Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Brave New World of the NHS
- Alan A Woodall (11 August 2006)
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Better NOT more management is key to the NHS
- Michael J. Walton (11 August 2006)
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Managers, not bean counters.
- Dermot Ryan (11 August 2006)
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We definitely don't need more managers
- Abhinav Gulihar (12 August 2006)
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An illustration of why the NHS is not working
- Andrew Beggs (12 August 2006)
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Good Management needs Good managers not More Managers
- Peter H L Aitken (12 August 2006)
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Management is not the key to fixing the NHS
- Costa Repanos (12 August 2006)
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More Management Please
- Andrew E Blewett (12 August 2006)
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Processes can only be changed by people who know them well
- Tom Billyard (12 August 2006)
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imagine.....
- benjamin dean (12 August 2006)
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Efficiency requires investment
- Stephen G. Costa (12 August 2006)
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Why the polarisation?
- Paul L Thorpe (12 August 2006)
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Doctors' Leaders should do MBAs
- Paul E Shannon (12 August 2006)
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Black - Quietly confident of his own unsurpassed humility.
- Steven Ford (12 August 2006)
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NHS is under-managed, but over-administered
- Stephen R Kirkham (12 August 2006)
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Just what do management consultants know?
- Peter G. Davies (12 August 2006)
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Quality or quantity?
- Chris Booth (13 August 2006)
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Management does not heal patients
- Franz J Eigenmann (14 August 2006)
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Better Management but no more Management
- Pushpinder S Sidhu (14 August 2006)
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Evidence-based management, preferably by medically qualified managers would be much better
- Adam R. Greenbaum (14 August 2006)
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Management techniques
- Joan McClusky (15 August 2006)
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An opportunity lost
- Joseph Mathew (15 August 2006)
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Better Management, Fewer Unskilled Managers
- David Dawson (15 August 2006)
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Stephen Black should remember that patients and doctors are people too
- Cliona M Ni Bhrolchain (15 August 2006)
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Communication is the key
- Andrew C Sherley-Dale (15 August 2006)
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So what are our current NHS managers doing?
- Jeremy E Oates (16 August 2006)
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Better, not more, management will help to fix the NHS
- Ruben D Trochez-Martinez (16 August 2006)
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NHS need more medically oriented managers
- Hany Wisa (16 August 2006)
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Capacity with some to spare
- S. Michael Crawford (16 August 2006)
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Better, not more, managers
- Geoffrey M K Schrecker (16 August 2006)
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A plea for more thinking
- William J. Lang (17 August 2006)
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Clinicians and managers work better together
- David L Wallace (17 August 2006)
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Medical management is different
- Michael Paul (17 August 2006)
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Second Law of Thermodynamics
- Luke J Ball (18 August 2006)
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Audit Commission Report on bed numbers
- David O'Hagan (19 August 2006)
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Good management and appropriate staffing : mutually exclusive?
- Sunil Nair (19 August 2006)
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Straw man argument
- Anjan Chakraborty (23 August 2006)
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Missed Management
- John A Anderson (23 August 2006)
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Violent Agreement?
- Jim Easton (24 August 2006)
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Re: Violent Agreement?
- stephen black (25 August 2006)
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A Fix For The NHS
- Imogen C Felton (12 January 2007)
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Re: A Fix For The NHS
- A F Goodman (16 January 2007)
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Re: A Fix For The NHS
- Thomas de Albuquerque (16 January 2007)
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Alan A Woodall, GP trainee/SpR public health medicine Shrewsbury and Telford NHS trust
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Mr Black suggests that there is 'no relationship between staffing levels and NHS performance', and that further investment in NHS IT systems, managers and management consultants would lead to better performance than spending on 'frontline staff' such as doctors and nurses. Ironically for one of those who chose a career motivated by profit and flipchat catchphrases rather than public service, he quotes data from the Healthcare Commission to support this incredulous statement. It somewhat overlooks the pertinent fact that some relationship between staffing and clinical efficiency must exist - otherwise departments across the country would be runnning very efficiently with no clinical staff whatsoever. As Disraeli said, there are lies, damned lies, and statistics - be careful how you use them. I invite Mr Black to join me this month at my NHS trust when I am on duty for a Friday nightshift in Emergency Medicine, when I will be the only doctor on duty in the department, to see how 'little' staffing levels are related to performance. Yet, in my experience of working in the NHS, I cannot recall any management consultants (or NHS managers for that matter) shadowing me in the early hours to see the clinical reality beyond the numbers that generate their soundbites and flipchart statistics. An extra doctor would help throughput, efficiency and patient satisfaction. Another manager wouldn't get the suturing done or the thrombolysis started quickly, or help the nursing staff deal with the drunk teenager who is becoming aggressive. A shiny new IT system to remotely bed shuffle numbers wont do this as efficiently and compassionately as an experienced nurse bed co-ordinator who considers the needs of each patient beyond being a statistic. To us 'antireformer' frontline clinical staff, it seems external management consultants who are divorced from the reality of the job would like to view the NHS as a docile clinical workforce of Gammas, Deltas and Epsilons best overseen by a few Alpha managers with clean hands and laptops measuring patients as output targets rather than people. They seem to understand little of its ethos or mission and how different (rightly so) the NHS should be from the commercial sector. A Brave New World indeed awaits us if we allow them and their politician sponsors to control the NHS for much longer. Competing interests: I am a doctor working in the NHS |
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Michael J. Walton, Specialist Registrar South West
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EDITOR - In response to Mr Blacks article that more and better management is key to the future of the NHS and his tirade against the anti -reforming clinicians working in the front line; I have to aggree that better management is key to our future. However, Mr Backs appraisal of the situation has demonstrated the management consultants obsession with the measurable, the quantity, and not the immeasurable, quality, that the NHS has long stood for. The highlighted progress in the 4 hour A&E wait may be music to management ears but how this arbitary figure has affected unnesessary admission rates, the distortion of clinical priorites, the deskilling of A&E juniors the impact on the emergency teams of other specialities is overlooked. Expensive IT solutions will be hugely beneficial to the future NHS but can we really justify this expense when we have not yet got our present house in order. Most clinicians are at present working to their maximum capacity, much of this without remuneration or gratitude. The idea that staffing levels have no effect on performance shows such naivey of our work. In times of need frontline step up and get the work done, all patients need seeing. The measurable quantity stays the same. But, the quality of each interaction lessens, the mistakes increase, the morale falls and most importantly the patients' care deteriorates Frontline staff are the NHS's most expensive but also its most valuable assest. It is us who diagnose, treat and care for all of the patients whom we meet to the best of our ability. We should be setting the clinical priorities and the best possible managers implementing these in the most efficient way. At present this sitation is reversed with the disasterous consequences many as predicting. Poor leadership, management and managers are destroying morale within the NHS and threatening the employment of frontline staff. Without us and the hardwork we provide the NHS will fail, good management or not. Competing interests: None declared |
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Dermot Ryan, GP Woodbrook Medical Centre, Loughborough, LE11 1NH
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Although the title suggests that better managers might help rescue the NHS from its' current state, the author only seems to address quantity in his personal view. He also makes unwarranted assumptions e.g. that the term NHS manager means that the person so named has any management skills or abilities. I am sure that many would agree with me when I suggest that the term "NHS manager" is an oxymoron. He states that the Healthcare Commission is not a "dodgy" consulting firm, but it is this organisation that is responsible for handing out stars and performance ratings which bear no relationship to what these trusts actually do or achieve. To manage within the NHS, a manager needs to understand that the basic unit of currency is the consultation. A consultation with an appropriate health care professional, taking place at an appropriate time and place, with adequate diagnostic facilities which can be accessed and used in a timely fashion leads to an adequate assessment and management of the patient. Managers and their political directors seem to ensure that the consultation is not adequate because of time pressures, often exacerbated by some management target and lack of diagnostic or treatment facilities. Failing to listen to clinicians as to what is needed to do the job competently leads to the employment of more managers who lay down more impossible and innapropriate plans for dealing with the deficiencies which compound the initial problems and this goes on ad infinitum. Managers with management abilities do not last long in the NHS. They are seen as a threat by their management colleagues and thus sidelined. Incompetents rise to the top of the tree where they perpetuate the inertia. I agree with Stephen Black: we need more managers with management skills employed to achive optimum clinical outcomes, which they will only succeed in doing by working in collaboration with their clinical colleagues. The first thing competent management would do is clear out the logjam of dead wood which is hampering change and innovation in service delivery within the NHS. Competing interests: I am a doctor |
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Abhinav Gulihar, SHO Orthopaedics Leicester General Hospital, LE5 4QP
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I think Mr Black has proven from the above article that management consultants have no knowledge of how the UK Healthcare system runs. He disagrees with Paul Miller, chairman of the BMA’s consultants committee and says that NHS needs more managers. Even a non-medical person would agree that managers should be familiar with atleast some level of medicine before they start running departments and wards. Mr Black has quoted the Healthcare Commission (Acute Hospital Portfolio Review : Accident and Emergency, August 2005) that there is no relation between staffing levels and performance. Having worked in one of the busiest A&E departments in the country, I know that is not true. Doctors from all levels have been stretched to the limits in this department and shortage of nursing staff is a common problem. Sometimes there is enough staffing but no space to see a large number of patients who may arrive within a very short period of time. I am sure that we need more money and more staffing to bring the targets down, what is a management consultant going to achieve here. In his second statement, Mr Black talks about hospitals not discharging patients in the afternoon. Is he aware of the fact that most senior doctors who make decisions to discharge patients are busy atleast until 5 pm doing a busy clinic or theatre list, so should we let managers make that decision? Very recently, I was faced with a bed problem. Being the on-call doctor for urology, I had four emergency admissions and four more expected and not even a single bed available. I spent half my time waiting for beds, and a quarter on trying to find a nurse because the only nurse looking after that area was extremely busy. The sister in charge had to help with ward work instead of completely concentrating on arranging beds. Eventually, we managed to treat all patients and get them all a bed by 8 pm. If we had a more senior doctor to discharge ward patients, a sister to make sure those beds were ready for new patients and another nurse to help out in admissions, those patients would not have had to wait in chairs. So again I don’t understand how a minor change in working practice could help on such a day which is definitely not uncommon. Mr Black also says that fewer patients are discharged over weekends. Does he suggest that teams that are not on call should come in and make decisions on their patients or maybe the on call team should make such decisions even when they would rather be cautious not to make such decisions on patients (under the care of other teams) they don’t know everything about. One more idea would be for the non-resident registrar who does a full round in the morning and covers three hospitals can come in the afternoon and evening for another ward round. Of course, these are minor changes in practice. I fail to understand how management consultants can help in such situations. The NHS clearly needs more money for expansion and infrastructure and there is often a need for more staff (rather than sack them). Maybe the government can recruit managers who can make these important (but obvious) decisions. And then we wonder where the money goes. Competing interests: None declared |
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Andrew Beggs, Senior House Officer, Trauma & Orthopaedics St Georges Hospital, London, UK.
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Sir, The personal views espoused by Stephen Black are typical of the facile attitudes displayed by management consultants when dealing with the NHS. I have noted, in my relatively short time in the NHS, that management consultants view the NHS as a commodity, that can be managed ,using the example given in the article, like a hotel room. This demonstrates a fundamental lack of understanding on how health care works. Hospital beds are nothing like hotel rooms. The care of patients is best done in a specialist unit in the area the patient is admitted under. A psychiatric patient would not recieve the best standard of care on a Orthopaedic surgery ward, and vice-versa. Patients are not discharged at weekends because of the snails pace social services and intermediate care seem to operate at the weekend, if indeed they operate at all. Hospitals need major investment because of the frankly shocking standard of physical facilities in the NHS. These would not be tolerated in any other modern industrial country, so why by us? Poor facilities demoralise staff which leads to a drop in productivity. To argue that increasing resources will not improve performance is management rhetoric at it's worst. And to conclude, from my personal experience, the reason Emergency Departments in the UK have had a dramatic improvement in their waiting times is the tripling (at least) of medical staff employed there and the buckets of money that has been thrown at the problem, not because of any efficiencies in management. The sole point I agree with the author is that the NHS could be better organised with greater use of IT, however this should be in addition to greater investment, not lesser. Yours sincerely, Andrew Beggs Competing interests: None declared |
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Peter H L Aitken, Consultant, Director of Research & Development Devon Partnership NHS Trust, Exeter, EX9 6DA
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The cover of this weeks BMJ provokes with its statement 'The NHS needs more managers not more money'. Great journalism perhaps, a hook with impact. Appropriate for a scientific journal supplying the evidence base? Probably not. It is inaccurate and unfair to Stephen Black's imapssioned personal view that swathes of the clinical audience are missing the value of good management. Does his piece help? I doubt it. It has many good points to make but damages their delivery by unfairly stereotyping a health profession that has had to endure years of poor mangement from poorly trained, poorly equipped managers. Could health care be delivered by management consultants alone. Probably not. Can health professionals deliver care on their own. Most certainly. We only need to be organised when we have to be organised in health care systems. Most clinicians recognise management talent when they meet for all the reasons Mr Black articulates. Life gets more coherent. Practice gets easier. Results improve. Unfortunately the general experience in the NHS is of administrators rather than managers, preoccupied with their own world of estates, finance, and central directives, with little experience of engaging or bringing their most precious and expensive resource with them, the health & social care professional teams. This polarisation of position and lack of understanding of each others language, culture and agenda underpins the great missed opportunity of the NHS reform. Health professionals and professional managers need one and other if their organisations are to be successful. Health Care Managers need to be very good at their jobs and very skilled in managing the professional resource as well as the services they provide. Health professionals need enhanced management skills. A common framework of management skills around delivering the process of health care would be welcome. So BMJ,lets have a clear appeal for better managers with more effective skills and a common understanding with their health professional colleagues. Lets not obscure this real deficit with a spurious appeal for more managers, or more of the same. Mr Black, there is more a need for high quality management training than more management consultancy. I want the expertise in our organisation, not visiting it. So if we're spending money differently lets spend it on training managers and health professional learning how to get the best out of each other in a common process to the benefit of patient and the experience of work. Competing interests: None declared |
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Costa Repanos, Specialist Registrar in Otolarygology Derriford Hospital, Plymouth, PL6 8DH
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Editor – I read with interest the article by Stephen Black, a management consultant from London, expressing his opinion that what the NHS really needs is more management, and of a higher quality. Is the BMJ so short of letter submissions that it feels the need to commission deliberately provocative articles from embittered nurses (1) and aggressive management consultants (2) in order to raise a response from its readership? Mr Black may feel that managers are being persecuted and denigrated by “the anti-reformers” and that doctors are preventing progress, however I would argue that we as doctors are currently the only real arbiters of quality in a target (not patient) driven management culture. The “performance” that Mr Black eludes to when he cites that “there has been no correlation between staffing levels and performance in A&E” is the same surrogate marker for excellence that the public are being duped into believing has any qualitative merit. Mr Black’s “conveyer belt” mentality belies profound lack of understanding of how patients are looked after. The most worrying aspect of this article is not that these are common views amongst management consultants, but that people like Mr Black with a background in how to get more Volvos off the conveyer belt have the ear of gullible politicians who hold and wield the strings of power. Knowledge is power, and apparently a little knowledge is bad thing, but power without culpability or responsibility is unsafe. Yours sincerely Costa Repanos Specialist Registrar in Otolarygology Derriford Hospital, Plymouth, PL6 8DH costa@repanos.com 1. Young G. The nursing profession's coming of age. BMJ 2005;331: 1415. 2. Black S. More and better management is the key to fixing the NHS. BMJ 2006;333:358 Competing interests: None declared |
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Andrew E Blewett, Consultant Psychiatrist Wonford House, Exeter, EX25AF
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Stephen Black highlights one aspect of the woeful tradition of medical moaning about managers, recently championed by the chairman of the BMA consultants' committee (1). Doctors and managers are both prone to the part truths of their respective stereotypical professional personas. Doctors are liable to intellectual and social arrogance, tend to exist within their own limited clinical horizens, and are keen on self- replication as a solution to perceived demand. Managers are liable to resort to totalitarianism, and are keen on shuffling things around when unsure what else to do. In the 25 years in which I have worked in the NHS, the quality and competence of management as a professional group has consistently risen, (anecdotal, but does anyone seriously think it's getting worse?). My non- clinical management colleagues can do things that I will never be able to do, and I am glad of it. I would like them to be able to do more. I want to have the most highly skilled, wisest and best organised managers possible supporting the service I work in. This is a context in which as a clinician I can deliver. Medical moaners, shroud wavers and managerphobes would do well to examine which bits of the NHS work best. They will invariably find at the heart of it a reasonably stable group of people with different clinical and organisational roles, making a virtue of getting on with each other, generally happy, sharing a common vision, hearing each other, willing to drop what doesn't work and take up what does; in the interests of a common purpose. It's called co-operation and it is a skill without which a service quickly becomes a kindergarten. The chairman of the BMA consultants' committee must know that projection and splitting are primitive and generally destructive mechanisms which emerge when vulnerable people experience threat. The shared endeavour of alleviating the misery of ill-health is too important to sacrifice to posturing and slogans. An enlightened profession interested in the radical ideals of the NHS would have worked out by now that we doctors are in an excellent position to make a political case for the best managers available, allowed to manage; and plenty of them. Some may even join their ranks. (1) Black S. More and better management is the key to fixing the NHS.BMJ 2006;333:358(12 August) Competing interests: I work in a cash strapped mental health NHS Trust. I work with clinicians and managers. I am a full time clinician. |
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Tom Billyard, Foundation year 2 research fellow University Hospital, Coventry, CV2 2DX
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EDITOR - Stephen Black is broadly right when he says that more management is required in the NHS to achieve reform. This is undoubtedly true; what must be avoided is more management dead weight damaging the service and the morale of the people who provide it with counterintuitive and dysfunctional ideas about how things can be changed. Everyone who works in the NHS is aware that there are numerous inefficencies in the way we work, and I'm sure that we have all thought about how they can be improved. It is the opinion of the frontline staff that should be listened to when proposing reform - a management consultant is unable to suggest sensible changes because he is not involved in the process and so does not understand it. Take for example Mr Black's description of how bed management can be improved. This is exactly the kind of improvement that sounds brilliant, and obvious, to a lay person, but completely unworkable to anyone who has ever been involved in the process of discharging a patient. Because of the way the NHS works, beds cleared of elective patients early are likely to be filled with emergency patients before you can get the next set of elective patients anywhere near them. Discharging patients as early as possible is a noble idea but since discharge summaries and prescriptions prepared before the day of discharge are meaningless in many cases, there will always be a delay while these are completed. One thing he is right about is the situation where patients are not sent home at weekends; it would make a lot of sense if discharges continued at the same rate at weekends as this would ease the weekend bed pressure from emergency admissions. However, the only way this can happen is for every patient to have medical review at the weekend. With the trend in most hospitals to reduce the out of hours staff to a bare minimum this becomes completely impossible - a skeleton on call staff cannot be expected to review patients they don't know on the off-chance that they are fit for discharge. Black's overall concept is sound but his lack of understanding of reality in the NHS serves to discredit his suggestions. Perhaps if he tried following frontline clinical staff for a few weeks he would be able to give his ideas a little more credibility. Competing interests: None declared |
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benjamin dean, sho oxford
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a world where management consultants rule, where increasing management is seen as the solution to all our woes, where long winded bureaucratic protocol stifles progress and where the last few remaining non-management consultants do all the productive work. Listen to management consultants at your peril ( remember the downsizing scam of recent years ). Competing interests: None declared |
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Stephen G. Costa, SpR ED Salisbury District Hospital SP2
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Few would doubt that a commitment to efficient management in the NHS would could and should lead to massive improvements in the general milieu. But to promote one over the other regarding investment, manpower and management is my opinion, naive. Staffing levels are more often than not suboptimal, benefits are slowly being removed, job security is far from what it was and the expectations of the service are rising. When discussion of the conditions of employment in the NHS erupts there is generally a consensus of fewer carrots, more stick. No surprise then that the prospect of reform is met with opposition or at least indifference. Competing interests: None declared |
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Paul L Thorpe, Spinal Surgeon Musgrove Park Hospital TA1 3PX
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This article unfortunately embodies the problem in the NHS at the moment - a polarised position with Government/DoH/NHSE and managers often on one side, and healthcare professionals on the other. To the author, anyone who criticises the current direction of the NHS is 'antireform'. Many points in the article show the problem that management consultants have in oversimplifying the processes of the NHS - for example, I visit my inpatients every day, including weekends when not on call. But how am I to discharge them into a system where social service provision and even transport home or pharmacies are not available at the weekend? To help me discharge patients appropriately, the whole system of community care has to adjust as well. The statement that doctors do not have the management expertise to know how to organise process well is, I am pleased to say, not true. Doctors have been the driving force behind the vast majority of positive developments in the healthcare environment. Do we think that Day Case and minimally invasive surgery leading to decreased length of hospital stay, discharge lounges and hotels, cross-infection procedures trying to minimise infections and complications were developed by Government or management? They were not - they were conceived, driven and popularised by clinicians. Hospital doctors have at least 2 degree level qualifications, and often 3. Many also have qualifications in management/business or organisational psychology. We, every day, have to manage an extensive multidisciplinary team, with complex and ever changing processes, deal face to face with our clients, the public, in some of the most stressful situations possible. We are required to maintain competency, keep up to date with organisational as well as clinical change and we usually achieve that effectively. This drive, necessary educational performance, as well as at least 10 or 20 years training, clinical skill and understanding of how the NHS works is precisely what many politicians and managers find personally threatening and difficult to manage - and end up criticising as 'conservatism' or 'anti-reformist' . Of course, doctors who voice these problems are immediately criticised as arrogant or elitist - elitism being the greatest crime in the homogenised mediocrity that often seems to be the aspiration of New Labour 'reform'. The polarisation therefore occurs because politicians, civil servants and managers often find it hard to manage highly educated professional people, who need to clearly see and be engaged with the benefits of a change - not a change to deliver a minister's soundbite, or change for change sake. This Government has a particular problem with this. They have undoubtedly spent more on the NHS than any other; they have started to address the chronic underfunding of healthcare that has been the legacy of many of their predecessors. However, they have been so desperate to show instant benefits to the voting public, that they impose meaningless and often damaging targets that end up making clinicians more and more cynical towards change. The 10th recent reorganisation of how we manage the NHS under this Government is another example of what we see as meaningless change. They also find it extremely difficult to deal with professional organisations that might suggest changes in their policy. Many of the current managers in the healthservice are health professionals who see a job in NHS management as a way to escape the grind of clinical work, or the only way to achieve suitable career progression. I therefore agree that these managers find it very hard to achieve the difficult task of managing the health service. What we don't need is more managers, it is fewer, better managers - possibly better remunerated, maybe recruited from outside the healthcare professions completely. But those managers need to understand that the JFDI school of management doesn't work; that they need to respect clinician's fundamental understanding of the NHS and be prepared to represent their local health communities in telling SHAs, the DoH and Government when they are getting it wrong, not just see themselves as the local delivery system for Government policy. Doctors themselves must be prepared to engage with reform or change that has been proven to be effective - not just stick to 'the way things have been done here'. This is a tough task, and will only work when clinicians and managers work together. The article, I'm afraid, is an indication of how far we have to go. The difference between the clinicians and politicians/civil servants/managers is that we are in the NHS for life - the others often seem to move on. Competing interests: None declared |
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Paul E Shannon, Consultant anaesthetist Doncaster & Bassetlaw Hospitals NHS Foundation Trust, DN2 5LT
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How refreshing to read Stephen Black's Personal View! He challenges the established paradigm amongst clinicians (especially doctors) that they always know best, even in areas where they have no expertise, like management. I, too, used to believe this until I did an executive MBA (Master of Business Administration) at Leeds University Business School. I realised that as a doctor I, unsurprisingly, knew very little about how to organise effectively. I had trained in medicine, not management. But I also saw that many so-called managers in the NHS had received very little training themselves! Clinicians were put into senior managerial positions with little or no training and expected to perform well. It's no surprise that they do badly. And, don't forget, that the BMA is a trade union with a stated aim of promoting doctors' interests (not patients'). I would like to see medical leaders in the NHS who understand leadership, management, and business. This may well mean that an MBA (or equivalent) is an entry-level qualification for any formal position, such as Clinical or Medical Director, or, dare I say it, Chair of a BMA committee! Competing interests: None declared |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice. NE47 6LA
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Editor The Primary Health Care Teams throughout Northumberland, painstakingly assembled and honed over decades, are currently under direct attack following a report, acquired at gigantic expense on the unaccountable whim of some functionary, prepared secretly and it's key message delivered to the frontline in the form of a one page fatwah. At a handful of weeks notice our Health Visitors are being whipped away and everyone is scrambling to hold the gaping breach that is developing. That's the sort of management that gets managers a bad name. If Black is serious, as opposed to merely inflammatory, then he should find space to condemn that which is wrong in his own world. Heavens knows, it's obvious enough to everyone else. The NHS should be viewed as a three legged stool - users, workforce/clinicians, managers/politicians - none more important than the others and each fully cognisant of the risks of under or over playing their roles. It's a collaboration or it's a failure - simple as that. Yours sincerely Steven Ford Competing interests: Currently, along with colleagues locally, under attack by lunatic management consultants hired by PCT - or whatever it's called this week. |
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Stephen R Kirkham, Consultant in Palliative Medicine Poole Hospital NHS Trust, BH15 2JB
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The NHS is indeed under-managed, and even many of those managers have no formal management qualification. So why do so many clinicians believe there are too many managers? Because, as the author points out, there is too much bureaucracy, which is performed by administrators who are called managers. If this distinction between management and administration were made explicit, and the centre demanded less bureaucracy, managers might be both recognised and rewarded for their skills. I have the excellent good fortune to work with a superb manager, and if all Trusts had sufficient good managers, there would be no need for management consultants! Competing interests: The author is Associate Medical Director at Poole Hospital NHS Trust |
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Peter G. Davies, GP Principal, Keighley Road Surgery, Illingworth, Halifax, HX2 9LL
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Stephen Black (1) has written an interesting piece here. I agree with his conclusion that the NHS needs better organisation, but question whether managers are effective agents for this. I also agree with his statement that more resources without organisational changes are often futile. Indeed the last few years of NHS history prove this. What I actually want to know is what exactly is Stephen Black's (or another management consultant's) qualification for even being involved in the debate? On what basis does he stand to give advice to NHS staff, hospitals or the Department of Health? General intelligence alone would not be sufficent warrant here. Has Mr Black managed many hospitals himself? Has he dealt with their day by day operations? What sort of track record does he have at doing this? Does he understand a hospital's operation well enough to know what to measure? To know what information matters to patients, to staff and to management? Unless Mr Black, and his fellow management consultants, can show their basis of knowledge and experience (and not their knowledge of buzz phrases, false targets and obfuscation by data blindness)I do not see on what basis they have the right to give advice to NHS staff, to NHS trusts or the Department of Health. (1) Black, S (2006) More and better management is the key to fixing the NHS. BMJ 333:358 (12/8/6) Competing interests: None declared |
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Chris Booth, SHO Anaesthesia Pennine Acute Hospitals Trust OL1 2JH
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Editor - Stephen Black's article on management in the NHS makes some useful points in support of management. It is undeniable true that better management of any institution will result in an increase in efficiency and productivity, and this is indeed highly applicable to the NHS at large. He makes the valid point that poorly organised units will not perform better if they are simply given more resources – they will in fact just have more to waste. Unfortunately he manages to underline why many clinicians feel that managers are not the answer; by exposing a lack of understanding and knowledge of the underlying systems that he hopes to improve through better management. The suggestion that A&E waiting targets be used as a measure of performance will surely antagonize anyone who has any clinical involvement in an emergency department. The majority of improvement in waiting times has simply meant that other areas of the hospital have had to absorb extra work at the detriment of patients. It is frustrating, for example, when an ICU (Intensive Care Unit) patient is ready for discharge to a ward but is delayed because the bed has been allocated to an A&E patient so that they do not breech the target. The target itself has of course been managed very well and those who have achieved it will feel they have performed well; unfortunately the hospital system has not. The underlying issue is illustrated within the title to the article. Better management is the key, not necessarily more. In fact Mr Blck alludes to this underlying principle when he himself suggests that more doctors and nurses are not the answer; by the same token neither are more managers. The message should be that it is the quality of the management that matters. To manage something efficiently one must understand the way in which it works. The traditional argument of the clinician is that we know the system so we by definition are better at managing it. This is not true, as knowing the system alone is no guarantee to managing it well; one must also be a good manager. Being a clinician does not mean you will by default be a good manager. The problem is we either have good managers who don’t know the system or bad ones who do. The answer is to have someone who is good at both, whatever their professional background is. Competing interests: None declared |
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Franz J Eigenmann, Consultant Gastroenterologist Kantonsspital 5400 Baden Switzerland
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Sir, Stephen Black (BMJ 2006;333:358) suggests that more and better management is the key to a better and possibly even cheaper health care system. Unfortunately at least to someone outside the British system his case is not convincing. Doctors as a whole have traditionally readily accepted new forms of organisation when they have been obviously more effective than old ones. Remember how many changes were necessary - long before management came into play - to progress from the asylum of the 19th century to a modern teaching hospital. If Stephen Black was right the United States - where management is high on the agenda (they even came up with "managed care") - should have solved their health care problem long ago. Certainly non-medical management is important especially in larger units and for the many necessities in a hospital service that are not directly linked to patient care. Managerial expertise can help doctors to provide a better service. When managers try to tell doctors how things should be done things start to go wrong as I know from personal experience. The cause of these failures is usually the attempt to transfer techniques that have worked well in other industries e.g. the car industry into medicine. In the car industry management, mass production, fierce competition and the employment of relatively unskilled and relatively low paid workers have resulted in an affordable high quality product. In medicine however the final "product" is produced on the spot for individual patients more or less handicraft style by individual, (hopefully) highly skilled, experienced and motivated nurses and doctors. I cannot see any number of costly layers of managerial hierarchy change this fact. For laboratory services automatisation has brought efficiency gains similar to other industries. Presently no one expects such efficiency gains in direct patient care, perhaps robots will one day offer some possiblities. I cannot comment on the efficiency or lack of it in British emergency departments but Mr Black must be fairly ignorant of the medical literature and of practical realities to suggest that staffing levels and results do not correlate at all. (See Lancet 2000, Jul 15, 356, 185-9). It is also interesting how he discusses hospital beds. He seems to see them as actual beds whose use can be shuffled at will while the term hospital bed in reality is a metaphor that includes quite a lot of actual or potential services that are provided to a hospital patient who happens to sit in that particular bed. If you have shortened the duration of hospitalisation to the bare minimum then it starts to make a difference for patients if you send them home early in the morning or in the evening. It also makes a difference to staff workload. To sum it up I am still waiting for the the ideal hospital that is relatively cheap to run and provides the very best services and where all the staff - medical and non-medical - are happy. If you find one call me quickly, I would very much like to copy their ideas. Competing interests: None declared |
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Pushpinder S Sidhu, Consultant Cardiothoracic Surgeon Royal Hospitals Trust, Belfast. BT12 6BA
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Editor, I read with great interest the article by Black(1) stating that the NHS needs more and better management. I have several points to make regarding his views. Firstly I am amazed that a conflict of interest statement is not provided. The level of conflict between PA Consulting and the NHS is at the highest level: as an example, the new Chairman of the Audit Commission, Michael O’Higgins is an ex-managing partner of PA Consulting and recently chaired an external panel of the Department of Health on commissioning a patient led NHS and has previously chaired the Group advising the Minister of Health on the operation of NHS Research Ethics committees(2). One can only assume that Black has knowledge of the NHS but does not work on any NHS associated projects undertaken by PA Consulting. Perhaps he should be. Black’s statement that “few doctors or nurses have the management expertise to know how to organize processes well” is frankly insulting. How does he think doctors manage clinical, administrative, teaching, recruitment and continuing medical education duties amongst others? Furthermore many doctors, such as myself, have management qualifications because we have learnt that it is easier for us to learn the language of management than for managers to learn medicine. I am concerned that Black cannot see why “intuitively” obvious factors such as major staffing changes do not influence performance in a hospital department such as Accident and Emergency; he obviously has not realized that A&E is an integrated part of the rest of the hospital. Unless services improve in the entire hospital or previous work has identified that the performance was particularly related to a reduced staffing level in A & E, then increasing staffing in A&E alone will not make a difference, especially if the performance indicator used is the amount of time spent in A&E for a patient who has been admitted. The Healthcare Commission report which Black quotes states in its conclusion: “There is evidence that patients perceive higher satisfaction with departments that are smaller than average and which have lower than average nurse vacancies”(3). Black does however raise the important issue of better management for the NHS. Tony Bovaird, Professor of Strategy and Public Services at Bristol Business School, University of the West of England, has highlighted that although “no change” is not an option for the public sector, neither is the current “all change” approach (4). Further enlightenment is obtained from the article by Beer and Nohria from Harvard Business School: They state that 70% of change initiatives fail because “in their rush to change their organizations, managers end up immersing themselves in an alphabet soup of initiatives. They lose focus and become mesmerized by all the advice available in print and on-line about why companies should change, what they should try to accomplish and how they should do it”(5). Most clinicians in the NHS can, I am sure, relate to this statement. They will also be able to relate to the words of Henry Mintzberg, Cleghorn Professor of Management Studies at McGill University, Montreal, Canada, who states “Leaders engage others by, above all, engaging themselves. They commit to their industry, their company, their job-seriously, quietly. Instead of preparing to spring to better ones, they stick around to live the consequences of their actions. That is how they earn the respect of those they lead, and so engage them”. He also states in the same article “It’s time to bring management and leadership back together and down to earth” (6). Perhaps this goes some way to explain why politicians and management consultants do not and will not have the solutions to the issues facing the NHS but clinicians will. Finally if Black is convinced that the views of Paul Miller, Chairman of the BMA’s Consultants committee “typify the arguments of those against reforming the NHS”(1) may I refer him to the Deloitte Touche scandal in Ireland, whereby the management consultancy earned 60 million euro (£40 million) for services relating to the Personal, Payroll and Related Systems (PPARS) and Financial Information Systems Project (FISP) computer systems projects, both of which program developments have been suspended by the Health Services Executive. The initial estimate for PPARS was about 9 million euro but had soared to 150 million euro by the time the project was suspended(7). Any clinician or indeed manager will recognize some similarity to the Connecting for Health or NPfIT situation that we currently are facing. REFERENCES 1. Black S. More and Better Management is the key to fixing the NHS. BMJ 2006;333:358. 2. technology.net. 2006. 3. Healthcare commission. 2005. 4. Bovaird T. Strategic Management in the Public Sector. In: Bovaird T, Loffler E, editors. Public Management and Governance. London: Routledge; 2003. p. 74. 5. Beer M, Nohria N. Cracking the Code of Change. Harvard Business Review 2000;78(3):133-141. 6. Mintzberg H. Enough Leadership. Harvard Business Review 2004;82(11):22. 7. Wall M. Date is set for PPARS hearing. Irish Times 2005 Nov 1, 2005;Sect. 7. Competing interests: PS is a Consultant Cardiothoracic Surgeon employed by the Department of Health and Social Services,Northern Ireland. |
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Adam R. Greenbaum, Consultant Plastic Surgeon Guys & St. Thomas' NHS Foundation Trust, St, Thomas' Hospital, Lambeth Palace Road, SE1 7EH
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In Stephen Black's personal view (BMJ; 333; 12th August 2006; page 358) he complained that that his “profession” (management) is unfairly blamed for a large part of the NHS's problems. He cites emergency departments and bed management as two good examples of the benefits of better organization in the NHS, which is palpable nonsense. He says that over the last few years waiting times have improved dramatically in English Emergency Departments; but he uses the wrong yardstick and he advances this as part of an argument for more management, yet offers no evidence that management is responsible for the “improvement” he claims. We all know there is no real improvement. We are told there is one because we are meeting waiting time “targets”. But these so-called improvements are based on how many patients are “treated” and leave emergency departments within target times. These are artificial measures, set by politicians and enforced by a cadre of managers whose jobs depend on it, and they have resulted in patients being shifted to “medical assessment areas” which are staffed inadequately by overwrought junior doctors and agency nurses, or treated on trolleys converted to beds by taking off their wheels, or a myriad of other dubious tricks allowing definitions to be fudged and targets reached which have nothing to do with looking after acutely ill people optimally. He further argues that discharging patients more efficiently in the morning rather than the evening would improve bed availability by 10% at the busiest times of the day. He wants to apply to the elderly, sick and infirm, the methods of goods supply and logistics management; which might, when applied relevantly by medically- or nursing-trained managers make improvements, but instead lead to nonsensical and dangerous situations on a daily basis when applied with ignorance and a weather eye to political targets. Mr. Black provides no evidence for more and better management being the key to fixing the NHS. Rather he demonstrates the equal, opposite, narrow view he ascribes to the medical profession. It is time we all stopped squabbling in a partisan way and analysed the problem: the foundation of modern medical practice is an evidence base, and evidence-based practice should be the standard to which we hold our management. The NHS is charged with providing the best available healthcare to the whole population, according to need, free at source. In a changing environment with financial constraints, our challenge is to match practice to purpose and to achieve this, our resources must be allocated after first identifying and prioritising the critical elements in the process and outcomes of service provision, to provide a measured response to perceived need. Therefore, everything turns on the definition of “need” and who defines it. Too many of the decisions concerning the allocation of medical resources are made for the wrong reasons, using the wrong criteria, by the wrong people who rarely have to face the consequences of their actions by personally receiving NHS care. We are short of funds, with increasing abilities and patient populations, so we all know we must squeeze more from what we have. But financial constraints do not mean we must use inappropriate financial yardsticks to measure health care provision. Outputs and inputs are beloved of politicians and usually irrelevant. We must focus on the process and the outcomes of NHS care, which truly reflect quality in care provision. Why has our profession abrogated responsibility over these vital decisions to people who should not be making them? We don't allow the care of individual patients to be judged solely in terms of inputs or outputs, yet we seem content to allow the strategy for caring for large numbers of patients to be decided on those criteria alone. For as long as politicians and management are not held responsible for the impact their actions have on patients' illnesses and deaths, we will feel that they are responsible for much of the problems the NHS experiences. We do not need more and better management. We need much less, but significantly better management, and we need more management to be undertaken by doctors trained in the necessary core skills to do the job well. Managing medical resources is part of delivering medical care. Politicians and administrators can ignore detail and seem to get away with it. Doctors and nurses cannot: they talk to patients every day, share their lives and deaths, win their trust and interact in the most intimate ways with people at their most vulnerable and therefore, they will not forget the purpose of the NHS and the services it provides. In difficult times, quality of care will only be maintained if medical resources are managed by doctors and nurses, rather than by managers tasked with minimising cost. The greatest threat to the NHS is from professionals who work within the NHS, who do know better, who claim to care about what happens to patients, yet complain from the sidelines rather than doing something to improve matters. Doctors and nurses who are not willing to set about becoming part of the solution to bad management, are inevitably and culpably part of the problem. Competing interests: None declared |
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Joan McClusky, Medical writer New York, NY
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Regarding Stephen Black's article on the need for more managment in medical care, I worked as a "communications specialist" for a management consulting firm many years ago. Black's article speaks to the worst of that industry. First, his assertion that "managers are not slave drivers"is based on the assumption that managers--not health care providers--should be steering the ship. Absolutely nothing drives people in any field crazier than having someone who can't do their job telling them what to do--and that they know more than the people in the front lines. Second, he talks about performance measurement. Performance in healthcare means helping sick people get well. All else is second level-- although he would raise it to the highest. Third, his solution is--wonder of wonders--more managers. The first goal of managers is to stay employed. They do this by constantly pointing out how important they are. The fact that he simultaneously says the problem is not a need for more doctors or nurses--belittling the opinions of those actually doing what he is measuring and directing--should in itself be enough to indicate his self-serving advice. Good management consultants--and there are many--see the people doing the job they are analyzing as the experts. They get "buy in" from those they are assessing. They make recommendations, with clear indications of how the changes will improve things for those doing the job. Competing interests: None declared |
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Joseph Mathew, Consultant in Histopathology TR13J
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Stephen has had an ideal opportunity to define the enormous contribution managers make to the running of the NHS, devolving down to NHS Tusts, a large percentage of whom are now reeling with enormous financial deficits, no doubt attributable to the Consultants Contract and Agenda for Change (cunning plans hatched by the medical and allied community). Instead he has written an article of three columns and close to 1000 words focussing instead on bed management and taking pot shots at "anti-reformers".
I agree with him that we need managers within the NHS, in every clinical group, who have insight into service delivery and the needs of the service rather than grunts who move every two "tears" from one post to the next leaving destruction in their wake. What we need are professional managers, managers from our ranks rather than the poorly informed and short-sighted gifts that we are currently blessed with. What we need are Medical Managers.
Competing interests: A physician and pathologist committed to patient care and excellence within the NHS |
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David Dawson, Consultant Anaesthetist Bradford Teaching Hospitals, BD9 6RJ
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Editor Stephen Black’s Personal View includes some good points, but I would disagree with his assertion that we need more and better management. We simply need better management. Not all doctors are Luddites. In 1991 I spent a month at Ashridge Management College. It was a centrally funded initiative to bring doctors into management. I returned to base, an enthusiastic, bright eyed 35 year old anaesthetist successfully applying to become Clinical Director for Operating Theatres. My contacts with the business world at Ashridge caused me to take a wider look at providing healthcare and in 1993 I approached my Chief Executive with a concept that would now be called an Independent Sector Treatment Centre. I even had the private finance company lined up. This was far too radical and dismissed. As for more IT, I fought for, and obtained, a sophisticated theatre scheduling package. This would allow us to plan theatres to run to capacity, manage consumables and equipment, and plan staff allocation. Huge efficiencies all round. Except that the funding for the upgrade to the Patient Administration System was withdrawn so the functionality is still unrealised. I fully co-operated with a number of management consultants. I was genuinely interested to see what they would come up with. On each occasion they told us what we already knew and charged us an exorbitant fee for it. After 11 years managing theatres I pursued research interests instead. As a result I have developed a diagnostic and therapeutic process that allows me to manage patients without them coming into the hospital at all. Currently patients have to wait up to 3 years for treatment in a tertiary centre. I can deliver the service within tariff and with no capital outlay, but the Primary Care Trust mergers mean that nobody is making decisions. I hope that you appreciate my sense of frustration. Mr. Black’s article is sadly divisive and reveals his lack of understanding of the real NHS outside London. If he wants to understand the antipathy of doctors towards managers he should look at: • “Managers” who have not trained as managers, but have been appointed to posts way above their level of competence. • Politically motivated targets that skew healthcare and result in managers developing gaming skills to hide the reality. • The scandalous waste of resources as a result of perpetual reorganisation. (Lets see the real costs for the very rapid loop from Area Health Authorities through Primary Care Groups to PCTs and now back to the AHA under another name). • Incompetent manpower planning that leaves 90% of physiotherapy graduates without jobs and uncertainty for medical graduates. We need good quality managers who have the experience and gravitas to push forward new concepts but also have the integrity to stand up to politicians when it is clear that their vision for one group of patients is compromising care for another group. Even more than that though, we need politicians to hand the NHS back to those who work in it and use it, just as they have handed interest rate control to the Bank of England. Competing interests: None declared |
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Cliona M Ni Bhrolchain, Consultant Community Paediatrician Wirral Hospital NHS Trust, Child Development Centre, Clatterbridge Hospital, Wirral CH63 4JY
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Stephen Black’s Personal View (1) illustrates the problem with some management consultants in the NHS. In his piece, he mentions patients in only 2 paragraphs, and then only in the context of how they use beds. His tone is aggressive throughout. In his very first sentences he makes a personal attack on a senior colleague and persists in tarring everyone with the same brush. He does not appear to grasp the idea that the NHS is a service industry focusing on people – people who are at their most vulnerable, often old, unwell and anxious. True, we perhaps could get patients out of bed at 6am to make room for today’s admission. But when he has his prostate operation at 85, can he imagine how he might feel sitting in some ‘departure lounge’ clutching his belongings from then until his son/daughter come to pick him up at 6pm, when they have finished work? This is the real world patients and their doctors live in. Management consultants come and go…… and good business leaders rarely antagonise their workforce. 1. Black S. More and Better Management is the key to fixing the NHS. BMJ 2006; 333: 358. Competing interests: None declared |
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Andrew C Sherley-Dale, SHO Care of the Elderly Bristol Royal Infirmary, BS2 8HW
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EDITOR More managers, better managers those words caught my eye in Mr Black’s personal view article this week. But what is better in this context? A cursory view of the internet leads one to the conclusion that there is in some quarters considerable antipathy between the “frontline angels” (nurses, ward staff, doctors etc) and the so-called villains (managers behind the scenes). Undoubtedly both fields must be reeling under the constant changes imposed from central office and so much uncertainty that prevails. Although change is often good it can be unsettling and I wonder if some of the hostility that is found at times between medical staff and management reflects the insecurity that all the current changes are bringing to bear on both sides. How much better it would be if we were able to feel that we were working as a team in the same organisation, for the same customers as in fact we do. I do not think that increasing the number of either parties will result in improvements per se. In my experience communication is the foundation stone of meaningful change, that and courageous leadership. Managers today are charged with meeting targets, achieving stars and the suchlike. This may actually detract from clinical care. I know of senior colleagues who have resigned from the NHS due to frustration with perceived inappropriate changes to clinical care made in order to “get the figures right” for targets. The events at Stoke Mandeville would appear to reflect adverse decisions in the face of a Clostridium difficile outbreak although the Healthcare Commission was at pains to point out that “targets are not to blame for the Trust’s leaders taking their eye of the ball”. I’d accept that there have been some notable improvements in hospital organisation, and agree that bed management has been transformed. I’m not sure how Mr Black proposes to discharge patients early in the day but it’s an idea worth pursuing. Perhaps ward rounds starting at five in the morning? The principle makes sense and if patients understood the reason it could work. We are back to communication. The notion that no relationship exists between changes in staffing and performance can only be true in my opinion so long as the ever- challenged devotion of NHS staff to their work continues. I see staff on a daily basis making sacrifices to ensure that the work is done. This goodwill may not last forever. It is, I believe, one of the most precious qualities of our NHS and can be ignored only by those who would see the system crumble. Leadership values its people, listens to them, and of course sometimes makes unpopular decisions. Dare I say it again; communication is vital, not necessarily more managers, more money, or more frontline staff. Perhaps this is the essence of “better management” that I mentioned earlier. Good management is of vital importance and should be valued. I work in a trust where the Chief Executive’s door is open. One of my enduring first impressions of Bristol was finding myself as junior doctor-to-be welcomed into the office of this most senior manager because I had simply asked for an appointment. This is all the more impressive in a trust whose leadership has made huge financial improvements. I have to add that this has not been my experience elsewhere when I’ve seen a care system wither and die due to frankly absent constructive involvement of management in discussions despite willingness of highly motivated clinical staff. The latter have since resigned in frustration after a long fight. Isolated examples should not distract from the principle of building on what we have, but my experiences in the latter fight lead me to challenge Mr Black’s statement that antipathy to management prevents implementation of change. Too often I hear frontline staff being subjected to change without consultation and without adequate warning. This surely flies in the face of change management principles that are core to anyone involved in the implementation of improvements. Robust and consistent lines of contact between healthcare and management staff results in pooling valuable knowledge and building trust. If frontline staff feel that their managers listen, know their situation, and understand their issues the relationship will improve. I’m sure that this will lead to shout of “we’re doing that already”. Well there are times when it doesn’t feel that way. I’d like to see management on the wards, and in general practices inviting these and other important views, and not just when the inspectors or audits are due. This need not be a utopian ideal. Perhaps organise people better rather than employ more of them or get them to work harder. The rhetoric of work smarter not harder is well- known. This makes irrefutable sense. I think the most constructive way ahead is to encourage the breakdown of the antipathy that Mr Black mentions. Sharing knowledge and the principles behind the need for reform in an open organisation, and inviting meaningful participation of the staff in those changes can only help morale. Let management start with that and the dedication of the NHS frontline staff that exists for its customers and their wellbeing may yet spread to you. Andrew Sherley-Dale SHO Bristol Royal Infirmary United Bristol Healthcare Trust dr.goo@btinternet.com Competing interests: None declared |
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Jeremy E Oates, Clinical Research Fellow Christie Hospital, Manchester, M20 4BX
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Editor, After reading the many responses to Mr Blacks' article, one obvious question springs to mind. He suggests that changes in working practice and the way hospitals run would dramatically improve efficiency. The title of the article and the majority of the text suggests that the way to implement this change is to employ more managers. Which leads to the question - if the presence of managers will suddenly produce a paradigm in the way we work, why has it not happened already? After all, most hospitals have one or two management types knocking around somewhere! Maybe Mr Black should forward his article to them (though the incurred fees from PA Consulting would no doubt bankrupt the NHS!). Competing interests: None declared |
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Ruben D Trochez-Martinez, Specialist Registrar O&G Derriford Hospital, Plymouth, PL6 8DH
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Black expresses the view that to fix the NHS its management should be more and of better quality.1 He argues that increasing staffing levels and resources is a poor way to fix performance problems, then he suggests that the key to fix the NHS is, believe it or not, to increase management staffing levels and resources! Managers wasted the golden opportunity to capitalise on the biggest investment the NHS has ever had in the last eight years and, as they frequently do, try to put the blame on someone else.We all, clinicians and managers, have part of responsibility on the current state of affairs, either by action or omission, and we all can do something to improve it. But don’t forget that the healthcare process is essentially about health- carers and patients, management is only a small part of it and rightly so. Bureaucracy doesn’t add value, only hassle and spending. I don’t think the NHS has been “under-managed”, it has been very badly managed and certainly much better, not more, management would make a difference. I am not one of the “anti-reformers” Black refers to, I am just one of those many who think that reform per se doesn’t necessarily mean improvement, therefore it has to be carefully thought and shouldn’t be let to managers only. My suggestion is: involve more clinicians in the management process and let them implement the changes; clinicians will learn a lot quicker about management than managers will about running of clinical practice. 1 Black S. More and better management is the key to fixing the NHS. BMJ 2006;333:358. (12 August) Ruben D. Trochez-Martinez Specialist Registrar O&G Plymouth, UK e-mail: rubencho@btinternet.com Competing interests: None declared |
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Hany Wisa, Formerly Clinical Fellow in Obstetrics and Gynaecology East Surrey Hospital RH1 5RH
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Editor-The article written by Stephen Black with the title More and better management is the key to fixing the NHS says that according to the health care commission there is no relation at all between staffing levels and performance and continues to say that no relation exist between change in staffing and performance. I find very hard to accept that more experienced medical staff that will deal faster and better with patients thus reducing the time a patient will spend in hospital will make no difference compared to less experienced or fewer staff. I agree that better management is needed but is it the management dictated by management consultants who never see patients and don't understand patients' needs or should it come from experienced medical practitioners who understand why some patients may occupy beds longer than others. Why can't we invest in training selected doctors to be managers as well instead of paying high figures to non-medical consultants with the NHS problem doesn't seem improving at all? I am not suggesting to get rid of medical consultants but I suggest more involvement of medical staff in organizational decisions making. We are unfortunately forgetting that the reason hospitals were build is to treat patients, not to have multimillion pounds worth IT system and no beds. Basic needs should always have priority. Competing interests: None declared |
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S. Michael Crawford, Consultant Medical Oncologist Airedale General Hospital , Keighley, West Yorkshire. BD20 6TD
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Colleagues will readily appreciate that we are born with two kidneys and two lungs but we can survive with only one. We have a liver that is too large for our everyday needs but if part is resected this organ regenerates to its original size. This extra capacity enables us to survive in adversity. Clearly this design was attained without input from management consultants nor does it rely on resources rationed by HM Treasury. Competing interests: I am an NHS consultant in a staff-strapped department. |
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Geoffrey M K Schrecker, General Practitioner Gleadless Medical Centre, Sheffield, S14 1PQ
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Stephen Black cites the Health Care commission report to illustrate his point the improvement in performance in A&E departments does not correlate with clinical staffing levels. He does not however show any evidence that there is a correlation with increased management staffing either. From my recent exposure to Primary Care Trust level management through practice based commissioning it is quite clear we need better, not more, management. Competing interests: I am a GP on the steering group of Sheffield Central Cluster PBC consortium |
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William J. Lang, Consultant Psychiatrist in Psychotherapy Psychotherapy Department, Heatherwood Hospital, Ascot SL5 8AA
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What was so wonderful about Stephen Black's article was the way in which it confirmed all one's predjudices about management consultants as not really understanding the organisations and processes they pronounce upon at great expense. The two pieces of "evidence" he described are both presented in a superficial way, the author failing to question their validity or grasp their true significance. Anyone who is involved in the actual clinical work of the NHS knows that figures relating to A&E waiting times have nothing to do with the functioning of the departments but are instead to do with how shamelessly the hospital managers will delay routine and other variably urgent operations and medical treatment in order to present a wholly false and distorted result. With regard to bed occupancies, again the author fails to understand that the issue is not bed-steads and mattresses but is to do with staff and proceedures necessary for patients in the beds. Staffing levels are often lower at weekends, community support services also in short supply so discharge of a stable and low demand patient on a saturday makes no sense. Similarly discharging early in the day and admitting late has knock on effects for pharmacy, transport, investigations etc., all of which would no doubt be described as "unforseen effects" of the proposed management "reform". Finally it is interesting that the author presents no actual evidence that increasing the numbers of managers will have any positive effect! Perhaps it is he , rather than the BMA, who is making a "naive assumption". As ever, "joined up thinking" (and un-joined up thinking is what is known as psychosis) is sadly lacking. Competing interests: None declared |
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David L Wallace, Plastic Surgery SpR University Hospitals Coventry + Warwickshire
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Management is defined in a variety of ways, essentially it is getting things done through the process of community. The NHS community consists of patients, managers, doctors and nurses. Stephen Black is to be commended for approaching clinicians in a clinicians’ journal, unfortunately his words are unlikely to further the process of community. There is little doubt the NHS needs better managers. However the clinical staff do remain critical to outcomes. Stephen Black is selective in looking at staffing levels and performance in emergency departments. Doctor and nursing staffing levels are inversely proportional to hospital mortality1,2, senior staff do result in improved outcomes3, and there is a safe level of staffing4. All staff need to show their value. Doctors and nurses have exacting minimal standards to attain the privilege of their profession. Clinicians are responsible for their patients by law and to their own professional regulatory bodies. In the UK the National Institute of Clinical Evidence guides clinicians from a broad evidence base. On average consultants are in post for 23 years compared to 3 years for a manager. Therefore clinicians find difficulty being organised by managers who do not have an exacting minimum standard, do not have a sound broad evidence base, are not responsible to a professional body, and who do not stay in post long enough to view the consequences of short term planning. In the management of bed occupancy Stephen Black is correct to state much can be done. Clinicians can draw on ideas from other professions5, but great care needs to be taking analogies too far. Hospitals are not hotels, but bed management would improve if the rate limiting steps were visualised by clinicians and managers together. We see nurses struggling to organise the timely organisation of patients for theatre, provide the ongoing care of their patients to a high standard, and facilitate the discharge of patients. Therefore we will have inefficiencies in the timely process of moving patients. Simply put, more trained nurses would help. European health care providers recognise that bed management becomes inefficient when occupancy is consistently over 70%. The UK consistently runs in the 95% region, which is actually less efficient for the process and journey of the patient. IT has much to offer clinical care, and Stephen Black is correct to say appropriate IT. Clinicians are at the forefront of developing clinically relevant systems6,7, and PACS is a great benefit for radiology. Though the early radiology viewing systems were inadequate8, and hospital wide IT systems have lead to the loss of specialist departmental IT due to a lack of ability to link up9. In view of the numerous debacles over IT systems in the NHS, and the sequential postponement of the NPfIT clinicians are correct to question whether the clinical rather administrative benefits do materialise10,11. Clinicians and managers are going to get things done when we act together in a community, not when we sling mud at each other. Stephen Black’s is correct to state that we need to organise better, i.e. work smarter. However if we want to be truly business orientated individuals we should keep in mind “if you do not touch the product, what are you doing here?” Reference List 1 Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. JAMA. 2002 Oct 23-30;288(16):1987-93. 2 Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Lancet. 2000 Jul 15;356(9225):185-9. 3 The association between seniority of Accident and Emergency doctor and outcome following trauma. Wyatt JP, Henry J, Beard D. Injury. 1999 Apr;30(3):165-8. 4 Nurse-staffing levels and the quality of care in hospitals. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. N Engl J Med. 2002 May 30;346(22):1715-22. 5 Error, stress, and teamwork in medicine and aviation: cross sectional surveys. Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000 Mar 18;320(7237):745-9. 6 Integration of image transmission into a protocol for head injury management: a preliminary report. Servadei F, Antonelli V, Mastrilli A, et al. Br J Neurosurg. 2002 Feb;16(1):36-42. 7 Telemedicine for acute plastic surgical trauma and burns. Wallace DL, Jones SM, Milroy C, Pickford MA. JPRAS (in press) 8 Interpretation of emergency department radiographs by radiologists and emergency medicine physicians: teleradiology workstation versus radiograph readings. Scott WW Jr, Bluemke DA, Mysko WK et al. Radiology. 1995 Apr;195(1):223-9. 9 "Computers can land people on Mars, why can't they get them to work in a hospital?" Implementation of an Electronic Patient Record System in a UK Hospital. Jones MR. Methods Inf Med. 2003;42(4):410-5. 10 Challenges to implementing NPfIT: nothing counts except what is in front of the clinician to use. Ford S. BMJ. 2005 Sep 3;331(7515):516. 11 Challenges to implementing NPfIT: computerised medical history is key to connecting health. Llewelyn H. BMJ. 2005 Sep 3;331(7515):516-7. Competing interests: None declared |
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Michael Paul, Independent GP London SW10 0BB
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For the past fifteen years I have opened and then managed four private medical centres in central London employing 20 doctors and 60 other staff. All this was managed by a central team of six people. Our approach to medical management was to set the parameters of our practice (detailed in 'the manual'), provide the means (build the premises and sell services to clients), ensure a high quality service (cpd for all staff with regular and thorough external appraisal for medical staff, including video consultation analysis) and then let them get on with it. And this approach has proved very successful. Whilst in industry management's role might be to decide to make widgets, say how many and then employ people to do their bidding, in my view medical management's role is quite the opposite. It is supportive not directive. It is not medical management's role to tell professionals how to treat patients, even the professionals themselves do not agree on that. Rather it is to ask them 'what do you need to get the job done as well as possible?' and then go out and find the resources for them to do it. So to echo other contributors, less is more, and we have shown it is possible. Competing interests: Founded and managed a group of private general practices |
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Luke J Ball, GP locum Exeter
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The better the management, the greater the throughput. The greater the throughput the more the survivors. The more the survivors the greater the demand. The greater the demand the greater the need for good management. The better the management....... But wait a minute, without increased resources, doesn’t this contravene the second law of thermodynamics? Competing interests: None declared |
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David O'Hagan, GP Wirral
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Mr Black demonstrates his ability to manage information well. In defence of his argument for more managers, he quotes the audit commission report Bed Management. This interesting report is short and to the point. It starts with 4 assumed patient requirements, and it demonstrates that the best way of fulfilling them would be to have more beds. The last section on bed occupancy takes as its start the assumption that bed occupancy is too high. It incidently compares paediatrics to adult medicine, wondering why adults have to wait in Emergency Departments when their occupancy rate is 95-97%; whilst the childrens bed occupancy rate of 65.8% leads to an absence of waiting. Perhaps I am misreading the report, but I think that it suggests more beds are needed, not more managers. Competing interests: None declared |
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Sunil Nair, SPR medicine QE-II Hospital, AL7 4HQ
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I don't think anyone would argue that increasing staffing level alone improves efficiency. What I think is unacceptable is the premise that better management and appropriate staffing levels should be mutually exclusive.One at the cost of the other would be a dangerous move. Closing wards and sending medical and nursing staff on their way before clearly demonstrating that more managers can generate empty beds and improve performance in the NHS appears illadvised. Competing interests: None declared |
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Anjan Chakraborty, GP n/a
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Stephen Black's characterisation of doctors as "anti-reformers", and his reduction of their arguments against reform to a glib reaction against ISTC's, IT and managers is reminiscent of a straw man argument - he is creating a position that is easy to refute, then attributing that position to doctors. Reform may be good or bad. The way it is proceeding in the NHS is bad. I am not an antireformer, rather anti-"this particular reform". The alleged model for NHS reform is the free market with choice, the benefits of which were most clearly enunciated by Adam Smith. Crucial to acquiring the benefits (lower prices, improved quality) is the existence of competition between independent providers with the customer exercising free choice. This simply is not happening (despite all the rhetoric about choice) with the NHS reforms. Two examples - a healthcare company wins an APMS contract to provide GP services with a PCT, getting paid over double what a GP would get paid for the same work - an ISTC gets paid more money for less work, cherrypicking the cheapest caseload and washing its hands of responsibility for complications (which occur at a higher rate compared to NHS hospital trusts). In both these cases, it is the PCT, not the customer, who is exercising choice in the sense Adam Smith would understand. The result has been a poorer quality of service, increased costs and supernormal profits for the companies concerned. I am a GP. Any reform which allows me to set up in direct competition against a PCT-favoured APMS company, on the same business terms, competing for the same patients, would be welcomed. As things stand, I cannot do this. These reforms go in the opposite direction, with only PCT-favoured companies getting a look-in in an opaque commissioning process. The patient does not get a look-in. This is not a functioning market. PA consulting and other management consultancies have advised HMG to create this monster. These companies will deserve the scorn and opprobrium heaped on them by the taxpayer and patient that end up poorer in pocket with poorer healthcare. Though HMG is most culpable. Competing interests: None declared |
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John A Anderson, SHO, Obstetrics and Gynaecology Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne. NE1 4LP
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Editor - Stephen Black raises valid concerns regarding managment within the NHS. The UK National Health Service is the largest employer in Europe and is statistically undermanaged when compared with multinational corporations of similar size. Further compounding this problem are those management staff who have moved from clinical roles, lacking basic management training. However, Mr Black's comments regarding the "anti-reform brigade" and "tabloid rhetoric" are unhelpful and perhaps highlight an alternative "blinkered attitiude" held by management professionals when dealing with the NHS. Many of the examples cited as reducing hospital "productivity" relate to understaffing; clinical decisions to enable discharges may require senior input - sometimes a scarce commodity out of hours, thus reducing patient turnover and bed availability. Investment in IT infrastructure and adaquate management expertise are important to run a large and complex organisation, however ongoing investment in medical and nursing staff must continue to form a pillar of reform. Throwing money at the NHS will not sove it's problems, but the relentless march of efficiency will undermine the ultimate aims of good healthcare provision. Competing interests: None declared |
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Jim Easton, Chief Executive York Hospitals NHS Trust
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As an NHS manager I enter this debate with some trepidation, but nevertheless.... For all the volume and noise in these responses, I actually detect a strong consensus running through most of them, which I would characterise as follows: 1. Of course the NHS needs to be well managed. It has huge responsibilities to its patients, its staff and the tax payer. It is deserving of the best management. 2. Of course what is important is the quality of management, not the volume of managers. Although in the equivalent debates with my exceptional medical colleagues on sustaining clinical service quality the volume of clinicians often - rightly - is raised. There probably is a relationship between volume and quality of management - but it is not linear or simple. 3. Of course the tasks of health care management are best done by people with a deep knowledge of health care. 4. Of course this can and often does involve professional clinicians taking full or part time management roles, and all clinicians being involved in management at some level. Some clinicians make fantastic managers. 5. Of course there is also a role for the "professional manager", not least because it might, in some circumstances, be a waste for highly trained clinicians to spend all of their time in management activities, and not all wish for such involvement. 6. Of course, in successful organisations, the mix of professional and clinical managers work well together, with an appropriate mix of respect and challenge on all sides. 7. Of course, good information should be used to inform decisions. This can include information which challenges fixed views. Such an attitude to information is necessary for the science of medicine to progress and also for the management of medical services to progress. 8. Of course, we all hate management consultants. But beneath this protective layer of hatred, I am sometimes forced to admit that the perspectives they bring from outside the service we are so close to, can appropriately challenge our thinking, techniques and processes in a way which we don't like, but sometimes need. Like all else in our service, they should be used where they represent value for money in delivering or improving care. Competing interests: I am a manager in an NHS Trust. |
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stephen black, management consultant london sw1w 9sr
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Wow! That was some response. I need to make an apology to those who were mislead by the headline about the article in the original BMJ. I never argued for more managers, just more and better management. I also hope that my comments are not seen as an attack on the medical profession: I don’t believe all doctors are against reform (and many of the proposals I have advocated were developed by or with doctors or nurses). Neither do I think that existing managers are all good. But the debate about reform is dominated by anti-reform rhetoric that does not often refer to relevant evidence: I wanted to challenge this imbalance. The goal of managers (and management consultants in health) is not to treat patients but to organise the people who perform the treatment to deliver higher quality, faster care and to do it as efficiently as possible. Reform-skeptics tend to assume that speed and efficiency either don’t matter or can only be achieved by compromising clinical quality. The hidden axiom here is that organising the processes in a hospital in a different way cannot possibly improve anything. The evidence does not agree. My experience of health started with the A&E target. The target was not, as has been alleged, developed as some arbitrary management bollocks by people who didn’t know the system: It was developed in collaboration with clinicians because the public were becoming increasingly unhappy at how long they had to wait for even minor treatment. Moreover, it is not that easy to clinically justify 12-hour waits on trolleys or 6 hour waits for the treatment of a minor injury. But both were common in English A&Es. There is no good clinical reason for any waits of over 4hrs. I learned how A&E departments work in reality by visiting a lot of them and watching how they worked. I developed a tool, in collaboration with the Department of Health, for analysing the weekly flow of patients in a department and identifying patterns of activity and patterns of problems. The purpose was to increase the understanding policymakers had of what worked and what did not, but at the same time help A&E departments to identify their own specific problems and thereby fix them. The tool is still in use in many departments as—perhaps unusually—it proved to be a tool developed by the DH that was useful in the hospitals. More than half of all departments have probably used it and we have a series of samples over time from many of them. We also visited many departments and spent time observing their work. We know, for example, that “See & treat” (streaming “minors” though a dedicated and streamlined process) is very effective at delivering speedier and higher quality care (though I will admit that speed is easier to measure). We helped many departments solve more specific problems (eg staff overwork is as often caused by poor rostering as it is by an overall shortage of people). Getting access to beds for patients requiring admission is a common problem. But it sometimes caused because A&E can’t find the medical doctors who make admitting decisions to general beds, not just because beds are short. The tool is also good at differentiating “gaming” from real improvement (gaming is very obvious in the distribution of waiting times) which is why I am confident that the national numbers represent a real and significant improvement for patients. By the way, departments who have improved a lot often reported big improvement for staff not just patients. Less stress, less aggression and anger from patients, lower staff turnover were all benefits. Some departments have not achieved benefits, but that doesn’t prove they can’t be achieved. The goal of management here is to make sure the right things get measured and analysed so that the medical staff can constantly improve the care given to their patients. And it is this attitude, not major changes in staffing levels, that cause the improvements in A&E. What about bed management? This turned out to be a big problem for A&E (but outside their control). But the real problem is that free beds are not available within an hour or two of when they are needed. The national occupancy numbers measure occupancy at midnight Thursday and sometimes tell us little about what is happening during the other 167 hours (see our work and the references: NC Proudlove, S Black, A Fletcher, Journal of the Operational Research Society (2006), advance online publication 19 July 2006; also see http://emj.bmjjournals.com/cgi/eletters/21/5/575#446 ) I was criticised for advocating early discharge and late admission as if patients were mere commodities on a production line. But the majority of flow through the beds consists of relatively short stay patients who are easy to discharge. I don’t advocate turfing out 85 year olds with no transport the day after major surgery. There don’t appear to be many clinical barriers to my proposals for the majority of patients. The fact that consultants have "full diaries" and so can only do their discharge rounds last thing in the day (as one correspondent argued) is an organisational problem not a clinical one and reflects the view that managing beds is unimportant. Many hospitals (especially private ones) achieve morning discharge and afternoon admits with no detriment to patients. I was criticised for ignoring the clinical needs of patients in my approach to bed management. But a hospital that gets a grip on the controllable factors that influence its bed occupancy hour by hour will achieve major benefits to patients. There will be no operations cancelled at the last minute, emergencies will be admitted to beds quickly and rapid responses to isolate episones of infection will be possible. All of this is directly beneficial to the patients and to staff who won’t have to wander round trying to find spare beds. It is still astonishing to me that many hospitals don’t even collect the basic information about what is happening to their beds and so have no hope of improving their situation. In short there is plenty of hard evidence that organisational improvements can bring major benefits to staff and patients while at the same time improving efficiency. And I learned this by looking at real hospitals and talking to real clinicians, not by flying in from outside with fancy consultingbollox. Competing interests: mangement consultant |
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Imogen C Felton, F2 TN1
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Dear Sir, Re: A Fix for the NHS As a junior doctor working in the NHS, I have to take issue with the lack of balance displayed in Sir Gerry Robinson’s BBC2 investigation into the failings of the NHS (8th Jan). The lack of intelligent cogitation of the issues at stake was notable. Namely: Why NHS management initiatives, offering ‘simple and effective’ solutions to NHS Trust problems, so often fail to meet with Consultant approval. It appears that Sir Gerry and his team take the view that a perceived culture of consultant-lead objection to such measures is based not in clinical grounds for concern, but on an antiquated idea that medical professionals must exert their autonomy by directly opposing management-lead directives. By implication, it is the patients who suffer at the hands of such behaviour. This gross neglect by way of broadcasting the many complex and sensitive issues at the heart of NHS mismanagement, in such a coarse and unbalanced manner was tantamount to malpractice by the editorial team. They should be held to account for their lack of journalistic rigour. The reality of the situation is this: A ‘simple’ and laudable NHS management directive as cited in the programme, of reducing the waiting-list time for Child Health out-patient appointments in Rotherham, by increasing the number of patients seen per clinic by two patients per consultant, will naturally have clinical ramifications. This basic concept fell unreported. The fact is that such ramifications may well be to the detriment of patient care and long-term specialist management, but nonetheless result in the meeting of a ‘government target’ such as in this case, and a debt-relief of sorts for the trust. So clinically illogical are some of these management-measures however, I must cite two examples which have met with queries: In order to improve the current waiting-list time for medical out-patient appointments, consultants were told that this would be achieved by increasing the number of ‘newly referred patients’ seen in each clinic. “How will this be possible, in such a resource-starved scenario?” they asked. Simple - by restricting the regular follow-up of patients already seen by the specialist. Lost then, would be the ability of the endocrinologist to regularly review and tailor a well-known patient’s hyperthyroidism management after a course of radioactive iodine therapy for example; this unlucky patient is no-longer deemed currency enough in our target-driven market to warrant logical, medical care. It is absurd and amounts to robbing Peter to pay Paul; faintly ridiculous, except that it might be your Uncle Peter’s regular oncology follow-up that gets the chop. Yet more querisome was the initiative that simply stated: On receipt of a ‘normal’ result, the patient must be discharged from the specialist’s clinic. The issue here is that a decision to discharge a patient from care involves the weighing-up of years of experience and clinical training, which put bluntly, can be encapsulated by understanding that a ‘normal’ result may helpfully exclude certain differential diagnoses, but by no means is synonymous with good health nor indeed the end to clinical investigation of the patient’s on-going symptoms. Medicine is full of aphorisms, but one in particular springs to mind here: Treat the patient, not the test result. Such a management initiative, as in this case, has been met with amazement as one foresees only malpractice suits piling up, and not the craved solution to the ‘problem’ waiting-list. The consultation process between clinicians and management that Sir Gerry found so delaying in terms of ‘progress’, is clearly of critical importance here. In a drive to improve efficiency and ultimately patient care, NHS management teams are charged with a crucial and complex task. Undoubtedly hurdles, such as legitimate debate regarding clinical or financial issues will be met by the different disciplines involved and will shape progress in a safe manner. Sir Gerry Robinson’s ‘investigation’ has only served to compound old divisions through a derisory lack of understanding of what the reality is for many clinicians and thus poorly illustrates how one might effectively ‘fix the NHS’. Yours sincerely, Dr I Felton MBBS BSc. Competing interests: None declared |
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A F Goodman, M.O.P SW6 2QX
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Some valid points raised by Dr.Felton. Perhaps Sir Gerry Robinson should have a read of this letter? Competing interests: None declared |
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Thomas de Albuquerque, Law McGrigors LLP, EC4M 7BA
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Hear hear! A cogent response to a programme whose makers certainly seemed to prioritise attention-grabbing conclusions at the expense of old- fashioned, rational and analytical research. Competing interests: None declared |
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