The Matron is coming back. The NHS Plan (DOH 2000) included a commitment to reinstate the matron as a strong clinical leader with clear authority at ward level. The details of how this will be achieved were released in April of this year. Renamed ‘modern matrons’ these nurses will be in charge of five to six wards and have responsibility for the care delivered. They will have clear authority to prevent or remedy any shortcomings in patient care. This will entail improvement in standards of hygiene to reduce the incidence of Hospital acquired infections and maintaining patients' dignity by ensuring they are addressed appropriately (this will be emphasized by the donning of a new distinctive uniform so that patients will know ‘who is in charge’). Additional powers to withhold payment for cleaning services if the standard is felt to be unsatisfactory, are to be conferred in order to bring about direct improvements in quality. The Secretary of State for Health announced that 500 matrons, on salaries of up to £30 000 a year, will be appointed by April 2002, rising to 2000 by 2004.
This is an interesting development, particularly for the readership of a journal which focuses on nursing management issues. So what are the implications of this latest policy initiative?
Although the reincarnation of the matron is being championed by ‘New’ Labour, it is not without irony that in working to develop a health service for the 21st Century the Government has sought recourse to a term that has its origins in the 16th century. This would seem to be at odds with the modernization agenda. The rediscovery of the matron, and the intention to herald this development as the solution to patient concerns about health care, is an example of the Government trying to meet conflicting policy objectives (New 1999). The commitment to the enduring values of the National Health Service, stated in the NHS plan (DOH 2000), needs to be maintained yet this has to be ‘repackaged’ to demonstrate that something ‘new’ is being done. Acceptance of the value of an idea that is almost as old as nursing itself, does not convey the desired picture of a dynamic and reforming government, therefore the prefix ‘modern’ is added. In this way an idealized, inaccurate perception of a health service that was well-run and met patient needs is embodied in the person of the modern matron. The fact that health care is infinitely more complex than it was in the heyday of the original matrons and that at this time, despite the presence of the matron, nursing occupied a ‘secondary position’ in relation to other professional groups (DHSS 1966), seems to have been conveniently overlooked. In the face of multiple demands on a service under pressure it is important that action is seen to be taken. The very public failures of the service, demonstrated by the Shipman case, the Bristol heart surgeons, and most recently, the Alder Hey organ retention scandal, have shaken public confidence in the NHS and led to demands for the government to ‘do something’. In seeking to address this situation simple solutions are very appealing. The public consultation process conducted to gather evidence to inform the compilation of the NHS Plan (DOH 2000) ‘provoked a strong call for a “modern matron” figure—a strong clinical leader with clear authority at ward level …’ (p 86). Consequently, the opportunity to introduce a solution that was in tune with the mood of the public was too good to miss. Adopting such an overtly popularist and simplistic approach may satisfy the requirement for action, yet it presents solutions and problems in almost equal measure.
There are several issues associated with the reappearance of the Matron that are worthy of comment.
First, to what extent will the postholders have real power to bring about changes in practices and procedures? If the intention is to create strong clinical leaders with the power to make things better for patients, why is the power they will be given only to ‘withhold’ payment? The real power in organizations rest with those who have the authority to commit resources. This is a crucial point in this context. Views on what constitutes quality care differ (Øvretveit 1992). Unless a significant budgetary responsibility is part of the role, the power to change practice is unlikely to match the expectations that are currently being raised. Chief executives, medical staff, and politicians often have views on quality that are very different from those of nurses. Waiting times, technical excellence in procedures, and patient charter compliance are all dimensions of quality, yet they are not always compatible. Similarly, with the introduction of a system of earned autonomy (DOH 2000) as part of the next stage of clinical governance, quality is increasingly defined in terms of meeting targets of various kinds. The managers (chief executives and clinical directors) who have the responsibility for the achievement of these targets, and hold the budget for their trust/directorate, will take the final decisions concerning priorities in the provision of care. How will the modern matron fit into this structure? What happens if her concerns about quality are not shared by those who hold the budgets? There is a need for definitive statements about lines of accountability and authority. Will the matron be accountable to the chief executive, the clinical director or the nurse executive of the Trust? How will line management of cleaning staff be co-ordinated with external contractors? What will be the relationship of the ward managers to the modern matron? Initially the modern matron was conceived as a post at ward level yet it has already changed to involve oversight of several wards. This has implications for the authority and sphere of responsibility of the ward manager. In summary, how is the ‘strong clinical leadership’ to be operationalized? These matters will need to be resolved if the post holders are to achieve their targets in the areas the government has already identified.
Second, how will this initiative be received by nurses? The Royal College of Nursing (RCN) response has been broadly favourable (Carvel et al. 2001; Snell 2001), yet there are some questions that require consideration. Where are these matrons to be found? Nursing is experiencing a worrying recruitment and retention crisis. Whilst the introduction of a new type of senior post into the career structure may have a positive effect on recruitment in the long term, the more immediate requirement is for highly skilled managers who can meet the challenge of this new role. Given the staffing situation, even if nurses come forward in large numbers to become modern matrons, this will only leave gaps elsewhere in the service, in much the same way as skilled nurses moving to NHS Direct has resulted in shortages in other parts of the service. Is it likely that nurses will want to take on these roles when any achievements they hope to make will be compromised by a lack of staff?
There are other factors that may affect the way this new role is perceived by nurses. The conflict between management and clinical identities is increasingly being recognized as an issue of concern for nurse managers (Reedy & Learmonth 2000). Clinical and managerial identities are distinct and there are problems in moving from one to the other (Edmonstone 1997). Now that there are opportunities to become consultant nurses and retain a clinical speciality whilst working at a senior level, there may be a reluctance on the part of nurses to become matrons. Also should nurses decide to become modern matrons there will be a need for an extensive programme of preparation. Nottingham & O'Neill (2000) have commented on the inadequate training that has been provided in the past for nurses taking on management roles. If modern matrons are to be effective there will need to be a comprehensive and realistic training programme that will enable them to manage the dual responsibilities of being a clinician and manager. Simply creating a new title and appointing people to these posts will not automatically guarantee that the level of management expertise within the service will be increased. This has been tried before and it failed. The Nursing Officer role, which was introduced following the recommendations made in the Salmon Report (DHSS 1966), was not well received and was later abolished as part of the Griffiths reforms.
Third, how will this addition to the nursing hierarchy affect and relate to other elements of the Government's reform agenda? In the NHS Plan a strong emphasis is placed on the need for multidisciplinary working and the importance of breaking down professional barriers in order to facilitate effective care and treatment. Will the modern matron have responsibility and authority in this area? If quality care is to be assured the actions of all of the workforce, not just the nurses and the cleaning staff, need to be mobilized and co-ordinated. If the modern matron is to have the desired effect, is she to have authority over all of the workforce in her allocated wards? Past experience would suggest that this is unlikely. Also, how is this commitment to strong clinical leadership to be achieved in the areas outside acute trusts? Nurses have a presence in Primary Care Groups but this is a different role. Is there going to be an equivalent to the matron in the community?
These questions indicate that behind the headlines there are many aspects of this initiative that need to be clarified, however, this should not detract from the essentially positive nature of this element of policy. Whilst it is inevitable that the original proposal will be changed and undergo considerable modification during its implementation, the implicit recognition of the worth of nursing and the realization that the loss of a senior nursing management presence in the past was a retrograde step is extremely encouraging. The hope is that nurse managers will be able to capitalize on the current popularity and visibility of the term matron to ensure that the fundamental management function within the NHS is genuinely directed to the needs of patients. This is necessary because although much of the health care delivered today is responsive, innovative and patient centred, there are regrettably some aspects of service delivery that are more akin to the 19th century than the 21st.
The overall conclusion that can be drawn from this is despite the lack of detail and clarity concerning the role nurses should take heart. Initiatives and new titles come and go and, as is the case here, some titles return, however, what remain are the needs of patients and the need for nurses. However it is represented, reinvented, or reinterpreted nursing is the enduring and central feature of health care. The health service in the 21st century needs nurses as much as it did in the era of the original matrons. The challenge is for nurse managers to take this ‘new’ role and shape it to the best of their ability to ensure that the focus of management is care.