What lessons can the National Health Service learn from an ‘upside-down’ management style?

Timpson’s stores are familiar sights on our high streets, attracting those in need of a new key, shoe repairs or mobile phone restorations. This visible commercial success is mirrored internally, with the company reporting consistently high levels of staff satisfaction and gaining a place on the Sunday Times ‘Hundred best companies to work for’ list on every attempt. One of Timpson’s most notable characteristics is their ‘upside-down’ management style, which contrasts strongly with how many institutions, including the National Health Service, are currently managed.

Timpson’s management system¹

Underlying Timpson’s system is the principle that front-line staff should be enabled to perform at their best. ‘Treat the right people well and they will do a good job’. By logical extension, this will lead to recommendations and future custom. Management is designed to be a ‘helpline’ rather than ‘control centre’ and its role is seen as supporting autonomous front-line workers and determining capital allocation – so-called ‘upside-down management’.

Staff are chosen on the basis of personality, are sacked if they do not perform, but are well rewarded if they do. The company aims to foster an ethos of inclusivity and holistic support. All staff are referred to as ‘colleagues’ and the management chart, which places customers at the top and Mr Timpson at the bottom, is designed to underscore a sense of staff value.

The National Health Service

In contrast, the National Health Service has a highly centralised management style, where policies are determined nationally and imposed in a top-down manner. Unfortunately, all is not well. Performance on almost all key targets is decreasing,² morale is low,³ age-adjusted funding per person has already been reduced and is expected to decline further,⁴ and public satisfaction has fallen.⁵ General practitioners and junior doctors express seriously low levels of morale and high-burnout rates,^6,7 with the latter recently resorting to industrial action.

Improvements are clearly needed and successful companies such as Timpson’s could hold some answers. However, there are important limitations to consider. First, any state system is under political control, with the Secretary of State ultimately answerable to Parliament. Second, a commercial business can judge performance by the single, easily measurable metric of profit. The aims of the National Health Service are far more complex and difficult to assess; broadly encapsulated as the prevention and treatment/management of illness but with additional subtle outcome measures, such as staff morale and patient satisfaction.

Moreover, the National Health Service must deal with uncertainty. Unwell patients present diagnostic and management challenges beyond those of Timpson’s customers and complex investigation and treatment pathways sometimes involve considerable risk, thus requiring a more detailed legislative and bureaucratic framework. Finally, the National Health Service must address a diverse range of agendas, ranging from those of professionals to patients and those taking funding decisions, which presents its own managerial challenge.

Thus, while wholesale application of an ‘upside-down’ management style may be inappropriate, consideration of certain principles may be helpful.

Valuing front-line staff

Any organisation is only ever as good as its staff. Valuing them is vital and will ensure optimal performance. Giving praise, where it is due, is an important principle within ‘upside-down’ management. Handwritten letters from the Chairman and frequently awarded bonuses are common examples within Timpsons. While the latter may not be possible in the National Health Service, in a digitalised world, handwritten communications have become increasingly meaningful and could easily become more prevalent.

Small initiatives can have significant effects on staff morale and wellbeing. At Timpson headquarters, staff have access to subsidised healthy food, a gym and no fixed working hours. All individuals enjoy their birthdays as holiday, can use the company’s holiday homes and have access to a hardship fund and defined-benefit pension scheme. While free health checks and health promotion services, subsidised canteens, onsite gyms and cycle-to-work schemes are becoming more common in the National Health Service, further development and take-up of these ‘investments in staff’ should be encouraged.

Many staff frustrations within the National Health Service are administrative. Repetitive induction documentation, e-learning and identity checks or incorrect tax code assignments could and should be minimised within a ‘national’ system. The model of in-house human resources and payroll departments enjoyed by Timpson employees may be ideal, but at a minimum, communication between National Health Service Trusts could be greatly enhanced. Moreover, it should be possible to deliver rotas and contracts on time and enable truly flexible working hours and leave where possible – to a far greater extent than is currently the case.

Restoring front-line autonomy

Encouraging ownership and facilitating autonomy for front-line staff can have significant positive effects for provision and improvement of services. Within an ‘upside-down’ model, individual staff members make decisions regarding pricing, compensation and practices within individual retail outlets, reflecting the trust the company bestows on them.

This facilitates a ‘carrot’ approach to boosting sales, as each shop (and staff member) receives a weekly breakdown of their sales figures – with bonuses if particularly successful. Individuals are then free to use their initiative to improve their own (and their team’s) performance.

Such innovative thinking is hugely important for service development and improvement. In the National Health Service, many organisations are so large that it is difficult for individuals to feel that their views will make any difference. Moreover, as compulsory aspects of annual performance reviews, audits and ‘quality improvement projects’ are often viewed as unpleasant necessities, as opposed to positive innovations, and are frequently accompanied by daunting administrative requirements.

Management–staff interactions

Within an ‘upside-down’ management model, staff are proactively encouraged to contact the management team regarding any everyday problems they experience and receive individual feedback about how they have been addressed. Moreover, senior managers are highly visible and accessible. Within Timpsons, for example, they make annual visits to every establishment to talk directly to staff. This helps foster both communication and a shared sense of identity and cooperation. In contrast, many National Health Service employees do not know (or would not recognise) the senior management team heading their institutions, leading to a disconnect between management and staff.

Similarly, ‘upside-down’ management models do not support formal performance management assessments and appraisals of staff. Instead, they are reliant upon performance sales figures and peer feedback. While some review of training progress/staff performance is essential, the admin-heavy nature of current reviews within the National Health Service is frequently cited as a frustration for trainees, contributing to their low morale and dissatisfaction.

Effective planning and communication of services

Deliberate use of ‘public relations’ and external consultants is minimised within the ‘upside-down’ model. The idea is that good service will speak for itself. This ideal may be possible within an organisation with a single aim; but the complexity of National Health Service demands effective communication of services in order to achieve optimal outcomes. However, senior managers and members of governing boards should be capable of undertaking the majority of necessary promotion – given appropriate time and support.

The ‘upside-down’ model also promotes in-house training of managers who began working as front-line staff. This has the benefit of allowing for training in specific skills and for particular roles, but also promotes an understanding of and loyalty to the company. While some postgraduate training is available for National Health Service staff with an interest in management, more formal provision of managerial skills should be integrated throughout medical and nursing courses, with well-supported opportunities for individuals to take on management roles if they desire.

Similarly, recommendations for service improvement or change are ideally developed by those with personal experience of working within the National Health Service following full consultation with the research community, patient groups and current staff, rather than external consultants. Active listening, thorough piloting and discussion is essential to minimise potentially detrimental effects and could be improved by the reintroduction of ‘Green Papers’, outlining the evidence for the provisional policy and facilitating formal consultation. Moreover, introducing a Royal Commission for the National Health Service, with its advantages of independence, cross-party status and tradition of close consideration of the evidence, could be a constructive step forwards.⁸

Small is still beautiful

The National Health Service, as the world’s fifth largest employer, is biased towards creating bigger institutions. Large Foundation Hospital Trusts, which have the advantages of scale, also suffer complex lines of communication and greater hierarchy. This generates a potential for more inefficiency and a challenging environment in which to try and ensure staff feel valued – individuals often feel inhibited within a larger organisation.⁹

People are happier working in smaller organisations and this manifests in clear outcomes such as significant reductions in sick leave.¹⁰ An example within the National Health Service, of how this directly impacts on patients can be seen in that. For example, continuity of care is worse in larger general practices than in smaller ones.¹¹ Perhaps discussions regarding expansion of National Health Service Trusts or conglomeration of GP practices also need to include a consideration of the negative aspects of larger institutions alongside the potential savings of scale.

Conclusions

Given that so many health professionals in diverse professions are frustrated and unhappy, review of National Health Service management systems is clearly required. It seems logical that we should begin by studying management styles in companies that regularly report high levels of staff satisfaction. While it is inappropriate to assume that whole management systems from incomparable companies can simply be translated into the National Health Service, certain aspects may clearly be applicable.

Declarations

Competing interests

None declared.

Funding

None declared.

Ethics approval

Not applicable.

Guarantor

EL.

Contributorship

Both authors have made significant editorial contributions to the document.

Acknowledgements

The authors would like to acknowledge the Timpson Company and John Timpson for his advice on an ‘upside-down’ management style.

Provenance

Not commissioned; editorial review.