Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
A truly innovative plan
- Ashok Beckaya (5 August 2007)
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Is there a UK NHS?
- Alan P Gibb (8 August 2007)
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The Rise of the Doctor-Manager
- Sean W O'Kelly (8 August 2007)
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Barriers to participation in management
- Peter G Davies (8 August 2007)
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Doctors as Managers
- Piotr Szawarski (9 August 2007)
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Management for Undergraduates
- Julia D Jones (9 August 2007)
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A blinkered view?
- Antony F Sara (11 August 2007)
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Supporting doctors to become managers; BAMMBino
- Claire E Woolcock, BAMMBino Board Members (13 August 2007)
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Let us face the facts
- Anton E Joseph (13 August 2007)
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The RISE and FALL of the doctor-manager
- Stephen R Humble (15 August 2007)
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Rise of the Doctor Manager
- Charles P Swainson (22 August 2007)
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Ashok Beckaya, Associate Specialist in Paediatrics and Child Health Epsom & St. Helier university Hospitals
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It was a pleasure to read the article, "The rise of the doctor- manager. We know that only a minority of individuals have a natural flair and aptitude for 'management' and doctors' are no exception. It is also true that most clinicians due to the nature of their training and aptitude are comfortable mainly with clinical work for which they have been trained for so long. However, recent experiences in the NHS have finally lead to realisation that it is important for the medical profession as well as for the health service to have more clinicians' in senior management and chief executive positions. This will be good for the profession and health service as a whole and a move in the right direction. The plan to introduce management and leadership curriculum in undegraduate teaching is indeed a splendid idea and I congratulate Dr Patricia Hamilton and the Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement for working together to develop this novel idea into a reality. I couldn't agree more with Partricia Hamilton's comments that, "Everyone will do it, and everyone will benefit. All doctors will need to exhibit leadership skills sometimes." I am convinced that this is the best way of getting doctors interested in top management jobs, in the future. This is indeed an innovative idea of immense proportions. Competing interests: None declared |
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Alan P Gibb, Consultant Edinburgh EH16 4SA
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Is David Nicholson the UK National Health Service's chief executive? Surely he is the English NHS's chief exec, and not responsible for the separate services in Scotland, Wales, and Northern Ireland? The Nationality of the NHS is a source of great popular confusion, but surely something that the British medical journal should be able to get right. Competing interests: Employee of the NHS in Scotland |
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Sean W O'Kelly, Interim Medical Director Northern Devon Healthcare Trust EX31 4JB
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I share David Nicholson’s belief that NHS organisations will have an improved chance of dealing successfully with the complex challenges they face if led by people who have significant personal experience of providing clinical care to patients. However, management skills are not necessarily intuitive. Currently, too many clinicians with management roles rely on innate instinct and gut- feeling, honed by variable on-the-job experience, when dealing with issues and situations that require more than this. Those clinicians who really wish to provide high quality leadership to NHS organisations need to become more familiar with the existing body of management evidence and theory at both operational and strategic levels. Having been directly involved with healthcare management for the last dozen years, both in the UK and USA, my experience has been that, until becoming formally acquainted with current management thinking by undertaking a MSc in Strategic Management, my approach was based largely on a set of well intentioned but vaguely random principles. Learning systematically from current academic thought in areas such as negotiation, innovation, leadership, marketing, strategic development and financial management has provided a rigorous and robust platform upon which to think and operate. There are no short-cuts to successful leadership within NHS organisations, as the Gerry Robinson experience so publicly demonstrated. Clearly, not all potential clinician managers need to study management theory to degree level, but by carefully selecting developmental opportunities that make use of the large body of management thinking and evidence currently available, and by targeting these at those clinicians who have the desire to contribute in this way, skilful, clinically- experienced and patient-focussed leadership could realistically be given the driving seat at the top table of NHS organisations very soon. Dr Sean W O’Kelly
Competing interests: None declared |
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Peter G Davies, GP Principal Keighley Road Surgery, Illingworth, Halifax. HX2 9LL
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Harold Macmillan once reported one of his tutors in the classical languages and humanities as saying: “Nothing you will learn in the course of your studies will be of the slightest possible use to you in after life save only this; that if you work hard and diligently you should be able to detect when a man is talking rot.” (1) I detected rot whilst reading this article. (2) The idea of doctors and managers working together is of course sensible. Permanent conflict is hard to maintain, and has a high cost in organisational and personal stress, and poorer service to patients. But, for all the current talk in the NHS of “clinical engagement” the impression I have is that the process is supposed to run one way only, from the centre outwards. Many managers have bemoaned the effect of “Central credit, local blame.” For years the value of clinicians has been downplayed, and criticised as a “vested producer interest.” The debacle over MTAS shows how little ordinary doctors are listened to. This contrasts unfavourably with the excessive influence wielded by certain powerful but unrepresentative doctors. My overall sense is of an increasing gap between the NHS policymakers, and those of us who actually deliver care to patients. (3) The DH is aware of this gap, hence the current emollient language from David Nicholson, asking for doctors’ active engagement, rather than sullen acquiescence with DH policy and the NHS disruptions. (4) I have heard Nicholson himself say that the NHS changes need medical input if they are to succeed. There are plenty of meetings we can go to. However there is little current basis on which a doctor can engage with them sensibly, with personal and professional integrity intact. Personally I think current NHS policies are misinformed and misdirected, and unlikely to improve the lot of either patients (5) or doctors. 1. Barrow, R. (1999) The Higher Nonsense: some persistent errors in educational thinking Journal of Curriculum Studies, 1999, vol. 31, no. 2, 131-142 2. Day, M. (2007) The rise of doctor-manager British Medical Journal 335: 230-231 http://www.bmj.com/cgi/content/full/335/7613/230 3. Davies, P. (2006) The Beleaguered Consultation. British Journal of General Practice 56: 226-229 4. Mandelstam, M. (2006) Betraying the NHS: Health Abandoned Jessica Kingsley Publishers, England ISBN 10 1843104822 5. Steane, A. (2007) Who Cares?: One Family's Shocking Story of Care in Today's NHS Original Book Co ISBN-10: 1872188079 Competing interests: None declared |
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Piotr Szawarski, SpR Anaesthetics Queen Elizabeth Hospital, SE18 4QH
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Many doctors are natural leaders. Leadership however should not be confused with management. They are two separate entities. The skills required for the latter are outside most current medical curricula. Knowledge of relevant psychology, economics, marketing and general management science combined with a well-polished art of compromise, diplomacy and good interpersonal skills form the fabric of being a successful manager (1). While I fully agree with Mr Nicholson’s intention of trying to marry up coalface exposure with managerial expertise I feel that more time and thought should be given to educating future doctor managers or else disappointment awaits all involved. 1. Valerie Iles Really Managing Health Care, Open University Press 1997 UK Competing interests: None declared |
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Julia D Jones, Foundation Year 2 Wrexham Maelor Hospital, Wrexham, LL13 4TD
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I can only support the introduction of undergraduate management education. Personally, I received no undergraduate teaching regarding management. I often overheard senior staff say 'Medical Director' and 'Chief Executive' but it was only after I qualified that I realised I had no real understanding on the roles of these. My first lesson in management was during Foundation Programme teaching and this topic was thought up and presented, not by managers, but by a fellow FP1 trainee. I then attended a medical directorate meeting of my own volition to gain further insight into management. This demonstrates that early on in their career doctors are eager to learn about management and what better place to start than at medical school. Competing interests: None declared |
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Antony F Sara, clinical informatics, medical manager 2068
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Sir I was disappointed, as a medical manager in Australia, that overseas experience (eg Australia - see http://www.racma.edu.au/; USA - see http://www.acpe.org/acpehome/index.aspx) was not mentioned in the article (BMJ 4 August 335:230,231). I am also surprised that the excellent work being done by BAMM in the UK was not mentioned (http://www.bamm.co.uk/CMS/index.php) Tony Dr Tony Sara MB BS BSc(Comp Sci) MBA FRACMA JP Director Clinical Information Systems SESIAHS Director Clinical Services Wollongong Hospital SESIAHS Competing interests: None declared |
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Claire E Woolcock, SpR Psychiatry South London and Maudsley Foundation Trust, 190 Kennington Lane, Kennington, London, SE11 5DL, BAMMBino Board Members
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As this is a time of great opportunity for doctors to become more involved in the management of the healthcare system, BAMM (British Association of Medical Managers) has launched a Junior Doctors division called BAMMbino for those doctors in training who aspire to a career in medical management. It has been raised in earlier responses, there are plans to introduce management and leadership in undergraduate courses for all medical students to increase the knowledge and skills universally. BAMMBino aims to become a network for those junior doctors who want to know more about management and leadership and who may even hope to become the Chief Executives who David Nicholson talks about. We hope to be able to encourage and guide doctors who are looking for further training in management, providing mentoring and managerial work experience for our members. Doctors are in a privileged position of having a training and career that gives them an insight to the way healthcare should and could be provided. However, the skills to become a good doctor do not automatically make a good manager. It is important for the doctors aspiring to be NHS Chief Executives to be educated in management practice and theory just as you would expect for any top manager in private enterprise. If you are interested in more information about BAMMBino, please email luke@bamm.co.uk Competing interests: Secretary of BAMMBino; Current MBA student at Tanaka Business School, Imperial College |
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Anton E Joseph, Consultant Radiologist Mayday University Hospital, Croydon CR7 7YE
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Mr. Nicholson has now joined the chorus with the BMA and the BAMM in wanting more doctors as chief executives. What may otherwise appear to be a reasonable ambition on their part is ‘remotely realistic’ when Mr. Nicholson sets a deadline of two years to have doctors on all shortlists for chief executive posts. Michael Day has expressed the reasons advanced by those who support this. However they all seem to be based on wishful thinking, personal or anecdotal evidence rather than being evidence based. How strange that men and women who want evidence based action suddenly opt for ‘gut feeling’. It is however more important to question the purpose behind this enthusiasm. Is it important to place the emphasis on the need for good managers as chief executives or to have doctors in these posts. Don’t we have a feeling that the politicians have placed the importance on waiting lists at a price for patient care. It is worth looking closely at the present situation before plunging into this line of action. Figures that I obtained reveal that 35 to 40 percent of senior managers are from a clinical background, composed of nurses, midwives and doctors. It was not long ago that Susan Hodgetts, chief executive of the Institute of Healthcare Management in her evidence to the commons select committee admitted that there is no regular assessment or accreditation, let alone any training programmes for managers: these being carried out only on an ad hoc basis across the trusts. There is no programme worth talking of for doctors either. Waving a magic wand and converting doctors into chief executives is perhaps not the answer. Gill Morgan’s thoughts should be given serious considerations. Medical students when they are selected for medicine are not selected for their aptitude for management. Studies of profiles required for management and practising medicine reveal significant differences between the two groups with relatively little overlap. Of course this does not exclude doctors but this is not to be ignored either. There are some unpleasant facts that also need to be taken into account. Who are the doctors currently seeking to go into management posts? It would be true to say that it is not the cream of the profession. In fact it may even be justifiably said that a significant number are those who were not successful in their own clinical specialties. On the other hand the NHS is unlikely to attract the highest quality of non clinical mangers with the remuneration that is on offer, which is a short sighted approach by the NHS. The NHS probably could not offer much higher salaries if each trust is to have a chief executive. Is it necessary for each trust to have a chief executive. It might be more sensible to place trusts into groups and have group executives. This would not only allow better planning for service delivery but also allow for higher salaries for these more able chief executives. Is it just possible that the NHS hierarchy have realised that nurses and midwives on the whole perhaps do not have the capability to make good chief executives. Bringing in doctors might be a ploy to keep them out with positive discrimination in favour of doctors, which might have to be the way if Mr. Nicholson wants to achieve his end given the training and the ability of doctors who are likely to aspire to such posts. If the management of the NHS is to be improved it makes far better sense to provide the facilities to attract successful doctors respected by their colleagues to undergo the necessary training rather than expecting them to undergo training in post. Again if the remuneration continues to be what it is, it is highly unlikely that top executives who would be far better off in the private sector would opt for the NHS. If we were to take some of the arguments advanced for having doctors as chief executives, perhaps the BMA should demand that the Secretary of state should be a doctor. Competing interests: None declared |
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Stephen R Humble, SpR in Anaesthetics Ninewells Hospital, Dundee, DD1 9SY
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Dear Editor, There are many interesting issues raised in this article. The counsel and expertise of the medical profession has been somewhat overlooked in the modern-day management of the NHS. More doctors in senior managerial positions would certainly be a move in the right direction. This is because medical staff have a unique insight into the interactions that occur between doctors and patients and between medical colleagues themselves. They do indeed “represent an untapped pool of intellectual and managerial resources.” (1) The incorporation of management training into the undergraduate curriculum would enhance the leadership potential of medical students. It would also give their clinical practice a broader foundation and enable them to attain a greater understanding of the bigger picture. At this stage some individuals may even see management as an attractive career option. Indeed, it is not unheard of for medical graduates to leave medicine to work in another profession entirely such as business. I had the opportunity of taking a managerial course as an optional extra at medical school in Aberdeen. It did not turn me into a manager, but it did provide me with a wider perspective at an early stage of my career. I agree with Dr O’Kelly’s response that there are no short cuts to successful management.(2) While clinicians may run their own department very well, running an entire hospital is a completely different proposition. Indeed, the chief executive of a hospital is a manager and therefore, it follows that they should be formally trained in management. Given the length of time it takes to learn systematic managerial techniques, the target of having a doctor applying for every chief executive post within 2 years seems a tall order. Not only that, but why are we rushing? This needs to work, and not be yet another expensive failure, of which there are far too many to mention in the last myopic year alone. It is interesting to note that Gerry Robinson was not for or against the appointment of doctors to senior managerial posts.(1) A medical background plus managerial ability may be a distinct advantage over managerial ability alone. However, the emphasis first and foremost, must be on having good managers regardless of what background they are from. In his response, Dr Joseph (3) makes the point that the typical medical student and the typical management student have different personality profiles. In addition, Gerry Robinson feels that management skills in the general population are a relative rarity.(1) Following this logic, there is not going to be a stampede of applicants for the office of chief executive. Fortunately, we do not need an army of people to stand at the top of the pyramid and supervise its maintenance. Dr Joseph (3) explores further the question of who will apply for positions in medical management. He concludes that only the dregs of the profession and failed clinicians will be attracted to these jobs. However, this is an unsubstantiated insult to doctors who are already medical managers or are going to apply for these highly challenging positions. There are many valid reasons for a doctor wanting to take on a role in senior management. The skills required to be an excellent clinician are not the same as those required to be an excellent manager. Therefore, how can it follow that good clinicians will make good managers and vice versa? A doctor with poor hand-eye coordination may make a mediocre surgeon, but that does not bestow all-round mediocrity upon him; he may have an excellent managerial brain. The key is to allow this individual the opportunity to make the best use of his strengths and be paid appropriately. The suggestion of only taking doctors who are highly successful and well respected within their chosen specialty will potentially leave gaps in their specialty and a chief executive that is better at clinical work than at management. Similar arguments can also be used for the appointment of nurses and mid-wives to positions of senior management. If they have a specific aptitude for management then let them become managers, but only with the appropriate training. If we appoint senior staff from these professions based on clinical ability and experience alone we are asking for trouble. It may seem like a way of saving money, but poor management costs the NHS millions of pounds every year and good managers pay for themselves many times over. On the other side of the globe, as noted by Dr Sara (4), The Royal Australasian College of Medical Administrators has a recognised fellowship program akin to any other medical specialty. Perhaps this is the way we should be going. In his or her capacity as a senior manager, a doctor may be able to improve the health of a given patient just as well as they could have done as a clinician. Organisations such as the British Association of Medical Managers should be applauded and may be instrumental in changing attitudes and initiating progress.(5) In conclusion, we need doctors who are properly trained in management but who are not so obsessed with corporate thinking that they become merely an extension of the target-driven government bureaucracy. “An uproar of voices was coming from the farmhouse…Yes, a violent quarrel was in progress…The source of the trouble appeared to be that Napoleon and Mr Pilkington had each played an ace of spades simultaneously. Twelve voices were shouting in anger, and they were all alike. No question, now, what had happened to the faces of the pigs. The creatures outside looked from pig to man, and from man to pig, and from pig to man again: but already it was impossible to say which was which.” (6) 1. Day M. The rise of the doctor-manager BMJ Aug 2007; 335: 230-231 2. O’kelly S. Rapid response to: The rise of the doctor-manager BMJ Aug 2007; 335: 230-231 3. Joseph A. Let us face the facts. Rapid response to: The rise of the doctor-manager BMJ Aug 2007; 335: 230-231 4. Sara A. A blinkered view? Rapid response to: The rise of the doctor- manager BMJ Aug 2007; 335: 230-231 5. Woolcock CE. Supporting doctors to become managers; BAMMBino. Rapid response to: The rise of the doctor-manager BMJ Aug 2007; 335: 230-231 6. Orwell G, Animal Farm, 1945 Competing interests: None declared |
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Charles P Swainson, Medical Director NHS Lothian, Deaconess House, 148 Pleasance, Edinburgh. EH8 9RS
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Michael Day provides a thought provoking piece which reflects the changing fashion in NHS management. Having been alternatively feted and ignored at different times of the last 10 years as a Clinical Director and Medical Director, I am not surprised at the enthusiasm shown by David Nicholson. The last 10 years of comand and control managerialism in the NHS have certainly improved accountability and delivery against targets, but often at the expense of effective clinical engagement. Most NHS consultants enjoy a contract and earnings which are better than the average NHS manager. It is highly unlikely that many would wish to move from that to the risky career of a full time manager, and how does the NHS encourage that? Are managers treated well? Doctors bring different skills and behaviours to the running of the NHS based on the reasons they became doctors in the first place, plus knowledge and skills acquired along the way. It seems to me that the real task is to engage doctors and other clinicians more effectively, and give them both a stake and incentive in running clinical services. Too often doctors are disenfranchised particularly when the new contract encourages them to be treated as employees rather than partners in high quality and effective care. Yes, let’s build management and leadership knowledge and skills into training programmes for doctors from the cradle to the grave. Lets also support them to contribute in the most cost effective fashion that builds on those skills rather than try to turn doctors into something else that most are not. Competing interests: None declared |
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