The stretched middle
08/12/2014 § 2 Comments
My wife works in the NHS, the biggest employer in Europe. The NHS, providing free health care to all, has been a remarkable achievement. But there are many signs that pressure is building within the NHS at all levels – staff are unhappy and stressed (in my wife’s team alone, more than a quarter of the staff are absent with long-term sickness), finance is increasingly tight, more and more legal claims are being brought against doctors. Every now and then the system breaks down somewhere and horror stories emerge of badly neglected patients. Politicians are coming under increasing pressure to do something.
I was speaking to Cathy recently, a colleague of Dasha’s, who has worked within the system for more than 30 years, and asked her how she deals with all this. Her response was, in effect, “So long as I have a good team, I don’t mind.” She works in a team of 20 people who provide care in the community and she likes and respects most of the people she works with and that’s enough for her.
Organisations of any reasonable sort of size (let’s say over 30 people) can be crudely divided up into “tops”, “middles” and “bottoms”. At the top are the controllers, pulling the levers of power and hoping that they will get the response they intend further down the organisation. They tend to be strong on left-brain thinking, analysis and planning and they like to feel in control. Since it is pretty much impossible to really ever be in control of an organisation (you can certainly influence it but control it – never!), they are also quite good at pretending to themselves and others that they are in control. You can’t really blame them for this – the owners, the distant people who appoint them, expect them to be in control so they are obliged to pretend. One of the problems with this is that it gets in the way of them realising that they need information from the bottom in order to know what it is they are trying to control. Smart people at the top know that without this information they are worse than useless.
At the bottom we have the doers – people like Cathy. This is often the most satisfying place to work. If you have a good team around you, you can often ignore (most of the time at least) problems in the wider system. Their job is to get the work done within the constraints handed down by those above. They tend not to spend much time thinking ahead, or on strategy or big picture stuff – if they do, it can just get in the way of them doing their work in the moment. Yet they do need information about the big picture, in order that their work makes sense as part of the patchwork, and so that they can coordinate with others at the bottom to avoid duplication or gaps.
Then there are those in the middle – the multi-taskers. They have three critical functions. One is as a communication medium. They facilitate vertical communication, so the tops know what is happening at the bottom and the bottoms know where they fit in the system. Since the tops and the bottoms tend to think differently, they also speak different languages so the middles need to speak both languages. To communicate effectively, they also need to be good at filtering, sifting and distilling information – it is no use to the few at the top if the middles simply relay up all the information from the many at the bottom – the tops will quickly be overloaded. So the middles need to be good at extracting the essence and passing that up, and passing back down whatever comes from on high, translated so it makes sense in the local environment inhabited by the bottoms. Middles also have to be effective in horizontal communications – speaking with other middles to ensure that there is coordination across the organisation.
The second principle function of a middle is to appoint, monitor, supervise, inspire, hold to account, mentor and in general “manage” (there are so many complex and often hidden meanings in that simple word) the bottoms.
The third function of a middle (as indeed of tops and bottoms too) is to monitor, hold to account, and general manage themselves in their own tasks. This may be the hardest and most important of the lot.
Not surprisingly, the supermen and superwomen who work as middles in large organisations tend to get stretched, and the larger and more complex the business, the more stretched they get. It is rare to find a middle who can even do one of these critical and, let’s face it, usually very demanding, functions really well. To expect them to do all three well is fanciful. The way large organisations, whether private or public, tend to deal with this is to add more and more middles into the equation, promoting some of them to supervise the others. This can improve things for a while. After all, as studies have shown, almost any intervention from above can have a short-term positive effect, mainly it seems because those below like to think those at the top are paying attention to them (in one study, lights in a factory were turned up and the result was a measurable improvement in production productivity. At the end of the study, the lights were turned back down again by mistake and productivity improved again!). But since such an approach doesn’t address the fundamental problem, mostly what you get is a bigger wage bill (and the middles cost a lot more than the bottoms, though of course not nearly as much as a top) and often less efficiency, because the system gets more complex the more layers you add. What’s more, the organisation gets filled with professional managers who understand the theories of being a middle better than they understand the actual work of the organisation. This can be okay if they spend a lot of time with the bottoms, but because they have elevated salaries, many of these professionals feel it is beneath their dignity to spend a lot of time with the workers – so they hang about with other equally un-informed middles.
As far as I can work out, this is more or less what’s been happening in the NHS. People like Cathy carry on with their jobs but more and more they get weighed down by the pressure from the middle. I would love it if someone would measure how many managers have been added in the NHS in the last 20 years, as a proportion of the whole, and what the impact on patient care and efficiency (both important measures) has been.
An innocent outsider reading this might begin to wonder “Do we really need the middles?” This previously heretical thought is starting to occur to more and more tops (and indeed to middles and bottoms).
A talk at the RSA couple of weeks ago highlighted one of the most successful examples of taking this idea and pursuing it with rigour. Buurtzorg is a not-for-profit healthcare provider in the Netherlands. There is not a single manager in the place – instead it runs itself as multiple self-organising teams comprising 10 people each, who have broad responsibility for their own finances, scheduling and other key decisions. They do have “coaches” who fulfill the vital communicating function which is normally the responsibility of middles. But these coaches are not managers and they don’t have the power or responsibility that goes with it. Apart from anything else, there are simply not enough coaches for them to be able to pretend to manage anything. Buurtzorg has achieved remarkable success already. The most important indicator is the effects on patient satisfaction, which is far higher than in other organisations performing a similar role in the community. Staff satisfaction is likewise very high. By another measure too, they have been extraordinarily successful – in the space of just 10 years, Buurtzorg has grown from a group of 10 people to an organisation of more than 8,000.
Of course an organisation needs to be adapted to fit its context, and contexts vary massively from country to country, and industry sector to industry sector. So we don’t know how this approach might work, say, the oil sector in Texas, in aerospace in France, in pharmaceuticals in Sweden, or in the transport sector in Japan. But more and more examples are emerging of organisations taking this route to solve the problem of the squeezed middles. W. Gore, Vitsoe, Happy, FAVI, Sun Hydraulics, to name but a few. And this is not to mention open source communities and other on-line (Wikipedia, Flickr) and off-line organisings (Burning Man) that are radically re-thinking the way we organize. I dream that one day this sort of thinking will start to permeate the NHS and other great but troubled institutions.
For this to happen of course, we will also have to answer another question – having dealt with the middles, what you do about the tops? That is a question for another blog post!