The Spiral of Control and Power: Why Healthcare Managers Psychology So Often Focuses on Orders, Actions and Micromanagement.

The spiral of control and power explains a common psychological pattern of how  even well intentioned managers such as those in healthcare, find themselves focusing on control and power.

Controlling Managers in Healthcare.

One of the biggest complaints amongst staff in healthcare systems such as the NHS is that managers are controlling. Rather than being empowered to take responsibility and be innovative and learn to improve they find themselves stuck following rigid processes and strict plans, orders and actions. 

The 3 Big Shifts in the NHS Require Giving Up Control

The upcoming 10 year plan requires the NHS to make 3 big shifts:

• moving care from hospitals to communities
• making better use of technology
• focussing on preventing sickness, not just treating it

Each of these shifts require giving staff and patients more control about how and where healthcare is delivered. It could be argued they are necessary as a direct response to our micromanaging healthcare system. At heart to be successful they require learning, adaption and innovation. Community work will only be successful if they can respond to the needs of people’s and communities, the ever increasing pace of technological innovation means that we constantly have to change with it, whilst preventing sickness and managing long term conditions means a process of learning adapting to the exact needs, challenges and opportunities every patient has. These shifts will not work with a top down control attitude.

It’s Easy to Get Sucked Into The Psychology of the Spiral of Control and Power.

The spiral of control and power is a prevalent, but not inevitable, psychological pattern of behaviour many NHS managers find themselves falling into. This is rarely intentional. Instead, it is often a reaction to the complexity and uncertainty of healthcare, as well as trained reaction, whilst also being under pressure to achieve challenging targets. 

I’m not condemning people. I’m speaking from the experience of someone who also found myself falling into the psychological trap. There are few things as seductive to a manager under pressure than being confronted with an uncertain problem, identifying a solution then telling people what to do.

If you’ve gone into a confusing situation and within a short space of time finished, with a nice little action plan, for people to follow; yep you’ve probably fallen into this trap.

What is The Spiral of Control and Power?

The spiral is a self reinforcing psychological feedback loop with 6 components:

1. Uncertainty: (Conflicting or surprising information) A trigger, often external (e.g., patient delays, challenging targets, unrealistic budgets or conflicting policies and priorities).
2. Confusion: (What’s going on?) The natural human response to uncertainty, when there is conflicting or ambiguous information this robs people of confidence and creates stress. 
3. Seeking Coherence (Clarity): (How do we find a solution?) The desire to make sense of the situation, to find a narrative. A way of simplifying the problem to reduce internal conflict.
4. Desiring Order: (We need to take action) The urge to create structure and predictability to resolve the issue. 
5. Desiring Control: (How do we stop this being a problem?) The belief that control will eliminate uncertainty and restore order.
6. Requires Power: (How do i make sure this is done?) The need for authority to enforce control and avoid future uncertainty.

It is a Psychological Pattern

What it is interesting is this is a psychological pattern, We’ve gone from uncertainty to taking a controlling action. But nothing about the problem has changed, but what’s in our heads. The reality of the situation is that it is most likely STILL an uncertain situation. You’ve just sort of persuaded yourself (and maybe others) that it isn’t. The fact is unless you are testing different responses to the uncertain situation you have probably just jumped to conclusions. But let’s be honest we all do it sometimes.

Why Does this Spiral Self-Reinforce: ‘The Illusion of Control’

The feeling of relief from anxiety as well as the reward from taking action ‘The illusion of control’ first described by psychologist Ellen Langer in 1975 has been shown by neuroscientists as psychologically rewarding to people when they believe control over events (Even when they don’t). To be blunt people get a kick, believing they have solved a problem, even if they haven’t. We like the buzz of the moment of solving a problem and going back to find out if it worked feels like a drag. This might be why NHS England produce plan after plan to fix the NHS, but then never go back to check whether those solutions actually worked.

It is believed this mental bias exists so that we persist with healthy behaviours and socially adapted behaviours even without obvious benefit. It is the opposite to learned hopelessness which is often the source of depression. So it make sense to have an emotional defence against it. Like the striker who keeps shooting optimistically knowing one day he will score, whereas the one that gives up after a few misses never will.

However, this emotionally satisfying payoff at the of the spiral means that the end of it feels like the emotional cure to threats and pain of uncertainty further up the spiral. So we mentally train ourselves to move towards this psychological reward and away from the fear and pain of uncertainty and disorder. (Even if we are just deceiving ourselves.)

Why Does This Psychological Spiral Become Embedded?

1. Human Need for Certainty Arie Kruglanski’s research on the “need for closure” shows that individuals strongly prefer clarity over ambiguity. In healthcare, where uncertainty can affect patient safety and outcomes directly, managers are naturally driven toward exerting tighter control.
2. Organisational Response to Stress Barry Staw’s “Threat-Rigidity Hypothesis” explains that under stress or perceived threat, organisations become more rigid, centralising power rather than fostering flexibility. Ironically, this rigidity reduces an organisation’s ability to respond effectively to challenges.
3. Power Dynamics and Politics Graham Allison’s theory of bureaucratic politics suggests that committees within bureaucracies are inherently political spaces. Managers often assert dominance to protect their status, secure resources, or demonstrate leadership, reinforcing cycles of control and power.

Why Healthcare Focuses on Control and Power?

Healthcare environments put a very high emphasis on control and power for good reasons. A highly controlled predictable environment is usually a safe environment. This is why we put GP’s, hospitals, and operating theatres behind walls. If we can control an environment, who and what goes in and out and everything inside it’s likely are we improving the chance of safety.

The 2 Fatal Flaws:

1. Most People Are Not Average.

The first fundamental flaw in this approach is that all too often it assumes everyone is the same or average. That they fit into our nice little tick box processes. But when it does not work it fails badly. A Kings Fund report found that 5% of patients has more than 20 times the costs of the average of the other 95% of patients. So by focusing on the average person we are missing the biggest problems.

2. The Past Often Does Not Predict The Future.

We often find ourselves fighting today’s problems with yesterday’s solutions. We believe that the past will predict the future. This is very often true. However, the fact we are confronted with a decision means that it’s likely the current situation didnt go as planned. There are all sorts of scientific reasons that we cant accurately predict and plan for the future. (Read about that here). If we focus on control and power we stop ourselves adapting and responding effectively to an ever changing world.

Why Are Middle Managers in Healthcare So Prone to Focus on Control and Power?

Stratified Systems Theory, (SST) developed by Elliott Jaques, suggests that middle managers often find themselves squeezed between operational realities (frontline concerns) and strategic pressures from higher leadership. This squeeze amplifies uncertainty, anxiety, and a perceived need to exert greater control to manage conflicting demands. 

For example: A hospital manager may be focused on hitting waiting time targets, but have to deal with numerous problems and queries about problems with patients and staff, can feel like a pressure cooker.

This is amplified in the field of healthcare as managers often work in highly controlled environments. But at the same time have to deal with the complexities of staff and patients as well as the inflexible targets and milestones they get from above. 

• Middle-management Pressure: In SST, middle managers are uniquely vulnerable. They have to handle short term issues while expected to contribute to longer term strategies. This dual pressure intensifies their anxiety and stress. This can push them toward micromanagement or excessive control.
• Anxiety Response: SST highlights that when managers struggle to meet expectations from higher levels, they naturally gravitate towards tighter control to simplify their complex environment.

Evolutional and Social Pressure:

• Survival Behaviours: The control obsession can also be seen as socially evolved organisational survival behaviour. The healthcare system prioritises safety order and control as well as standard processes. Therefore the socially acceptable solution to any problem is to produce order where there is uncertainty.
• Accountability and blame: As order and certainty are seen as acceptable. When managers have not created simple solutions for problems (The dreaded red box in a report) they are often blamed and given actions to resolve this issue
• Reinforced adaptation: Managers who are not seen to be on top of issues often find themselves overruled and micromanaged themselves. Meaning that even when a more adaptive response is required, this can often be overruled by senior managers. (Going through the same control-power psychology). Over time a manager that is seen as lacking control, often find themselves having their powers taking away from them. Other managers see this humiliating process, so imitating the power-control loop can be a powerful self reinforcer.

The Consequences of Being Control Focused

A lot of the problems I believe stem from the  rush to solutions meaning you have rarely taken the time to understand the problem. Like a policemen arriving at the scene of a reported crime and immediately arresting the first person they think probably did it. We’ve not really understood what’s happening or if there even was a crime, before we’ve committed to action. Because the outcome is so attractive and desirable.

Persistent fixation on control has severe impacts within healthcare environments like the NHS:

• Stifled Innovation: Fear-driven control suppresses creativity, hindering the development of novel and effective healthcare solutions. Fear leaves us stuck in our comfort zone.
• Reduced Psychological Safety: Excessive control limits open communication, reducing morale and discouraging transparency (Read here how fear kills team performance)
• Poorer Decision Quality: Centralised control overlooks valuable insights from frontline workers, leading to less effective and less responsive decisions.
• Lack of Adaptability: Control strategies struggle to adapt to individuals and expect everyone to conform to the average.
• Decreased Resilience: Ashby’s Law of Requisite Variety shows that organisations that don’t effectively respond to the world around them start to fail.
• Increased Staff Turnover and Burnout: Excessive control contributes to stress, dissatisfaction, and burnout among healthcare staff, ultimately causing high turnover rates.
• Decreased Patient Satisfaction: Patients experience lower-quality interactions and outcomes when healthcare providers are constrained by overly rigid managerial control. This can result in Failure Demand: Where patients go around the system continuously with their needs unmet.
• Increasing Health Inequalities: When you define the problem and solutions for others you stop listening to their needs. You lose contact with reality. This inevitably increases the disenfranchising of those who are not having their needs met by existing services.   

Moving Beyond Control and Power

The Cynefin Framework (explained here) shows us that control and power do absolutely have their place when things are ordered clear and predictably. But are not effective when there is more variation for example when tradeoffs are required. Moving from a best practice approach to a good one. We have to empower people with expertise to make decisions when things become complicated.

But for the most complex situations, where there is high uncertainty (usually involving people and social factors) we need an entirely different model. Test and learning and using distributed leadership and decision making to monitor adapt and adjust to problems that defy simple solutions.

Managing Healthcare Polarities.

Healthcare is full of tradeoffs. As soon as you optimise for one thing you make something else worse. By taking rigid approaches to prioritise what we do we create structural polarities. Meaning that we accumulate problems. For example focusing on speed to cut waiting lists over time will lead to compromises on quality, increased failures and need for reworks. Polarity Managment can give you a much better flow between balancing the need between cost and quality and getting the best of both without the many of the drawbacks. (Read my beginners guide to polarity management here)

How To Safely Devolve Power

David Marquet’s Intent-based Leadership and Ladder of Leadership is a fabulous modeling for devolving power safely. He was the commander of a US navy submarine who moved from telling the crew what to do to building the leadership capability of his crew through asking them building trust learning and confidence. 

Actions to Move Away From Control.

Breaking the focus on power and control requires deliberate action:

• Create Psychological Safety: Cultivate an environment where employees feel secure expressing doubts, ideas, and uncertainties, using uncertainty as an opportunity for collaborative learning and innovation.
• Develop Collaborative Leadership: Delegate roles and responsibilities broadly, establish networks and cocreate solutions, equipping leaders to handle uncertainty constructively and collaboratively.
• Empower Frontline Staff: Decisions are often made where the information is best, typically this is where frontline staff closest to the problems, can be empowered to respond and act to emerging problems and correct quickly when things don’t work out. Using their firsthand knowledge to make, more responsive decisions.
• Stop Motivating People Using Fear. We need to stop using fear to motivate people in healthcare. Use love empathy and compassion instead.

Understanding and addressing the focus with control and power in healthcare management can significantly improve organisational culture, decision-making quality, employee morale, and ultimately patient care outcomes.

Conclusion

Breaking free from the spiral of control and power requires NHS managers to recognise and resist the allure of certainty and simplistic solutions in complex situations. The 3 big shifts will only be successful if we can release the controls and empower staff and patients to learn and adapt. Through fostering psychological safety, empowering frontline expertise, and cultivating collaborative leadership, healthcare organisations can move away from rigid micromanagement towards adaptive, responsive decision making. Only then can we create a healthcare system capable of genuine innovation, adaptability, transforming care and closing the gap on health inequalities.