieatt, Titi Adepitan, Edgar C. Knowlton, Jr., Emanuel Mussman, Sally Todd Nelson, Robert O. Preyer, David Diego Rodriguez, Guy Stern, James Thorpe, Robert J. Wilson, Rebecca S. Beal, Joyce Simutis, Betsy Bowden, Sara Cooper, Wheeler Winston Dixon, Tarek el Ariss, Richard Jewell, John W. Kronik, Wendy Martin, Stuart Y. McDougal, Hugo Méndez-Ramírez, Ivy Schweitzer, Armand E. Singer, G. Thomas Tanselle, Tom Bishop, Mary Ann Caws, Marcel Gutwirth, Christophe Ippolito, Lawrence D. Kritzman, James Longenbach, Tim McCracken, Wolfe S. Molitor, Diane Quantic, Gregory Rabassa, Ellen M. Tsagaris, Anthony C. Yu, Betty Jean Craige, Wendell V. Harris, J. Hillis Miller, Jesse G. Swan, Helene Zimmer-Loew, Peter Berek, James Chandler, Hanna K. Charney, Philip Cohen, Judith Fetterley, Herbert Lindenberger, Julia Reinhard Lupton, Maximillian E. Novak, Richard Ohmann, Marjorie Perloff, Mark Reynolds, James Sledd, Harriet Turner, Marie Umeh, Flavia Aloya, Regina Barreca, Konrad Bieber, Ellis Hanson, William J. Hyde, Holly A. Laird, David Leverenz, Allen Michie, J. Wesley Miller, Marvin Rosenberg, Daniel R. Schwarz, Elizabeth Welt Trahan, Jean Fagan Yellin
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- Journal:
- PMLA / Publications of the Modern Language Association of America / Volume 115 / Issue 7 / December 2000
- Published online by Cambridge University Press:
- 23 October 2020, pp. 1986-2078
- Print publication:
- December 2000
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