Fixing the NHS: We need fewer and better managers
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7565.447 (Published 24 August 2006) Cite this as: BMJ 2006;333:447All rapid responses
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EDITOR- Who manages the NHS? How many of us really know who “the
managers” are? We recently conducted a small survey of junior doctors in
the southeast to find out if any of us actually know who we are dealing
with?
We found that of 80 doctors only 7 even know the management structure
directly above them from Clinical Director to Health Secretary. How are we
supposed to train and modernise our practise in order to work with
management if we don’t even know who they are or what roles they play?
Things seem to happen and missives passed down from a faceless mass of
people walking through our hospitals with over inflated self- importance
but no tangible connection with the people who work for them.
I should think even those of us with a rudimentary knowledge of
business psychology know that the “arm’s length” approach is not the best
way of keeping morale up amongst staff, especially when you want to force
through unwanted or unappreciated “reforms”.
There is no doubt that the NHS needs reform and was headed towards
reform for some time. It has a long history of being poorly managed from a
purely business perspective and we have only our own indolence and
resistance to change as doctors to blame for the current suffocating flood
of layers of management. We need to learn and move on in the world. There
are many doctors with the interest, ambition and business mind to move the
game on whilst keeping in mind the important and realistic aspects of
patient care. We should utilise these people and perhaps train more in
order to wrest control of our profession back from the interference of a
mediocre government and an aloof and “ivory tower” management.
Who knows, perhaps we should be teaching management skills and
concepts in medical schools. It would give us a stronger hand in our
working lives and perhaps change the face of things to come.
Competing interests:
None declared
Competing interests: No competing interests
Fixing the NHS
Dear Doctors,
I’ve read the ‘Fixing the NHS’ debate in the BMJ with great interest.
I’m 39 and have been an NHS manager for 5 years, with most of my career
spent in the pharmaceutical industry. I’ve got 4 degrees, one a PhD, 2
clinical (biochemistry) and 2 managerial. Although expensive, I subscribe
to the print BMJ for an indispensable insight into clinical practice and
the medical profession. I couldn’t resist replying to Dr Twisselmann’s
last sentence, ‘I wonder what the managers think’.
I showed Stephen Black’s article to 11 colleagues and asked for their
views, and responses mirrored your letters, including the sentiments:
‘polarised’ ‘blinkered’ ‘narrow health centric’ ‘thoughtless and
unhelpful’ ‘typical management consultant’. I realise this isn’t a
statistically significant sample and I wonder whether the lack of feedback
from other managers in this week’s BMJ is because the point made by Paul
Thorpe should’ve been glaringly obvious to anyone who’d ever visited a
hospital rather than just a meeting room, or the FSA enquiry into iSoft,
or the Guardian’s investigation into the £2bn spent by the Government on
management consultants
http://www.guardian.co.uk/frontpage/story/0,,1863468,00.html (the
Management Consultants Association have also suggested that £2bn
represents 0.4% of total expenditure whilst the private sector funds 3-5%
and therefore we need more investment, not less) or indeed the breadth of
evidence based publications evaluating PFI and e.g. revision rates for hip
surgery undertaken at IS providers. Or, God help us, because managers
really don’t read the BMJ.
I’m currently completing a secondment from an SHA to a trust, and
like Stephen Kirkham, I have the excellent good fortune of working with
some marvellous doctors who I respect hugely, enjoy working with immensely
and will miss very much when I have to move on. Having not been drained of
energy and vitality after relentless policy changes over decades in the
NHS, I’m still at the enthusiastic stage of my career (or have bipolar
disorder, who knows) and passionately feel that we can’t possibly meet the
health needs of our populations and provide a high standard of care
without doctors being given more managerial responsibility, not less; and
managers being subject to far more rigour in their training and annual
appraisals. Having never worked as a medic, I’ve not experienced the
special degree of trust and teamwork that you deal with every day, until I
did this secondment. Working with doctors is the best job I’ve ever had,
and I wish more people felt the same.
I agree that non medically qualified people almost always over
simplify a complex system. Whilst some industrial practices can be helpful
(Six Sigma, lean thinking and the Taguchi theorem
http://www.lmu.ac.uk/lis/imgtserv/tools/taguchi.htm), we must be careful
not to over extrapolate. Our risks are far greater, our clinicians not
automatons, demand doesn’t operate in a steady state, behaviour is
difficult to predict and any model has its limits. But when I read the
sometimes blistering rebuttals to various (admittedly weak) BMJ articles
written by managers, I’m frustrated because we seem to stop just when it
gets interesting. It all seems to hinge on the differences in our training
- critical appraisal simply isn’t in the syllabuses of most management
degrees, unless you do an MPH. Whilst doctors learn and thrive in the cut
and thrust of debate- some managers either hide behind ‘you disagree with
me, ergo all doctors are arrogant/rude/elitist’ (exactly as Paul Thorpe
says) or just hide full stop, because NHS life’s complicated enough as it
is. I found Jonathan Benger’s thoughtful, considered and constructive
response to Tara Hunt’s piece about her reluctance to do audit very
striking. I wish we had the same attitude to our individual learning and
development between professions that we do between seniors and juniors.
I’ve asked for a medical mentor and been refused, and when one of the
medical associations were recruiting mentors & I put my name forward,
it was met with bemusement. This is such a shame. My knowledge would
increase meteorically- I’m not so sure I could give back as much, but I’d
try- and the longer term consequences could be so beneficial. I also asked
to join the journal club, but won that battle of acceptance, and we now
review both the medical and managerial literature. I must confess I like
the challenge medics present to managers, and enjoy having to prove myself
every day, rather than just the once at interview.
And doctors do think very differently. You view the entirety of a
situation: the pathology, histology, pharmacology, family dynamics,
psychology………. We don’t have this breadth of take on an issue. An
accountant will tell us our budget, the SHA will tell us to increase our
CRES savings at very short notice, nurse managers will tell us about staff
issues, patients will complain to us, performance managers will ask us to
fill in a new set of spreadsheets, the Department will produce yet another
reporting requirement……… I know only a handful of excellent managers who
have a sufficiently rounded portfolio that enables them to work very
effectively across a broad spectrum. Perhaps that in itself indicates the
need to revisit the syllabuses of our MBAs and training schemes. But then
the NHS is very large and complicated, and maybe instead we need to
clarify our managerial specialisms, in commissioning/primary
care/operational management. This is exactly what the NHS Leadership
Centre is doing- there’s a large feature on this in the HSJ on 7 September
2006- as well as working with BAMM on projects designed to increase
medical leadership and involvement.
However, given that an advert went out to OJEU requesting expressions
of interest for management support
http://www.dh.gov.uk/ProcurementAndProposals/Tenders/RecentlyAwardedAndE...
and the timeframes involved, investment in management consultancy in
health is likely to increase not decrease, and perhaps not be UK based.
Decisions will be made by Boards, but pressure may be bought to bear on
organisations perceived to be failing.
It’s also interesting to consider how management consultants are
appointed. Macro level stuff, like Pricewaterhouse Coopers going into
trusts in deficit- no choice there, they were all negotiated nationally,
at the Secretary of State’s behest- likewise McKinseys who’re doing the
Fitness for Purpose reviews for every PCT in the country as part of the
latest reconfiguration. At the next level down, SHAs can insist. This can
vary enormously- from a systemic problem that’s eluded diagnosis over many
years (or executive unwillingness to address a long standing issue because
of difficult MPs/ staff issues/ general inertia), to a need for specialist
input where skill sets are lacking. Because of the financial position,
very few trusts actually commission management consultants themselves or
of their own volition unless they absolutely have to, and it’s for fairly
small sums because most will have Standing Financial Instructions that
limit this. Sometimes an agreement is reached between a trust and the SHA
re the need for an external view on an issue perceived to be too difficult
to be handled without outside help, e.g. closing a community hospital.
Because a handy source of savings are training and education budgets, we
can’t always grow our own managerial experts. I’m undecided. I know some
excellent NHS managers who’ve left the service due to ill health,
exhaustion or sheer frustration at the unrelenting pace of change, and set
up on their own, as an independent- and they’ve often been bought back in
for time limited projects because some organisations don’t have either the
capacity or the capability to implement things (the dental contract is a
good example). Equally, I know of cases where the experience has been much
more negative. Clearly a major weakness is that most consultants don’t
stay for the implementation stage- but the prevailing managerial view is
that this must be done by the existing staff in order to ‘own’ it
properly. I think this can have major shortcomings. But in 11 years in
industry, I never once used a management consultancy firm, although I did
buy in expertise a few times. I do however find it strange that the
response to quite a lot of difficult decisions in the NHS is to have a
review. Particularly when you talk to staff and discover it’s the
umpteenth since 1973.
I don’t think the quality of management qualifications is the sole
determinant. I know some fantastic directorate managers who’re ex-medical
secretaries; and excellent nurses who’ve really struggled in management
posts. What we need are managers not retraining as doctors or vice versa,
but learning some of the core skills we often assume in eachother, like
critical appraisal, operational management, risk, litigation, reflective
practice, finance. I really really struggled with the point made re
whether managers needed to be medical, because clearly I’m not in that
category and I used to think that it didn’t matter because having strong
transferable skills was enough. A day into my secondment, I knew it
wasn’t. Thank goodness for my CD and lead nurse. I sometimes wonder
whether the career structure for nurses, AHPs, PAMs etc may lead them to
aspire to managerial posts because of the salary differential. This leads
to attrition from scarce pools of staff and raises expectations- many of
the former Modernisation Agency (MA) posts were 40K+ but fixed term- and
most trusts can’t pick up a wages bill that large for so many people
returning from secondments brimming with ideas that aren’t always
achievable at the most solvent of times. Most businesses recognised this
in the 1990s and adjusted the gradients between income and function, and
my nursing colleagues tell me that this is something that the nurse
consultant role was intended for. I don’t know enough about this to have
an informed opinion. But I do think that although the MA had its good
points, it was an extremely expensive way of improving services.
And look how absolutely fantastic it is when a doctor takes an
interest in management processes http://www.steyn.org.uk/ and what an
immediate impact this can make- and to things we all hold dear. Thankfully
the idiotic perception that you were all operating on private patients in
between rounds of golf on NHS time has been shattered by the discovery
through implementing the consultant contract that we need twice as many
staff if you all stick to your official job plans. But being a non medical
manager is a dangerous business. NHS salaries are now in line with the
private sector, and in some parts of the country, it’d be difficult to
find a post with the equivalent pay. If you restructure as periodically as
the NHS does, you also self select people who’re best at personal
survival. Or those who use every reshuffle as an opportunity to move
onwards and upwards irrespective of the mess they leave behind. If
continuity of employment is competency based it would be acceptable, but
local politics, cash flow and organisational culture often dictate the
state of play. More seasoned managers than myself have said that the pace
of change since 2000 has been the swiftest for many decades- which’s also
been commented on by the international press. I used to think that doctors
could be more outspoken than managers, with less comeback, but now I’m not
so sure. Which in itself emphasises that we definitely do need far higher
standards to better develop the management profession.
And the NHS does need your help, particularly with the demise of
public health medicine. Undoubtedly, it needs clerks, IT staff, HR
managers, data analysts, accountants and others included under the
umbrella of management, but some of the tricky stuff- commissioning,
governance and dare I say, rationing- used to be under the purvey of
doctors who’ve since left to return to general practice, work overseas,
enter academia or industry. Public health appears to’ve segued into being
a combination of a local politician and a health promotion advisor. I
suppose what worries me is the rationing issue. Dedicated clinical staff,
supported by their managers and patients, are bound to strive to improve
funding for their service and good patient care. But how can we make
ethical decisions?
As for more staff- when I’ve been involved in decisions, I’ve asked
for substantiating evidence. Some doctors have found this difficult. I
know that not everything can be ‘modernised’ to the nth degree. But we
need proof that you’ve considered all options and can give some assurances
that we’ll meet our mutual needs. If you think a target’s nonsense, please
back your assertion up with some evidence, and then let’s work on it
together. Which is why Tara Hunt’s piece last week about her reluctance to
do audit is rather sad. I’ve found it indispensable. There has to be a
middle ground between putting Enid Blyton style post-it notes on flip
charts and being shouted at by an angry cardiologist.
Sadly we have no equivalent body to the BMA and the IHM = Institute
of Healthcare Managers http://www.ihm.org.uk/ is the nearest we’ve got,
with the HFMA for finance www.hfma.org.uk, and the AHHRM for HR
http://www.ahhrm.org.uk/. I’ve also hunted around for a decent healthcare
management journal and the best I could find was Health Services
Management Research
http://hsmr.publisher.ingentaconnect.com/content/rsm/hsmr but the number
of articles of relevance to the UK are minimal; hence my subscription to
the BMJ.
Yes, we’ve had Agenda for Change
http://www.dh.gov.uk/assetRoot/04/09/37/39/04093739.pdf which is supposed
to help improve practice, but one of the biggest challenges is the speed
with which our jobs change over very short periods of time. Inevitably, in
the current financial crisis, unless you’re working on cost savings or
meeting the latest must-do, it’s seen as fiddling while Rome burns. We’re
now supposed to have KSFs = Key Skills and Competencies Framework
http://www.e-ksfnow.org/ and this determines our career progress. I must
confess that I’ve not had the time or inclination to wade through these
enormous tomes (>800pp) to the extent I should’ve.
For me, the most recent indictment of the move away from quality and
care to finance and performance was epitomised in a recent Board paper
I’ve just drafted. I was asked to write some specifics about clinical
governance, and I asked a number of colleagues for their advice on sources
and views on content. I came across a wealth of publications from the late
1990s, about the introduction of NICE, the importance of evidence based
medicine, how medical leadership and training is fundamental to innovation
and development (all before my time)…… and I felt quite inspired. I’d love
to have been part of that NHS. How on earth did we get from all that
marvellous potential to where we are now?!
These points are all reflected in your letters; and all I can add is
my personal view that a good medical – managerial partnership should be
like a marriage without the sex. Different roles based on trust and mutual
respect, preferably without the in-laws…..
Warmest best wishes,
Di Vegh
07855 860489
Churchview, St Margaret’s Close, Torquay, Devon TQ1 4NR
Competing interests:
None declared
Competing interests: No competing interests