Christmas 2012: Editorial

When managers rule

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8239 (Published 19 December 2012)
Cite this as: BMJ 2012;345:e8239

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Displaying 1-10 out of 20 published

6 January 2013

I congratulate Sir Brian Jarman on an excellent and timely editorial (1). Sadly, in parts of the NHS patient care is sometimes seen as secondary to managerial imperatives. If a clinician is performing to high standards in terms of clinical excellence and professional conduct, yet gets on the wrong side of a manager or a medical director, whether it be for whistleblowing or other reasons, he/she may well suffer serious consequences as a result (2). This clearly needs to change.

Managers and medical directors require better training and regulation, and they need to be held more accountable for their actions. Any disciplinary process brought by managers or medical directors must respect the three key principles of independence, expertise and plurality. The Department of Health document, Maintaining High Professional Standards (3), is now over 8 years old and needs to be significantly updated, since it is open to manipulation and abuse. Any revised guidelines should apply to all NHS staff, and not just to doctors, dentists and pharmacists. There also need to be changes in legal and General Medical Council (GMC) settings. It is in the interests of employment tribunals and GMC panels to respect the three principles of fairness outlined above. NHS staff should not be at a disadvantage in legal or related settings simply because they cannot afford as expensive (and often as aggressive) legal teams as those employed by NHS Trusts.

GMC and legal panels need to be trained and forewarned about the cognitive psychology of legal reasoning, its fallibility and its biases, as is now a requirement in some legal settings in the USA (4). Doctors and others who undergo work-related stress, which must include stressful GMC or employment tribunal hearings, are more likely to suffer ill-health and to become suicidal (5, 6). Hopefully, the forthcoming Francis Report on the mid-Staffordshire scandal will send a wake-up call to the Department of Health, and the Department will see the need for radical changes at various levels in the NHS (7). The current status quo results in suffering to NHS staff, to wastage of public funds on legal expenses and costly settlements, and to poor patient care.

(1) Jarman B. When managers rule. BMJ 2012; 345: e8239
(2) http://www.ajustnhs.com/case-histories-of-victimised-nhs-staff/
(3) Department of Health. Maintaining High Professional Standards. London, 2006.
(4) Lilienfeld S, Byron R. Your brain on trial. Scientific American Mind 2013; 23: 44-53.
(5) http://www.whatdotheyknow.com/request/names_of_doctors_who_died_follow#i...
(6) Hawton K, Malmberg A, Simkin S. Suicide in doctors. A psychological autopsy study. Journal of Psychosomatic Research 2004; 57: 1-4.
(7) http://www.ajustnhs.com/a-manifesto-for-a-just-and-open-nhs/

Competing interests: None declared

Narinder Kapur, Neuropsychologist

University College London, 1-19 Torrington Place, London, WC1E 7HJ

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5 January 2013

At my age especially in the Festive Season everything takes a little longer but I applaud this editorial which illustrates some current NHS woes. It points out that whistleblowing can lead to rapid professional oblivion, illustrated by the following Editorial, BMJ 2012;345:e8330 on Ignaz Semmelweis.

I may have a partial answer. My 2010 unpublished investigation into retired doctors in N Ireland confirmed that most who replied could see ways in which their services to patients could have been improved but that their professional advice was usually ignored by the powers that be.

Retired doctors can have more detached judgement than younger colleagues and often know how to go about generating change without causing uproar. They have more time to engage with the media if appropriate and as potential patients can display enlightened self interest. Having no careers to blight they could act as effective proxy whistleblowers.

Though many retired doctors are happy to be removed from the medical scene, others are not and would welcome a chance to be of continuing service. Is this a neglected resource?

Competing interests: Elderly retired GP who misses being out of the action and who doubtless will soon be in need of good NHS care!

Robert Lewis Miller, Retired GP

Ex Woodstock Medical centre, 222 Woodstock Road, Belfast BT6 9DL

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5 January 2013

Patients First is a campaign group raising awareness about negative strategies often used against health professionals who raise concerns. Staff can be silenced via contracts of employment, often by bullying strategies,including via exclusion, suspension, dismissal or gagging clauses. Time and time again we hear the same stories. These abuses of power are widespread and symptomatic of what Brian Jarman describes in his article. When the health service lost its focus by putting patient safety and quality below reputation management or financial control then the corrosion began. There are solutions that lie within strong leadership, support from the centre and acccountability for those who victimise and abuse their power. This state of affairs cannot continue as it is a complete waste of talent and skill to have highly trained and committed staff stressed on leave and leaving the NHS. The fear that many of us have felt who have become whistleblowers is immense and should not be an acceptable part of our culture in a civilised society. We are all committed within Patients First to ending this climate of blame and fear, by trying to show leadership and empower others to speak up.

Competing interests: None declared

holt kim, Paediatrician

Patients First, London

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3 January 2013

Brian Jarman is right to highlight concern about systemic bullying in the NHS in England. His references to independent US evidence,corroborating UK experience (1) (2), in the context of the Mid-Staffordshire Inquiry, are particularly significant. Having myself given evidence to that Inquiry (3), I have good reason to believe that bullying, frequently associated with victimisation of whistle-blowers, is widespread and its impact under-estimated.

However, the reasons are complex and multifactorial. They cannot simply be attributed to one change, however significant, implemented thirty years ago. Many later developments (not least the introduction of competition, privatisation, constant reorganisation and relentless political targets) have contributed to unacceptable patterns of behaviour which most professional managers deeply deplore. Managers are frequently the subjects of such abuse and many have left the Service in consequence.

Jarman forgets that, since 1983, many general managers have been medically or clinically qualified. Since then, GPs have played key roles in commissioning and Medical directors have been universal. Why have they not challenged the obviously dysfunctional autocratic culture? The GMC has previously disciplined medically qualified managers who failed to protect the interests of patients. It must continue to do so. Existing voluntary management codes do require teeth but, in my view, can only be effective if NHS management becomes truly independent of the Department of Health.

Sadly, my own contacts with victims leads me to conclude that the BMA is part of the problem. It treats each successive case as a unique and isolated employment issue. If it were to reflect on its experience and publish aggregated data, preferably in association with other representative organisations, we might get a little closer to an accurate diagnosis of the evidence-based reasons for this deeply worrying problem.

1. www.patients first.org.uk

2.www.medicalharm.org

3.The Mid-Staffordshire NHS Foundation Trust Public Inquiry. Witness Statement of Professor David Hands. 27 Sept 2011.

Competing interests: Former Chief Executive of North Wales Health Authority and of NHS Trusts and health authorities in England. Married to a former Medical Director. Has worked with several individuals who have personal experience of bullying in the NHS

David Michael Hands, Visiting Professor In Health Policy and Management

University of Glamorgan, WIHSC, Pontypridd, CF37 1DL

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2 January 2013

Prof Jarman is incisive in his analysis of NHS management culture. Perhaps the most disturbing comment is the reliance on "'shame and blame'" and fear of job loss as quality improvement driver.

These comments would have been recognized by the quality improvement guru Dr W Edwards Deming as "deadly diseases" that are bad for the organization - and bad for the people it tries to serve[1]. Lack of constancy of purpose, an emphasis on short term profits and running on the basis of visible figures alone (only on what you measure) will contribute to significant problems. Similarly, blind reliance on technology can be counter-productive, as can "placing blame on workforces who are only responsible for 15% of mistakes where the system desired by management is responsible for 85% of the unintended consequences".

I wonder if part of the problem is a need for an alternative paradigm for (particularly non-clinical) management, both an aim and a methodology. The ISO 9000 series of standards for quality management define quality as "the degree to which a set of inherent charcteristics fulfils a set of characteristics"[2]. Perhaps less dry and more inspiring is Cindy Jimmerson's definition of the point of a healthcare system:
* To deliver what the patient wants & needs, defect free
* ...one by one, customized to each individual patient
* ...on demand, exactly as requested
* With an immediate response to problems or changes
* With no waste
* In an environment safe for patients, staff & clinicians: physically, emotionally & professionally

This definition makes the patient the principal focus. In terms of a methodology, the EFQM model of excellence[3] may be a useful place to begin, as it includes markers for 'excellent organizations to follow; for example that they have leaders who "inspire people and create a culture of involvement, ownership, empowerment, improvement and accountability through their actions, behaviours".

If we move from the culture of fear, shame and blame that Jarman describes toward a more excellent way, then I think the NHS will be better for both its patients (primary focus) and its staff. It is also far more likely to have embedded continual improvement in all departments with a consequent decrease in waste and increased effectiveness. That is worth striving for.

[1] Deming, WE (1986) "Out of the Crisis". Cambridge MA: MIT Center for Advanced Engineering Study.
[2] BS EN ISO 9000:2005. Quality management systems. Fundamentals and vocabulary. http://shop.bsigroup.com/en/ProductDetail/?pid=000000000030093429
[3] EFQM Excellence Model, http://www.efqm.org (accessed 31/12/12)

Competing interests: None declared

Philip Pearson, Consultant Respiratory Physician

Plymouth Hospitals, Derriford Hospital, Plymouth

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31 December 2012

There is nothing new in what Prof Jarman says in this his article.
What most of us, the coal face clinicians would like to know is, ‘What is the solution?’
No one seems to have an answer; so we just carry on doing the best we can. This is the real strength of the NHS, which is not as bad as we are being made to believe.

Competing interests: None declared

Nikhil C Kaushik, Consultant Ophthalmic Surgeon

Wrexham Maelor Hospital, Croesnewydd Road, Wrexham LL13 7TD

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31 December 2012

Jarman in his editorial ‘when managers rule’(1) eloquently highlighted the need to refocus on the quality of patient care and the importance of clinicians’ leading in the NHS. Darzi, in his review (2), defined quality as ‘clinically effective, personal and safe’ and reintroduced the concept of ‘clinical leadership’ as crucial to this vision. He envisaged ‘a lot of clinicians will now be responsible and will have tremendous powers within the system’ (3), thereby associating a clinically driven NHS with improved quality of patient care and safety. Kaiser Permanente achieved efficiency, improved quality of patient care and outcomes through making clinical leadership central to their reform agenda (4). However, at the most crucial of times, clinical leadership in the NHS is patchy at best, misinterpreted and unsatisfactory.

Clinical leadership has been described as ‘leadership needed to transform the performance of the health systems that must come principally from doctors and other clinicians – whether or not they play formal management roles’(5) thereby distinguishing it from clinical management. If quality is truly desired it is crucial that clinical leaders steer away from herd like thinking or safe opinion at face value and actually lead the way in strategy, policy development and implementation based on information and evidence. It is time to advance on achieving the ultimate goal of patients and clinicians at the center of decision making or the vision of quality and clinical leadership will remain ‘the emperor’s new clothes’.

References
(1) Jarman, B. When managers rule- Patients may suffer, and they’re the ones who matter. BMJ 2012;345.
(2) High Quality Care For All – NHS Next Stage Review Final Report, Lord Darzi, Department of Health, 2008.
(3)Gainsbury, S. Darzi turns up the heat on clinical leadership. Health services journal, 2008.
(4) Light, D., Dixon, M. Making the NHS more like Kaiser Permanente; BMJ, 2004: 328(7442): 763–765.
(5) Mountford, J., Webb, C. Clinical leadership-unlocking the performance in healthcare. Health International; 2008.

Competing interests: None declared

Shanaya Rathod, Consultant Psychiatrist

Southern Health NHS Foundation Trust, Tatchbury Mount, Calmore

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30 December 2012

Surely the job in itself cannot be 'amoral' (A K Anand)without blame being accrued by those colluding in carrying it out? Same old 'just doing my job/ just carrying out orders'.If it is a question of morality managers cannot be let off the hook as well as those who collude with them. But managers though are not all the big bad wolves and health workers simply powerless pussy cats, some actually believe what they are doing is right/moral. To vilify managers (and politicians) is perhaps understandable when cherished ideals are being broken in rather harsh ways. All the changes to the NHS cannot be brought about without the participation of all partners so the power is not all one sided. But If it is so unequal that NHS workers can be bullied into acceptance = or into leaving the NHS maybe there is the hidden agenda

Competing interests: None declared

susanne stevens, retired

none, cf24

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28 December 2012

In his incisive article, Professor Jarman omits a key word that explains the current predicament of the NHS. That word is 'corporate'.

The founding of a huge organization such as the NHS inevitably led to the need to manage its workers, hence in 1947 the process of doctors becoming ‘de facto’ civil servants commenced. The Griffiths Report was an important waypoint in the process, ensuring that the focus of a doctor’s attention would be on corporate goals defined mainly by government and enforced through non clinical managers. As Stalinist comparisons abound in any discussion on the NHS (and are mentioned by Jarman) this bears some comparison to the role of embedded non military trained commissars in second world war fighting units of the Soviet army. Commissars were responsible for strategy and discipline, often countermanding senior military officers; their presence was not widely regarded as a success.

A corporate management system can be effective: witness this decade’s dramatic waiting list reductions that have required both managerial and clinical resolve. But the replacement of a doctor’s duty to his patient by corporate aims determined by those with no professional responsibility to a patient was always going to be a recipe for disaster. Particularly so if the focus of these aims was on the survival and health of an organisation rather than the patient served by it.

It is unfortunate in this context that individual opinion is frequently seen as an affront to corporate aims. The net result of this is that professional responsibility is subjugated. A similar corporate culture has in the last two decades defined two other great organisations whose ethos was rooted in that of public service: the BBC and the Police Force.

Competing interests: None declared

Christoph C Lees, Consultant

University Teaching Hospital, Cambridge

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28 December 2012

Prof Jarman has brought together evidence that shows conclusively the way the NHS has been eviscerated. As far as the non-medical managers who carried out their masters' wishes are concerned, I blame them not. Their job is amoral. But, they could not have done all this without the acquiescence or connivance of doctors.
In the absence of a system of private confession and absolution in medicine, perhaps the guilty ones could anonymously send to the BMJ, a single word of remorse. For, they have sinned.
A happier new year. To all.
JK Anand

Competing interests: None declared

JK Anand, Retired doctor

Free spirit, 3 Wayford close, Peterborough

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