Moving into managementBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7080.2 (Published 22 February 1997) Cite this as: BMJ 1997;314:S2-7080
In the first of an occasional series of articles on careers in management for doctors, Dr Jenny Simpson, chief executive of the British Association of Medical Managers, discusses the role of the medical director of a trust
“Lose half my clinical work, go to endless boring meetings, and get all the blame when things go wrong - not likely,” was the typical initial response to the idea of a moving into management as medical director. Perhaps worse is the attitude that “only doctors who are no good clinically do jobs like that.”
Yet, five years on, things have changed radically. Doctors are keen to take on these roles - and it is certainly not those with clinical performance problems. Indeed, credibility - both clinical and managerial - is a prerequisite. These doctors are not, on the whole, regarded as having “crossed to the other side,” They simply spend a part or all of their working lives on managerial matters, and have learnt to be a bilingual and much valued link between the worlds of medicine and management.
Competition for posts is growing
So what is this job and why are able doctors so keen to do it? Early attempts to define the role proved to be difficult. Each medical director, it seemed, had an entirely different job and a single core element could not be agreed. Over the past two to three years, however, a far greater consistency has emerged, alongside markedly increased enthusiasm to take on the job. There is now considerable competition for medical director posts in many trusts and increasingly these jobs are being advertised nationally. Initially the job was always filled by a doctor already working in the trust. Now there are several examples of doctors moving trusts to take up a medical director post and fitting clinical work around the management commitment.
The role and responsibilities of the medical director, published in November 1996 by the Association of Trust Medical Directors, is the result of a comprehensive exercise of collecting job descriptions and identifying the common elements.(1) These were reviewed byAssociation of Trust Medical Directors members and circulated throughout the NHS, with comments sought. The aim was to identify not only what medical directors are doing at present, but also to initiate the debate on what medical directors should be doing, and how best they should be educated, developed, and supported. The project showed that the role of the medical director varies from trust to trust. The way in which the role is deliveredin each trust directors undertake the role full time while others have a part time commitment and share aspects of the job with deputies, a clinical director, or consultant colleagues. It clear that the job is extremely difficult to do in less than five sessions perweek.(2)
The medical director's job is managerial rather than representative. The old notion that the medical director is simply a reborn medical staff representative is quite wrong. Medical directors provide medical input to the long term direction of the trust, are major players on trust boards, and consequently hold powerful positions in the organisation. With the other trust board directors, the medical director shares a corporate responsibility for the general well being and financial health of the trust. Along with this statutory responsibility is a fundamental leadership role. The medical director plays a major part in steering and shaping the clinical service, ensuring that day to day clinical activities are aligned to the trust's long term direction. The medical director must be able to assess and understand what is happening clinically within the organisation and within the wider environment - and be able to influence, persuade, and convince his or her colleagues of the appropriate way forward. Issues of rationing and of determining which services to develop and which to scale down fall clearly into the domain of the medical director.
Core elements of the job
So what are the practicalities of the job? According to Alastair Scotland, director of postgraduate education at Chelsea and Westminster Hospital “The medical director is the guardian of the clinical probity of the trust.” In other words the medical director - along with the director of nursing - takes responsibility for every aspect of the quality of the clinical service.
Ensuring that medical staff appointments are made in keeping with the strategic, long term direction of the trust is a key function of the medical director. It is essential that doctors with the right training and skills are appointed to the right posts for the right reasons. Having appointed the appropriate staff, the medical director must also ensure that processes are in place to monitor the quality of clinical work by means of audit. Furthermore, the medical director must see that effective mechanisms are put in place to improve clinicians' performance if it is not up to scratch.
The role of the medical director in maintaining standards of professional performance, including disciplinary matters is detailed in Maintaining Medical Excellence.(3) In essence, the medical director must ensure that procedures are in place to deal effectively with the unfortunate situation of a colleague's clinical performance posing a threat to the wellbeing of patients. The medical director must ensure that clinical colleagues, clinical directors, and other members of staff can discuss their concerns freely with him or her. There must also be a clear, well thought out set of procedures to follow which allows the appropriate evidence to be gathered and action taken. Disciplinary procedure is generally not familiar to the majority of doctors and a need exists for support for medical directors encountering these situations for the first time. The Association of Trust Medical Directors has produced a resource pack to provide an easily accessible source of information for medical directors finding themselves in this predicament. The association is also developing a series of educational and personal development programmes for medical directors.
Widely varying duties
In addition to these core elements of the job, medical directors also find themselves responsible for a wide range of other duties. They may have line management responsibilities for clinical directors or at least some form of coordinating function, most commonly in the form of a trust management board on which the clinical directors sit, alongside the chief executive, other executive directors, and the medical director. This is, or at least should be, the single forum in which every decision affecting the trust gets made. It should provide an opportunity to address both strategic thinking and day to day reality simultaneously - to the great benefit of the trust. The medical director may also coordinate the contracting activities of clinical directors.
Most medical directors liaise with clinical tutors, postgraduate deans, and clinical directors on educational and training issues for doctors. Furthermore, they have a duty to ensure that management skills and knowledge are developed among the clinical staff and that a full programme of professional development is in place. Medical directors are increasingly developing and implementing appraisal systems and annual programmes of job plan review for all consultants. The need for personal development programmes for consultant staff, with a view both to career development and to succession planning for the trust is increasingly being recognised as a key responsibility for the medical director. Medical directors have a role in awarding discretionary points for consultants. Alongside this is the responsibility for occupational health matters, particularly relating to hepatitis B and HIV. Medical directors also take on a major role in risk management and complaints procedures at a strategic level. The major accident policy for the trust also tends to fall into the remit of the medical director as does an overall responsibility for ensuring that effective information technology systems are in place to support clinical and managerial decision making.
The medical director has a further vital role in developing strategy for developing clinical practice in the trust. He or she has a duty to advise the trust board on all clinical practice issues that have implications for the trust's ability to meet its contractual obligations. Finally, the medical director holds responsibility for the external relationships of the trust - liaising with the local community, postgraduate deans and royal colleges, healthcare commissioners, community health councils, directors of public health, the NHS Executive, the press, and voluntary organisations.
The job is undoubtedly a challenge and the list of tasks daunting. Why is it then that the role of medical director is proving to be attractive and sought after? The answer lies in the nature of clinicians and clinical work. Senior clinicians are highly educated, highly skilled individuals who have worked for many years at a hands on, operational level in the health service. They have an intimate knowledge of how the organisation works, particularly of its complexities and shortcomings. Many of these clinicians are totally frustrated - and have been so for many years - at being unable to influence the broader picture, which is often governed by those with little or no knowledge of clinical processes.The role of medical director provides an opportunity to influence and change the way the trust is run. Even if plans for radical change do not come to full fruition it is, as onemedical director puts it, “better to be in there having a go, than constantly being irritated by the way things are.” Despite the difficulties and discomfort of having to deal with the really tough problems facing the trust, the chance to sort out long term irritations and to play a major role in determining its future is deeply rewarding. There is stilla long way to go - certainly in terms of a system of rewards and a career structure for medical management. The British Association of Medical Managers and the Association of Trust Medical Directors have work underway in these important areas, and terms and conditions of service for medical managers are being addressed by the BMA.