Is the NHS' culture harming elderly patient care?

03 February 2017

  • Poor communication is leading to poor care for elderly patients in hospitals
  • Graeme Currie argue experts are being ignored by superiors
  • He says key changes also need to be made to how hybrid managers work
  • Professor Currie argues this broken comms chain needs to be fixed urgently

Elderly patients are enduring poor care in hospitals because of a communication block between the frontline and NHS management.

Research has found that hybrid middle managers - nurses and doctors that have moved from the frontline into management roles - are ignored by their peers, making it difficult to share knowledge up the chain of command due to a professional hierarchy where high status doctors ‘shut down’ peers of a ‘lower’ status.

In the paper HR practices and knowledge brokering by hybrid middle managers in hospital settings: The influence of professional hierarchy, published in Human Resource Management, Graeme Currie, Nicola Burgess, and James Hayton, of Warwick Business School, reveal key changes need to be made to how hybrid middle managers work if elderly care in the NHS is to improve.

For example in the case of geriatric specialists, the researchers found, despite their experience and knowledge, they struggled to get management and other doctors above them to listen and take on board their suggestions.

Similarly, they found nurses in a middle manager role can share knowledge downwards, but struggle to share that same knowledge upwards - they weren’t being listened to.

Yet Professor Currie argues it is often staff with practical experience and knowledge, such as nurses and geriatricians, who occupy hybrid middle manager positions.

He argues that in the face of the Mid-Staffordshire NHS Foundation Trust scandal and the fact hybrid middle managers represent around 30 per cent of staff in a typical hospital in England, more needs to be done to ensure they are sharing knowledge on elderly care effectively.

Professor Currie said: “At present there is a ‘broken’ chain of knowledge within and across nurses and doctors, but strong connections among healthcare professionals are essential for safe care to be delivered to older people.

“We need to understand how HR practices can best support the knowledge brokering role of hybrid middle managers, with attention to the complexities of inter-professional and intra-professional hierarchies, in ensuring high quality and patient-safe clinical care.”

The study, conducted between January 2011 and August 2013, draws data from three NHS hospitals, encompassing 127 interviews, 16 hours of focus group discussion with 48 clinical staff, and 60 hours of observation.

The interviews revealed the issues many NHS middle managers face in their day-to-day work.

How the NHS' culture is leading to a communication block

One nurse middle manager said: “When I came into my post as clinical lead it was like, ‘oh she’s a senior manager, don’t talk to her!’ As a change agent I need to be part of the team as well as a manager.”

A second nurse interviewee said: “The governance structure is very much a ‘black box’. Admittedly I am new in post, but I really have no idea how to push knowledge upwards to influence change.”

While a third added: “They [nurse team leaders] know that there are certain bits of this unit that just don’t work. I’m pretty sure that they will tell their bosses, but it seems to stop there, and it feels like nothing goes further.”

A geriatrician middle manager said: “Classically, the relationship that’s most fundamental in the NHS, is the consultant’s relationship with everybody else. Too often, consultants have been allowed to destroy, break-up or compromise change for petty or non-petty reasons... We should all be one team and I myself say this phrase, ‘one team - we’re in it together’.

“But regardless, people will view their professional identity in their own vision. So a nurse will have the right to question a consultant, but they don’t feel empowered to because of the hierarchical structure.”

The research data emphasises that professional status differences are creating a trend of inhibiting knowledge flowing between nurses delivering frontline care, hybrid nurse middle managers, specialist doctors, and hybrid medical middle managers.

To counter this issue the researchers have suggested a number of changes the HR department could look to implement in order to help such hybrid middle managers.

Dr Burgess said: “First and foremost, the focus of attention should at least include promotion of legitimacy through performance management, job design, and training and development. Furthermore, these efforts would need to include all parties rather than focusing on specific groups.

“The successful individuals who managed to overcome the boundaries of peer status were able to exploit their personal networks and credibility.

Related course: MSc Strategic Leadership & Innovation in Healthcare

“Therefore, in order to extend this influence to others, HR practices should focus on promotion of network building behaviours by individuals through training, performance management, and incentives and perhaps most importantly, resources such as time.”

Professor Hayton added: “Healthcare professionals need to build social capital with their peers to mitigate the negative consequences of status differentials.

"So, HR practices need to support the development of individual relationships between medical hybrid middle managers and their specialist medical peers, which transcend intra-professional hierarchy. Multidisciplinary team-working in particular, may be useful to increase the development of social capital.”


Nicola Burgess is Associate Professor of Operations Management and teaches Operations Strategy on the Distance Learning MBA and Managing Customer Service on the Undergraduate programme.

Graeme Currie is Professor of Public Management and is part of the National Institute for Health Research.

James Hayton, Professor of Entrepreneurship, teaches Managing Human Resources on the MSc Human Resource Management & Employment Relations.

Follow James Hayton on Twitter @ProfessorHayton.

For more articles like this download Core magazine here.

To register for our healthcare newsletter click here.

Join the conversation

WBS on social media