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Practice Comment

'Does the McDonald’s business model suit modern healthcare?'

  • 26 Comments

The Francis report into appalling standards of care in Mid Staffordshire calls nursing to reflect on history

The Francis report into appalling standards of care in Mid Staffordshire calls nursing to reflect on history. From 1860-1970 standards of patient care were the responsibility of the ward sister (or charge nurse). A powerful figure, she taught, organised and supervised all those working on her ward. Her authority came from her position as trustee and transmitter of an ethos: vocational, altruistic, practical service to patients.

This ethos was internalised in the culture of the ward and the NHS ward prayers were held regularly until the 1960s. Essential care for patients as an altruistic service corresponds to Klein’s (1995) model of the NHS as a “secular church”. Indeed, the terms “sister” and “service”, with their religious connotations, were fundamental.

During the 1960s, management theorists, educationists, sociologists and psychologists criticised the vocational model as demeaning, paternalistic and oppressive. Over the following decades, market-driven consumerist models from outside nursing, and a move to education inside it, affected values of care. The ward sister lost her role in training and her focus on patients. Vocation was replaced by utilitarian self-interest. Although the title “ward sister” remains, as has the term “service”, the nature of the role, and the meaning of the words have changed. The secular church model has become what Klein calls a garage model. This is a market-driven model, led by business managers who view the patient as the customer. It is the model of the supermarket and fast-food outlets.

The secular church model arose from the values of a specific historical culture. Despite the prime minister’s call for a revival of vocation, is it realistic to expect staff to be motivated by values of vocation and self-effacing service? Culture has changed, and those values are not so acceptable in a modern multicultural society.

Should we accept the garage model best fits diverse cultures, needs and finances of 21st-century Britain? Perhaps hospitals should resemble businesses, such as McDonald’s, and require similar leadership, management and quality controls? In this garage model the ward sister is the shop manager meeting tick-box targets, the nurse the team leader and the healthcare assistant the McDonald’s crew member.

But are patients more than just quality-controlled consumers? Are practical virtues, such as kindness and compassion, vital to ensure patients’ fundamental needs are attended to - as the Department of Health’s (2012) recent nursing vision recognises? As nursing history teaches, these values are not a technique. They are an inner attitude. Cultivating practical virtue in UK nursing requires re-orientating leadership, policy and training to a primary focus on the basic practicalities of direct care. But it also needs a revival of the vocational, secular church model, inducting staff into virtue, as the ward sister once did.

Ann Bradshaw is senior lecturer in adult nursing, Oxford Brookes University.

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  • 26 Comments

Readers' comments (26)

  • can I get a gold star on my badge please, I am a very good nurse.

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  • I disagree. As a manager, the worst thing has been the rise of people like me and the usurpation of the ward sister and senior nurse role, to spreadsheets and graphs. People are not burgers or widgets on a factory line. And our staff do a hell of a lot more than ask if we want fries with that. Although we probably pay them as badly.
    I think vocation needs to return to management too.

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  • good article.

    The general management model introduced to the NHS in my view was its downfall and I have written so much about this failed experiment I am not writing any more! what's the point?

    the NHS has a golden opportunity to take ideas from the best health services in the world and create its own model but its head is stuck in quick sand and it seems perfectly content to continue as it is pushing its patients through a conveyor belt system in the same way as inanimate and insentient goods, for which the general management model is very highly suited! It was assumed as this model was so successful and cost efficient in industry that it should also be applied to healthcare and that people, staff as well as patients, could be treated in exactly the same way as commodities.

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  • I entirely agree with The Nobody and anonymous 8.38.

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  • I studied management, spent 5 years as a manager in Mc Ds and 15 years in nursing. I have observed many nursing managers over that time.
    The NHS does not seriously invest in this role. It does not really matter what service you are delivering a good manager has transferable skills. A good nurse does not necessarily make a good manager.
    Mc Ds is a task centered organisation, that does not mean the individuals working there are only task centered.
    From my perspective the problems in the NHS are more of a HR issue, we want to be seen as good employers, so I can hire but if I find I have someone who cant do the job I cant sack them, we all know there are some terrible staff out there.
    The best thing about Mc Ds is that you cant duck responsibility, there are very clear standards for staffing, cleaning etc. it is not one of the most successful businesses in the world for nothing.

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  • I agree that many of the historical HR processes in the NHS have not been helpful and need changing. However, many of the problems recently highlighted are down to trying to manage the nations healthcare as a commercial business instead of recognising that patients and the public are people and not products on a conveyer belt.

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  • Handy if you want a big tasty and fries...... not so handy if you're up to your knees in blood and spew.....and your manager doesn't know the difference.

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  • Brian
    Several points:
    1) Are there clearly recognised international standards in nursing for the ratio of RNs to patients for safe care? It would seem to me that if such a thing existed, it is very much not noticed, adhered to or enforced by managers in very many areas of nursing.
    2) How do you “manage” when you have the “flu” or other similar common malady in your health? I ask because health is not, nor should be a “business”. So do you schedule your illnesses?
    3) When one cannot poo, or conversely poo too much, one is not a business decision. One needs someone who understands the potential issues, thinks about the potential or real issues and helps you deal with them. No business decision required unless one is thinking about how much toilet paper is involved (not).
    4) If one experiences one of life’s events such as a fracture or cut; is born with a disability; has genes which eventually cause a condition such as Parkinsonism, or Multiple sclerosis, or cancer, is this a business decision? “Oo I think I’ll book in a (insert condition here) for Wednesday next week” or “at 1 am on the 20th of the month”. No, life is not a business and neither is health. McD may be a successful business, but I do not want to be treated as a burger, (chewed up and excreted) and I think my patients want more from the health service and health professionals than the business model McD employs. A business model is just that a “business” model, fine for making cars or burgers, not fine for dealing with people and their needs, emotions, and co-morbidities (not to mention significant others).
    5) A good nurse may become a good manager if given the training, support and resources. I believe you stated you studied management, were you the only one in your class? Nurses are often already managers of a busy life, including spouses, children, further education, recreational time, and their employment. No reason why these “transferable skills” cannot be used in other aspects of management if they wish to pursue them.

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  • all nurses are managers by nature of their training and the job they do. admittedly some are better than others but without these skills they would not be able to manage the care of their patients or the day to day management of their ward!

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  • To Anonymous | 6-Mar-2013 9:39 pm

    I'll try to address each point.
    1) For PICU, ITU and HDU yes there are national and international standards, I would add I am leaving my current PICU job as these standards are being ignored.

    2) Yes fortunately sickness is predictable this is why flu vaccine is issued for the winter, there are many models available to predict sickness patterns.

    3) Business is all about personal interaction, even the move to internet commerce has had to retain a service aspect, eg feedback system on ebay.

    4) I have carred for many probably thousands of patients, seen a great deal of grief and joy, you look at McD's as simply producing food, that is not their only purpose it is the end result. They train and develop people because they know if they dont their business will fail. The NHS needs to do the same.

    5) I had formal mgmt training, Dip He Managment and fellow of CIM, then all the McD training. I am a band 7, I think I've had 5 SDs in as many years related to NHS management. Unfortunately managing a busy life does not qualify you as a manager.

    I have tried over the last 5 years to develop and support a team of nurses, my whole purpose is to do this, too many senior nurses are self centered following their own political agenda.
    Too many nurse managers think they can improve patient care by going to endless meetings. Each hour they are away from the clinical area is an hour of support for junior nurses lost.

    As a junior manager in McDs the owner of the franchise told me to spend most of my time in the restaurant with the customers, not in the back areas. He said thats how you know what youre trying to do is working. How many ward managers / senior nurses / matrons do you see interacting / available to patients. McDs is focused on the customer, the NHS is not focused on the patient.

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