Stephanie J Snow

?Animateurs? and animation: what makes a good commissioning manager?

Objectives To examine the managerial behaviours adopted by commissioning managers in English primary care trusts (PCTs), and to explore the impact of these behaviours. Methods Qualitative case studies were undertaken in four PCTs, focusing on staff engaged in the commissioning of hospital services. Both formal and informal observation were undertaken (150 hours), and 41 in-depth interviews conducted with managers and general practitioners (GPs). Results Managers adopted many managerial behaviours familiar from the literature, including sharing information, and networking inside and outside the organization. Multiple organizational layers and unclear decisionmaking processes hindered this activity. In addition, some managers with responsibility for facilitating practice-based commissioning (PbC) adopted a managerial mode that we have called being an ‘animateur’. This approach involved the active management of disparate groups of people over whom the manager had no authority, and appeared to be a factor in determining success. It was facilitated by managerial autonomy and was more prevalent where managers were seen to have legitimacy. Some organizational practices appeared to inhibit its development. Conclusions From 2012/13 it is planned that GPs will be taking more responsibility for commissioning in the English NHS. This research suggests that managers of the new commissioning organizations will require a deep and contextualized understanding of the NHS and that it is important that organizational processes do not inhibit managerial behaviour. Legitimacy may be an issue in contexts were managers are automatically transferred from their existing appointments.

Writing migrants back into NHS history: addressing a 'collective amnesia' and its policy implications.

The National Health Service (NHS) has used migrant workers from its inception. As early as 1957, the Willink Committee on medical manpower found that 12% of doctors in a random sample taken from the Medical Directories of 1953 and 1955 were mainly overseas-trained.2 The majority of these doctors had entered Britain during or after World War II, suggesting that many of them would have been Jewish and Central European refugees from Nazi-dominated Europe. Later, migration from the Indian subcontinent became a key dimension of the recruitment of doctors in Britain. At the end of the 1970s, the Royal Commission on the NHS estimated that between 18,000–20,000 registered doctors in the UK were born outside the UK, with half of these being from India or Pakistan.3 In the 1950s and 1960s, large numbers of Irish and Caribbean nurses were essential to the expansion of NHS services, a pattern that was replicated in the early 2000s when nurses from Africa, India and the Philippines came to the UK.4 A 2005 report found that in 2003, 29.4% of NHS doctors were foreign-born and that 43.5% of nurses recruited to the NHS after 1999 were born outside the UK.5 In spite of this long history of substantial migration into the NHS, little effort has been made to understand the ways in which it has influenced the development of healthcare in the UK. The popular perception of the NHS as a ‘typically British’ institution (in a restrictive white sense rather than in an inclusive sense) tends to prevail in public perceptions of the organization and in its self-image. Of the 19 photos used by the BBCs online archive to illustrate the development of the NHS up to the 1970s, not one shows a black or Asian person.6 The ‘historical timeline’ on the NHS website makes no reference to immigration.7 Political and organizational histories of the NHS pay scant attention to migrants. A word search for ‘immigration’ in Rivetts online National Health Service History yields little more than the occasional passing reference to overseas doctors.8 Nor can much be found in Websters two tomes on the health services since the war.9 Where there is a focus on migrant health professionals in the NHS, the themes most widely covered are the experiences of individual groups of migrants and discrimination. This includes the dearth of opportunities for overseas doctors,10 the lack of recognition of the skills and experience of migrant nurses,11 exploration of how Irish nurses construct identity,12 reflections on the experiences of Black and Minority Ethnic NHS employees in the North West of England13 and a vast literature on racism grounded in empirical evidence14 as well as theoretical analysis.15 These studies have generated a wealth of useful data but three fundamental issues require further examination. First, there is a basic need to document and recognize the scale of the dependency of the NHS on immigration. Second, to what extent were migrants facilitators of development and/or agents of change within the NHS? Third, can a better understanding of this history inform policy?