Corporate Conflict
Reducing the clinical-managerial divide
Written by: Andrew Vincent, Medicology Ltd. Published: 3rd June 2010
Corporate conflict tends to exist wheneverindividual or group interests appear todiverge within an organisation or wherethe organisational direction seems to bedeparting from the values or goals thatthe workforce believes are underpinningits true purpose. Within the NHS intraorganisationalconflict between managersand clinicians is often very high, with eachparty appearing to have an agenda which isincompatible with the others. Whilst in thepast organisations might have continuedto survive in spite of this internal conflict,survival and growth in the new world willbecome increasingly difficult in thoseorganisations where a clinical-managerialdivide remains.
Before we go any further, it is probablyimportant to define conflict in our terms.Conflict could be direct person-person orintra-group fighting i.e. active, direct conflictby any common definition. However, weinclude the more pervasive, passive formsof conflict too, in which no active fightingoccurs but in which there is an absence ofpositive collaboration i.e. resistance instead.All too many Trusts find themselves inpassive conflict with their clinical workforce.Dangerous territory indeed.
New World imperative
The NHS in England continues to movethrough unprecedented change; LordDarzi’s “High Quality Care for All” with anemphasis on new ways of working, withmany services shifting to the communitywhilst simultaneously centralising andstreamlining many other services; WorldClass Commissioning and Practice BasedCommissioning, with an emphasis onstimulating the market, improving qualityand driving down costs; the imperative toacquire Foundation status by December2010; the impending NHS recessioncommencing in 2011; all contribute to therisk of conflict in a melting pot for diversityof views, values and beliefs.
However, whatever our personal view,the NHS in England is changing and willcontinue to change for the foreseeablefuture. Competition, new ways of deliveringservices, patient and public involvement areall here to stay whichever political party winsthe next election. With change often comesan additional level of conflict. However,those organisations suffering from higherlevels of internal conflict could risk beingleft behind by an increasingly competitiveexternal environment. Whilst they wrestlewith internal conflict, the world around themwill move on, possibly without them. Howreal is the competitive effect?
All over the country there are FoundationTrusts developing business models to attractsignificant numbers of new users to theirservices from other surrounding Trusts, bothFoundation and non-Foundation. There areprivate and voluntary providers developingcommunity services whilst PCT providerarms themselves deal with developing newmanagement structures (often associatedwith conflict) in readiness for permanentdivision from the commissioning PCT anda consequential requirement to enterthe competitive game too. Unless theconsiderable energy spent in dealing withinternal conflict is re-channelled, by the timethese organisations wake up to the necessityfor internal collaboration, they may alreadyfind service erosion and possibly even loss.
The clinical wakeup call
Clinicians have always wanted to deliverhigh quality care to their patients and forthe most part that has involved a relentlessand applaudable focus on improvingoutcomes. Managers increasingly recognisethat only the fittest survive. Fit has oftenbeen misdiagnosed to mean ‘cheap’(which naturally suggests poorer quality)and yet to be “fit” we must use our finiteresources efficiently and responsibly whilstalso delivering on patient experience andclinical quality. If we do not achieve on thisbalance then we risk patients choosing to goelsewhere for their care or worse still, endingup with a Mid Staffs-type problem wherefinancial health predominated over qualityand experience.
To survive and thrive in the new worldwe have to be the best at our game.However, it is vital to recognise that ‘best’ ismultifactorial. It is effective, efficient, safecare delivered by teams who work togetherto deliver high patient experience at anindividual level. Furthermore, whether weagree or disagree with the principles, it willalso be care delivered flexibly, as close to thepatient’s home as possible, except wherecentralisation is necessary to improve thequality of outcomes. Survival and growthof organisations will occur where everyoneunderstands their contribution to this andthe organisational success as a whole,resulting in collaborative working for thegreater good of the organisation rather thana focus on their own small piece of a muchlarger pie.
If you are in conflict, active or passive thenyou need to ask yourself what is happeningin the world around you whilst you arefighting internally within the organisation.When you have finished fighting, regardlessof whether you have won the battle, youneed to be mindful of the wider war.What has happened to your service in themeantime? Are your preferred patientsebbing away, drawn to an evolving andcompetitive service nearby, along with thefunding they carry with them?
Dissolving the internal barriers
Without question it is critical that thisconflict, whether active, passive or just plaincompetitive, is resolved if organisations areto flourish in the evolving environment.The challenge is just how do we go aboutresolving an issue that has been embeddedfor many years? Some solutions need tobe delivered at an organisational level andothers are just plain old practical exercisesbetween individuals or groups.
The first step in most conflict situationsis to gain a perspective that is wider thanyour own. This increased objectivity allowspeople to more readily rationalise how tomove forward in a realistic and productivemanner. One way of doing this is to usean exercise which enables you to seethe problem from a number of differentpositions or perspectives. We’ll describe...
Place 4 chairs in a circle back to back. Sit onthe first chair and describe the conflict fromyour point of view. Why do you believe thethings you believe? Why are you behavingin the way you behave? What are you reallyworried about losing if you do not get yourway? What problems do you think willoccur?
Now move to the second chair and describethe conflict from the other party’s view point.Be absolutely sure you fully understand theproblem from their perspective. How mustthey see you in this conflict? How mustthey feel about this conflict? What must beworrying them?
Now move to the third chair. Imagine nowyou are looking down from above on thisconflict but as a neutral observer. Whatdo you notice and observe. Where are theagreements? Where is the win-win? Howcould the problem be reframed (see below)?Finally move to the 4th chair look at thisconflict from both an organisational andbigger NHS perspective. What is happeningwhilst this conflict continues? What will bethe long-term effect of this conflict? What isthe pain associated with it? What’s the resultof the do nothing strategy?
Moving from chair to chair may seempedantic but it definitely helps you see theproblem from the 4 view points – it must beone of those weird psychological effects –spooky!
Conflict often develops because we do nottake sufficient time to understand the otherperson or group’s perspective. I sometimeshave clinicians tell me they are in conflictwith their managers. When I ask “whendid you last sit down and talk with yourmanager to find out more about the thingsthat are important to them and why” theyall too frequently say never. Taking time toactively listen to another person has massivebenefits. The key is to truly concentrate onlistening to what they have to say withouttrying to solve the problem, interpret theirwords further or planning what you willsay in retaliation once they stop. It is alsoimportant for them to feel listened to.
Paraphrasing what you have heard back tothe colleague is an extremely useful skillwhich ensures you have acquired the correctmeaning, preventing working on the wrongissues and unnecessary conflict. If you takethis time to understand others then theywill want to take time to understand yourperspective; more importantly you willdevelop the knowledge which will enableyou to start working on problems together.
A further step, and perhaps the mostimportant one, is to step below the ‘positions’people take and genuinely understandthe needs underpinning them. It is on aplatform of need that solutions can be built.The root of a solution is a common andshared problem. For a clinical team thatneeds to know they have done the bestfor the patient, whilst their managementcounterparts need to ensure financialstability, the common problem may look likethis:
“How can we deliver the highest possiblequality of care at a cost that is sustainableand maintains our overall balance?”
This simple technique of re-framing createsa working problem that has both parties’interests at heart. As long as both partiestruly subscribe to the win-win approachto resolving the problem, it provides aplatform for truly innovative solutions. Atthe very least it’s a collaborative problemwhere all parties shouldn’t rest until theproposed solution is at least acceptable to allconcerned.
Big issues sometimes need bold,if simple, solutions
In answer to the original problem, whichinvolved breaking down the clinicalmanagerialdivide in favour of a collaborativeapproach in the best interests of theorganisation as a whole, there is a fasterway. It’s not a bug fix or a cheat and it iscompletely consistent with delivering longterm,collaborative working relationships. Itdoesn’t even require anyone to compromiseand it is proven too. What’s more, it’s asacceptable to clinical teams as it is tomanagerial teams and vice versa, with nolosers either. Does it sound too good to betrue?
Now, to truly challenge your belief, what ifwe told you it could be achieved in a day?
Working on an entirely different aspect ofservice success in the modern environment,we created a programme designed simplyto educate and inform. However, when wedelivered that programme, an annihilationof clinical-managerial divide turned out tobe an unexpected and most welcome sideeffect. With the passage of time we havemanaged to assess whether it was artefactor a robust outcome of the programme itself.Fortunately, the latter has proved to be thecase.
There’s one catch and it’s a simple one toresolve. If we tell ‘everyone’ about it, we mayadversely affect it effectiveness and thatwould be a loss to all, given how commonthe problem is. So, the simple solution istwo-fold. We can either tell you in private aspart of a plan to resolve the issue for you, oryou can hear it at the conference “EngagingClinical Teams in the Business of Health” on30th October 2009 in London. One problem,two options and if you are left thinkingthat sounds like a cheat, when you hear thesolution you’ll also understand why it’s theright thing to do.
In summary, an increasingly competitiveenvironment leaves no place for internalcompetition. In the new NHS there will beno place for underperforming departmentsand organisations. Given that organisationalconflict and poor performance generallygo hand in hand, the imperative to resolveit is clear. Whilst conflict remains prevalent,significant unproductive energy is wastedand organisations will remain ineffectiveand inefficient, saddled with inertia andindecision. Resolving conflict is fundamentalnot only for survival at an organisationallevel but also for the broader NHS.
