Section 1 Understand the specific responsibilities of middle managers in enabling the organisation to achieve its goals. My organisation is the Royal Brompton and Harefield NHS Foundation Trust, a foundation (semi-independent) National Health Service Trust comprising of two tertiary care heart and lung hospitals, the Royal Brompton Hospital in Central London and Harefield Hospital in Harefield on the London/Buckinghamshire border.
The organisation has been a single NHS Trust since 1998, prior to which it was two separate NHS Trusts. The organisation has 3104 staff of which approximately 300 are doctors, 1200 are nurses (the largest single staff group), 650 are Allied Health Professionals and the remainder are administrative.
The organisation is divided into five divisions, Heart Brompton which covers all cardiac treatment at the Royal Brompton site, and also includes the paediatrics departments on both sites for both cardiac and respiratory treatment; Heart Harefield which covers all cardiac treatment at the Harefield site and also includes all transplant surgery; Lung which covers adult respiratory treatment on both sites; Medical which is a division of convenience into which all doctors are placed for employment purposes, irrespective of which division they actually work in and finally Corporate which covers Research, Clinical Support and all of the non-clinical functions of the Trust (IT, HR, Finance et cetera).
Each operational division is run by a general manager, the Medical Division is run by the Medical Director and the Corporate Division has individual directors which run their own sections, including the Director of Operations to whom all the General Managers report. The organisation as a whole has clearly defined vision, goals and objectives at the level of the organisation as a whole.
The Trust’s Vision, which has been largely unchanged since its establishment in 1998 has been to be “The Leading Centre for Cardiac and Respiratory Medicine in the World, combining excellence in patient care with excellence in research. ” From this the organisational goals are extrapolated, and these are usually reviewed every 4-5 years depending on the length of the cycle in which they are placed. The current organisational goals which have been in place since April 2010 are as follows: 1) To make financial savings of £2 million per year every financial year until 2014/2015. 2) To resist the “Safe and Sustainable” review of the NHS, specifically their recent publication recommending the disbandment of paediatric surgery at this Trust. )
To earn at least £8 million in research grants by Mach 2015. 4) To increase Trust turnover by £5 million by March 2015. 5) To maintain excellent standards of healthcare as judged by all our regulators. These goals, though laudable and certainly forming a paradigm which all staff would happily given their backing are, however, of very limited within the actual workings of the organisation. No one individual, for example, could make a £2 million saving. As such it would naturally follow that actually objectives, which are SMART are required both at organisation and at operational (or corporate) level within the Trust in order to achieve this.
This is done in a standard cascade methodology – the organisation vision begets the organisation goals, which beget the organisational objectives, which beget the vision for each director’s area, the their goals, then their objectives for their direct reports and so on downwards to each individual via the Trust’s appraisal system. At organisational level the Trust’s Objectives are set annually (in April) by the Chief Executive in consultation with Trust Board, looking at the goals to see where achievement has so far been made, based on the previous year’s annual report and staff and patient surveys. It therefore follows that each goal becomes multiple objectives, which are then put to the Trust’s Management Committee for ratification.
The current (2012/2013) organisational objectives are: 1) To offer the NHS wide MARS voluntary redundancy programme in order to reduce the overall staff count to 2950 and; 2) Make £1. 5 million savings in staff costs. 3) Make savings of £500,000 in non-staff costs, £100,000 of savings per division. 4) To open skills and research labs at both sites and generate £500,000 of business to each one by the end of financial year. 5) To apply for every relevant research grant that the Trust could realistically service. 6) To have no more than a 0. 5% rate of patient complaints. 7) To reach and maintain NHSLA Level 3 of Risk Standards, thus keeping the insurance premium to NHSLA low.
It should be abundantly clear that each one of these objectives is related to one or more of the goals and thus the “cascade” is commenced from the organisations objectives, which are SMART, Specific Measurable Achievable Realistic and with a Timescale can be translated into the individual objectives of each director/general manager and so on downwards. Of course, in order for any of these objectives to make any actual sense, they need to be filtered through the divisions and then to the middle managers who can make them work at operational (or corporate level). With respect to evaluating the specific responsibilities of middle managers within this organisation, this can be quite complicated.
The Institute of Leadership and Management would define a middle manager as “a manager with at least two levels of staff beneath them, or one that controls a departmental budget and may set strategy within that department but not for the organisation as a whole. ” Within the NHS, however, these levels of responsibility may not be specifically related to rank. Rank within the NHS for everyone except doctors, is done by 9 pay bands ranging from approximately £12k pa to approximately £100k pa (and then some individual contracts beyond that for directors). However middle management responsibility as defined by the ILM may come at a relatively junior rank and, conversely, one may reach a very senior rank without ever having more than basic line management responsibility. This is because rank is very much tied in with trades within the NHS.
In a poorly paid trade, such as security, one may have the ILM-defined middle management responsibilities at pay Band 5 (mid-point £28,000pa) whereas a perfusionist would not have them until pay band 8c (mid-point £70,000pa). Similarly individual people may have middle management responsibilities in some areas and junior and/or senior management responsibilities in others. A further definition of a middle manager might be taken from Armstrong and Baron’s “Management is Key” which states that middle managers are “any manager with some leadership responsibility beyond that of simply following a framework but without strategic leadership of the organisation as a whole. This definition is actually a good one to take within the NHS and my Trust in particular as it works within the individual trades as well – a “middle” manager in any given trade would likely have some leadership responsibility for doing new things within their trade, but will not have it relative to the entire organisation. For example in my own role as a Ward Charge Nurse on Exocet Ward at Harefield Hospital, I would be classed as a “middle manager” by all the definitions above. I have two levels of staff under me in respect of forty individuals split into three teams lead by senior staff nurses. I have management responsibility for all of these and accountability for them to my Matron.
However I also have control of the ward budgets when I am on duty within particular guidelines and the ability to use my own discretion when an issue arrives that is outside of any existing policy. My major responsibilities, therefore, are to use the resources at my disposal to generate the best clinical outcomes for the patients on my ward. My specific objectives in respect of these are set at my appraisal by my line manager, (a Matron) who in turn has hers set by the Director of Nursing who has hers set by the Chief Executive in direct line with the organisational objectives. Because of this system my specific goals and objectives are therefore going to be aligned to the Trust goals and objectives.
For example the Trust objective of saving £100,000 in non-staff costs across my division is translated to my goal of “Keep Control of Ward Spending” and my two objectives of: 1) Except in emergency situations, ensure the ward supply budget does not exceed more than £250 per shift. 2) To pool all ward stationary orders to ensure that all shifts do not exceed £2,000 in the financial year. Thus the Trust objective of saving £100,000 in non-staff costs in my division is translated downwards through my managers across all their teams until it eventually reaches me, crucially the first individual in a position to directly do anything about the saving.
This ties in with Rangor’s definition of middle management “individuals at the top of field rank who are close enough to the ground but with enough power directly influence the operation of their company. ” It can easily be demonstrated that this is the case as my manager can set me targets to rein in spending, but cannot directly ensure that the savings happen, it is up to me to ensure this both by my own personal levels of spending and also what I allow my team leaders to do in their objectives. Therefore it could be concluded that the goals and objectives of middle managers are therefore cascaded from the organisation’s goals and objectives, becoming more specific at each point.
The organisation sets its specific responsibilities for middle managers through a system of well-defined job descriptions to set the general criteria and cascaded appraisal to set the specific requirements at any given time. All objectives therefore must be SMART, as the two examples that I have given of mine are SMART; specific because the amount of money and what it may used for are both finite, measurable simply by the expenditure at the end of year; achievable because it is within my remit and abilities to achieve this; realistic in so far as it represents a realistic (if tough) budget for the ward as a whole that all other sisters may adhere to, and the timescale is obviously given as within the financial year, so the objective would “self terminate” if not specifically extended on the 31st of March 2013.
These objectives are then added together with those of all other middle managers of my division, which each manager implementing their own objectives in their own areas, and all of this adding up (literally in the case of this financial example) to the overall Trust’s objective and goal. The system and the way that it operates does, however, have a two potential weaknesses. Using the Benson and Hedges model, those weaknesses can be defined as those of process efficiency and the other is that of process engagement. Process efficiency in this case requires that everyone who sets objectives for individuals is good at it and keeps the Trust’s objectives in mind. One slip and the Trust Objectives could be lost sight of.
Likewise “process engagement” requires that everyone is aware of the Trust Objective and therefore why their personal objectives are as they. Otherwise this can cause failure of an organisational objective from the ground up – as, if one of my staff nurses overspent because they did not understand the budget’s importance then I would fail my objective, which is not in itself enough to fail the Trust’s objectives but if this occurred perhaps a dozen times with people at my level across the organisation then that would be enough to do this. It should be pointed out that I have not personally seen a Trust Objective brought down in this way but I have seen individual objectives missed and therefore the possibility cannot be discounted.
An example of this occurring was in 2009 when my personal objective was to implement the use of a new policy for medical gas canisters and this was part of the Trust’s drive to become safer and thus obtain a discount on its insurance. However because the importance of this requirement was not communicated to me or any of my peers and the new process required extra work (filling in forms when moving a canister) for no apparent reason, whilst I was prepared to enforce it with my staff anyway, my staff often disobeyed my instructions because they had no time and saw no benefit for the new procedure. This had become very common across all the teams (not just mine) on my ward.
Only the direct intervention of the Risk department (on the request of us sisters and charge nurses) put this right. If we had been informed in the first place as to the importance of the task it would have considerably strengthened our hand in dealing with it. Therefore whilst the processes in this organisation do set specific responsibilities of middle managers on an individual basis and do this well, keeping all of us informed and engaged with the organisation’s objectives is crucial as otherwise we would fail to support them. Therefore the following recommendations for the organisation could sensibly be made within my department, and perhaps beyond.
1) That all appraisals are conducted within 4 weeks of them being due. ) That no manager shall set goals and objectives for anyone without being aware of their manager’s goals and objectives. 3) That all those goals and objectives set by middle managers add together to form the goals and objectives of their senior manager. 4) That all middle managers are made aware of the Organisation’s objectives and where their objectives fit in with these. The above recommendations are not original, as they fit within the cascade model of management from various sources thus proving that my organisation follows established management structures in order to achieve its goals and objectives, and based on its governance report it manages these well on most occasions. ——————————————– [ 1 ].
Registered office: Royal Brompton Hospital, Sydney Street, London SW3 6NP. Chairman of the Board: Sir Robert Finch, Chief Executive: Robert Bell. [ 2 ]. Since 1st June 2009 [ 3 ]. Tertiary care is the NHS term for specialist hospitals which only take patients referred from other hospitals (as opposed to directly from General Practitioners). [ 4 ]. Harefield Hospital, Hill End Road, Harefield Middlesex UB9 6JH. [ 5 ]. Since 1993 when NHS Trusts were established. Historically the two hospitals date back to 1847 (Royal Brompton Hospital) and 1918 (Harefield Hospital) respectively. http://www. rbht. nhs. uk , History of the Trust section, retrieved on 20. 8. 12 [ 6 ]. Correct to 20. 8. 12 [ 7 ].
Physiotherapists, psychologists, radiologists and other clinical trades that are classified neither as doctors nor nurses. [ 8 ]. Heart Brompton, Heart Harefield, and Lung are collectively known as the “Operational Divisions” as nearly all patient treatment takes place within them. [ 9 ]. Doctors in the National Health Service are treated as separate entity from other staff as they have their own pay scales, appraisal mechanisms and regulation. At this Trust therefore all doctors are considered part of the Medical Division and accountable for their medical practice to the medical director, but are responsible day today to the general manager of the operational division which they work. [ 10 ]. http://www. rbht. nhs. k Trust Vision page, retrieved on 20. 8. 12 [ 11 ].
Bell R; “Trust Goals 2010-2015” London: The Royal Brompton and Harefield NHS Foundation Trust (hereafter abbreviated in all references to “RBHFT”), 2010. [ 12 ]. Not as a result of government cuts (as foundation Trusts keep their own savings) but rather to build up a cash reserve. [ 13 ]. NHS Special Health Authority established in 2009 to take a strategic view of all NHS provision in England. [ 14 ]. “Safe and Sustainable – a Review of Cardiac Surgery” pp28-29 London: HMSO, 2010. [ 15 ]. Current trust turnover (2011/2012 financial year) is £201. 8 million (Bell R et all “Annual Report” London: RBHFT, 2012). [ 16 ].
The regulators are Monitor (regulator of Foundation Trusts), the Care Quality Commission (regulators of the entire NHS) and the NHS Litigation Authority (insurers of the entire NHS). [ 17 ]. Tallard C and Roscommon R, Harvard Business Journal vol. 8 (1983), edition 2; Boston: Harvard University Press. [ 18 ]. Vision-Goals-Objectives-Vision as translated and summarised from Cicero “De Officiles” (circa 3AD), by Mendes GP in “The Essential Guide to Applied Leadership” London; RBHFT 2012. [ 19 ]. Mendes GP and White T “Staff Appraisal System for Non-Medical Staff” London: RBHFT, 2009. [ 20 ]. Essentially the Trust Board plus the General Managers and other key senior staff. [ 21 ]. Minutes of the RBHFT Management Committee April 2012 [ 22 ].
Allows for payments of about half that which would be made through redundancy but on an entirely voluntary “no questions asked” basis. (NHS Employers, “Mutually Agreed Resignation Scheme” London: HMSO, 2010. [ 23 ]. ILM “Level 5 VRQ in Leadership and Management Qualification Specifications” Reading: ILM, 2011. [ 24 ]. NHS Employers “2012/2013 Pay Circular 1” http://www. nhsemployers. org Retrieved on 20. 8. 12 [ 25 ]. Armstrong N and Baron C, “Management is Key” London: Quillier Press, 1999. [ 26 ]. “Management is Key” p28. [ 27 ]. Armstrong and Baron take the “classical” definition of leadership as opposed to management, e. g. that Management is within a particular set of policies or frameworks and that leadership is beyond existing procedure and into new territory.
This basically dates back to the institutionally accepted Epstein and Rogers definition found in “Management versus Leadership” Berkley: University of California Press, 1971. [ 28 ]. Called a “Sister” if the post holder is female. Pay Band 7. [ 29 ]. “The post holder will be required to generate the best clinical outcomes for any patient that fit the given circumstances, using established protocols where these are helpful and using their own best clinical judgement where these are not” From my own job description (Gadd C et al “Sister/Charge Nurse in Cardiology Inpatient Wards” London: RBHFT, 2008. ) [ 30 ]. In 2011/2012 this was £275 [ 31 ].
From my own appraisal which took place on 9. 5. 2012 [ 32 ]. “Field Rank” is a military term denoting Captains, Majors and Lieutenant Colonels (e. g. middle ranking officers). Below this would be subalterns (Second and First Lieutenants) and above would be “Staff Rank” Colonels and higher). [ 33 ]. Rangor G “Management in the Modern Context” p99, New York: Varstein Press, 1973. [ 34 ]. Individuals are not appraised until their manager has had theirs. [ 35 ]. “To take day to day responsibility for ordering ward stock and stationary” – My job description. [ 36 ]. Benson B and Hedges H “Business Processes Defined” pp38-40, New York: Elsevier, 2001. [ 37 ].
Though I am not necessarily of high enough rank to be privy to such information even if this did occur. [ 38 ]. Linked to the then Trust Objective of Obtaining NHSLA Risk Standards Level 3. [ 39 ]. Benson and Hedges state “In order for the cascade process to truly operate all levels of management must not just be informed what they need to do, but must understand how this benefits them and their organisation. ” (Business Processes Defined” p56). [ 40 ]. In this case paraphrased somewhat from Baggins and Aragorn “Large Organisational Operations” chapter 2, Gondor: Middle Earth Publishing, Year 891 of the Third Age. [ 41 ]. Care Quality Commision “Governance of the Royal Brompton and Harefield NHS Foundation Trust” London: CQC 2012.
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