Top-down and bottom-up approaches to collaboration must meet in the middle

Meeting in the middle

The NHS has always had a top-down culture - Beccy Fenton suggests a collaborative approach between leadership and the front line is the answer to a successful organistion.



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Two Working Ants

Successful collaboration between large healthcare organisations will always require both top-down and bottom-up management. The leadership needs to set out the vision and the objectives of the collaboration, but the front line must be given the role of driving the delivery. You cannot have one without the other.

The NHS has always had a top-down culture. Because of this, staff do not know another way of working.

Regulation is partly responsible for the top-down mindset. When NHS regulators monitor an organisation’s performance, they first feed back to the board. The leadership are then tasked with kicking off a top-down cascade, which moves that information down a hierarchical funnel to directors, then directors to managers, then managers to ward managers and so on.

While this might seem like a logical approach to information sharing, it does little to engage the front line. Unlike those in the boardroom, staff working in the wards are the ones who have first-hand knowledge of how the organisation operates and how other services can be integrated.

This needs to be acknowledged by the leadership or they risk front-line staff feeling powerless to deliver better services or the benefits of a particular merger or acquisition. For me, this is the problem with a pure top-down approach. After all, without the full support of those on the ground and their specialist knowledge and insight, what would they be left with?

That said, leadership should still be responsible for setting out the vision and objectives of an organisation after a merger or acquisition. They hold an unrivalled view across the entire organisation that those on the front line will never have. In some NHS institutions, this front line is thousands of people. Asking them to have a bird’s eye view, coupled with a demanding day job, would be impossible.

That’s why the answer can only be a middle ground between top-down and bottom-up management. A mixed approach gives you the benefit of top-down clarity of vision, strategic thinking and a compelling reason for collaborating; and the bottom-up expertise in implementing the strategy. Persisting exclusively with one approach will mean the blind will end up leading the blind.

This article represents the views of the author only, and does not necessarily represent the views or professional advice of KPMG in the UK.

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