Even clinician led management won't fix the NHSBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.39045.400220.1F (Published 30 November 2006) Cite this as: BMJ 2006;333:1174
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Where did it all go wrong?
Recently I retired early from my job after 21 years as a consultant radiologist in the NHS at the age of 59. I had fully intended to stay until 65 but changes in the NHS in recent years left me so disheartened I had to leave to protect my sanity and health. So where did it all go wrong?
When I started my consultant post the vast majority of my effort was directed to patient care, and although the work was challenging, demanding and relentless, the job satisfaction was immense. The concept of Clinical Director did not exist, and all consultants were born equal. Hospital managers had a small and marginal impact on my working life.
A new breed of hospital managers appeared with a much more aggressive and invasive management style. Paid large salaries and with the carrot of large bonuses they were charged with reducing waiting lists and making ‘their’ hospitals more cost effective. To bring consultants into line they invented the post of Clinical Director. This was used as a tool by managers to create a tier of doctors who were paid extra to do their bidding. Pretty soon the Clinical Directors saw themselves as superior to ‘ordinary’ consultants and started to act like managers. They adopted management mannerisms such as sending condescending emails to their consultant colleagues thanking them for working hard. Before long they pressurized us to fit more work into the normal working day and when that didn’t satisfy their masters they pressurized us to work extended hours. It created a festering undercurrent of resentment between consultant colleagues which in large part is responsible for the almost universal disenchantment that senior hospital doctors working in the NHS now have.
In recent years the NHS has become obsessed with targets and achieving “better value for money”. For a senior manager to achieve a bonus means meeting targets and reducing costs. The only way to do this is to reduce staff levels, and make those remaining work harder for the same or less monetary reward. The vast majority of health professionals already work exceptionally hard, so it rather galling to be told to work harder so that in essence the ’boss’ can get his bonus. All good will goes out of the window.
In todays NHS so much time and effort is diverted away from patient care to satisfy the nonsense of revalidation, appraisal, clinical governance, mandatory training etc. it beggars belief. Enormous amounts of money have been spent on introducing IT into hospitals. This provides administrators with lots of data, but does little to enhance productivity. In my own specialty it has done the opposite. When images were analogue and voice recognition hadn’t been invented, for each examination I reported, 90% of my attention was devoted to actual image interpretation and 10% to ‘admin’ i.e. checking patient details and reading the clinical information. With digital imaging 90% of the time taken to complete a report is taken up by negotiating the often appallingly user-unfriendly PACS and RIS software. As a result the productivity of radiologists has plummeted. We are now glorified typists for the most part.
Despite the cumulative piece-meal reversal of the traditional doctor-manager relationship I would have probably have stuck with it but for one episode I had the misfortune to witness at close hand. A senior consultant of exceptional talent, loved by all his staff and the vast majority of his patients, was subjected to a charge of bullying which was laughable. How have we let it come to this?
The solution is simple. Stop bonuses for hospital management at all levels and additional payments for clinical and medical directors, they are an anathema in the NHS. Lets get back to ‘all doctors are equal’ and ‘all managers are peripheral’. Get rid of the huge machinery that has been put in place to support management with their ‘flavour of the month’ ideas. Case in point: I was required to spent a week full-time in a room with 25 other hospital employees including managers, nurses and doctors as part of a Rapid Improvement Team (God forgive me for using that phrase). The first half day was spent drawing conceptual pictures of a before and after scene; I didn’t return for the rest of the week. On the second day I walked into my workplace to find one of the RIT members, a fellow consultant radiologist, standing in the patient waiting room holding a clipboard. He was there for the entire morning mapping ‘the patient journey’ (God forgive me for using that phrase). If he is reading this I hope he is ashamed of himself. I escaped with my sanity intact. It was a close thing. Many more doctors are doing the same. Will someone please do something before the lunatics take over the asylum?
Dr David Green, BSc PhD MBChB DMRD FRCR
Clinical Director Bermuda Cancer and Health Centre.
1st December 2011.
Competing interests: No competing interests
Mr Flook has indeed described an idea that most clinicians would agree with. It is blatantly obvious that the NHS despite the various “targets” set and despite “quick fix” changes in its structure, is losing ground in the public opinion. I couldn’t agree more that managers are not the solution. The employment of 1000 more NHS managers last year, compared to 2004, has not yet proven to be a promising solution. Nevertheless, I cannot see how managing an underfunded NHS, even with clinician-led management, is going to yield the desired result, especially when most of the targets set by the government are unrealistic, as the current financial situation stands. As a junior doctor I become more and more sceptical about my future in the NHS. The “quick-fix” tactics and politically-driven changes have to stop and instead, long-term planning and adequate funding have to be implemented in order to ensure the future of NHS.
1. Flook D. Clinician led management can fix the NHS. BMJ 2006;333:1077.
2. Jo Revill and Gaby Hinsliff. Thousand more NHS managers appointed as nurses face the axe. The Guardian.23 April 2006.
Competing interests: None declared
Competing interests: No competing interests