The Matrix – Johnny Marshall

A couple of months ago Sky News came to my surgery to interview me about CCGs. Whilst there, they took the opportunity to interview some patients about their views on the health reforms. One of my patients explained that they were very concerned about the ability of GPs to plan health services by holding the budgets, as they were not accountants. My initial internal reaction was the usual, “but GPs won’t have to be accountants as they will work with healthcare managers, and other professionals, who have the skills they need to get the job done … blah … blah … blah …”.

More recently, when I was reflecting on these comments ahead of a presentation I was giving, a new awareness began to dawn. From this patient’s perspective the key skill that was needed in planning health services was one of accountancy. Is that really how commissioning in the NHS is perceived? Do people genuinely think that accountancy is a more valuable skill in planning health services than clinical know how? Is this just what they have come to expect? Is accountancy the defining NHS commissioning skill to date? In order to uphold the Trinity principle, “if the answer is out there and it’s looking for us, it will find us, if we want it to” then we will first have to solve the Agent Brown dilemma – “perhaps we are asking the wrong questions?”.

So it was timely during the review of the plans for the emerging directorate structure at FDG that discussion took place around how to put clinicians at the heart of the NHS CB. The challenge seems to be around coming up with an organisation design that enables operational delivery within the limited running costs, now that is a challenge that CCGs can relate to.

In order to meet this challenge, as a Neo-Commissioning organisation, NHS CB cannot simply become a central machine that draws on the energy of clinicians. Somehow, it will need to embed them in its every activity, however hard a red pill that might be to swallow.

The proposed solution is a directorate organisational design principle based on the “matrix”, designed to integrate parallel universes.

Essentially, it operates on the principle that directorates need to work together pooling their resources around a common purpose, which at face value sounds like a refreshing change from more traditional silo models of working. It gives the medical and nursing directorates a genuine opportunity to reach in to all parts of the organisation putting clinicians at the heart of the good ship Nebuchadnezzar. But, like any organisational structure, it is the attitudes and behaviours of the people operating within it that govern its success, just ask Mouse.

If clinicians are to be influential within NHS CB then this will probably require them to resist acting as the Oracle, by simply holding a series of illuminating conversations with other directorates, and to engage in joint working and shared accountability around a common purpose. It would seem likely that the more accountability any directorate takes for delivery the more influence they will have on delivery. In the words of Agent Smith, “listen … that is the sound of inevitability.”

However it is also clear that the boundaries of the matrix reach far beyond ship Nebuchadnezzar and that a multitude of organisations will need to join the Matrix to create the right environment for clinical commissioners to succeed, e.g. the Tariff Trinity of CCGs, NHS CB and Monitor. At the end of the day it is likely, in the words of Morpheus, that, “Unfortunately, no one can be told what the Matrix is. You have to see it for yourself”. Welcome to the real world!

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