Theory X or Theory Y?

James Gubb, 26 July 2007

There is a theory in management, pioneered by Douglas Macgregor in the 1960s, which say that when it comes down to it management basically takes one of two forms.
Theory X management is based on the belief that people will give their best only when under external pressure – they prefer to be directed, have little ambition, don’t like work and don’t want responsibility. A manager’s role must therefore be a preoccupation with coercing and controlling employees in order to get them to do what’s best. Theory Y management, on the other hand, assumes that people will give their best when they are given genuine responsibility and are able to have a sense of pride in their work – people have potential, like working and want to use their natural abilities. A manager’s role is then completely different – to develop potential in employees and help them release their potential for creativity, ingenuity and imagination.
The government and the Department of Health (DH) love to think they go in for Theory Y. It’s the public service ethos. I don’t think you’ll ever hear either of them saying they think NHS staff are fundamentally lazy and don’t really care about patient care unless they have to. But in reality while they pay a lot of lip-service to Theory Y – and may even think they believe it – they somehow can’t resist extending their tentacles. Actions speak louder than words. And the actions have more often than not been symptomatic of Theory X.

Delivering the NHS Plan is the best example. It talked much about the process of earned autonomy, devolving decision-making to local organisations and unleashing the greater flexibility, innovation and responsiveness to patients that was assumed to go with it. You might think this is the triumph of Theory Y, but far from it. For starters, is anyone else missing an inherent contradiction here? Do well and we’ll set you free to do even better. But surely if you really believe NHS organisations will ultimately do better if they’re free, then why not just set them free in the first place?
The justification oft repeated by the government was trawled out yet again by the Secretary of State for Health, Alan Johnson, on the Today programme earlier this month when talking about the ultimate example of the fact NHS organisations and staff are actually subject to Theory X: targets. Targets, he said, “were very necessary when we came in, in 1997. You could describe the NHS as being in intensive care. There was a terrible record of long waiting lists et cetera…[but now], as we are out of intensive care and on the road to recovery in the NHS, so to speak, we need to move away from targets.” Yet in the same interview Mr Johnson also concedes: “It shouldn’t be politicians or bureaucrats at the heart of decision making in the NHS; it should be clinicians” (the lip-service to theory Y coming out again). I’m sorry, but targets are the ultimate expression of politicians and bureaucrats being at the heart of decision-making and distorting clinical priorities, which has ultimately led to the medical profession spitting so much blood that the BMA has gone so far as to say that the government has ‘brought the NHS to its knees’. Mr Johnson’s logic just doesn’t stack up.
And the point goes deeper than this. The fact is that even Foundation Trusts, where the government has actually managed to stick to its rhetoric of devolved autonomy to some extent, have their hands tied by top-down instruction and the command-and-control mentality of Theory X. Targets still apply to all – which is highly significant, because they don’t work and wreak havoc in the system.
On the macro level they ensure the service is continually upward-looking, with organisations tending to take their cues from the centre; making it extremely difficult to think long-term and to be reactive to patients. Andy Buck, CEO of Rotherham PCT, reported to the NHS Confederation: ‘I think we have been encouraged to focus on this years targets – get the finance right, deliver the targets and don’t drop any clangers’ (NHS Confed). I’m sure pretty much any other CEO of an NHS organisation would say something very similar. Moreover, with the explosion of central targets, objectives and funding streams that emerged from the NHS Plan – placed at 121 by the Nuffield Trust – it’s small wonder anything gets done; NHS staff must be prioritising everything and nothing, in the words of the former Secretary of State for Health, Frank Dobson.
But perhaps even more damaging are the day-to-day effects this has had. I’m going to be controversial here, but it’s no accident that the Soviet economic regime collapsed. It was based on targets and central control; and politicians seem to be waking up to the fact the NHS will probably suffer the same fate if the obsession continues: “Doctors, clinicians and nurses complain they are fed up with top-down instructions and weary of restructuring. They want a stronger focus on outcomes and patients, and less on structures and processes” said Mr Johnson. As Gwyn Bevan and Christopher Hood wrote in an insightful paper in the BMJ last year: ‘regulation by targets assumes that priorities can [actually] be targeted, the part that is measured can stand for the whole, and what is omitted does not matter’. None of this is the case in the NHS. I can do no better than use the same analogy as they refer to ‘most indicators of healthcare performance are “tin openers rather than dials…they do not give answers but prompt investigation and enquiry, and by themselves provide an incomplete and inaccurate picture”’. Hence, for example, statistics may show waiting times have been cut, but give no indication of the effect on quality of care. Mortality from CHD may have fallen, but at what cost to stroke care?
Let’s just take announcements from last week as examples. A report released yesterday by the Healthcare Commission found some 45% of 155 NHS Trusts surveyed reported that waiting time targets for treating patients in A&E were putting infection control measures at risk. This confirms what many feared to be a more widespread than an isolated case at Stoke Mandeville Hospital where the outbreak of C-difficile was at least partly attributed to “the approach to the target for A&E [which] led to some patients with infections being admitted to, or moved to, open wards rather than isolation facilities”.
And then we have the results of a survey by the DH of more than 2 million people on GP practice, which showed that a quarter of patients still cannot book advance appointments with their GP – more than two years after Tony Blair promised to solve the problem, which has emanated from the 48 hour GP-appointment target. GPs are still manipulating appointment systems to meet targets.
If we go back a week, yet another example emerges. The government set a target for a two-week wait for urgent cancer referrals, but the urgent referral notice has been so captured by the ‘worried well’ middle-classes, according to the BMJ, that ‘an alarming two-tiered system of treatment has been created’ – an estimated 8,800 women eventually diagnosed with breast cancer were labelled ‘routine’ and not fast-tracked.
Theory X urgently needs to be replaced by Theory Y. And this must be more than just rhetoric; it must be in practice. Mr Johnson insists he will be moving away the Theory X and the culture of targets, but don’t go jumping up and down too soon because – as he says in his own unique way – “we have one main very precious target to meet, which is a maximum of 18 weeks between GP referral and treatment.” Hmm…