Leadership in the NHS
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3375 (Published 31 May 2011) Cite this as: BMJ 2011;342:d3375
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I would be grateful if Mr Stephen Black could tell me, please, what
his occupation as a management consultant entails. He declares no
competing interests.
Competing interests: Elderly, NHS patient, no private health insurance
Clive Peedell believes that markets, by their very nature, must be in
conflict with the public service ethos and the professional values of
doctors. But his argument relies on a demonisation of markets that doesn't
stand up in the world outside the NHS. Nor is his cynical interpretation
of public choice theory convincing.
Julian LeGrand's idea (characterised by the "Knights, Knaves, Pawns
and Queens metaphor) is not a cynical assumption that all public workers
have base motivations, but a recognition that no large organisation
consists entirely of Angels. Moreover, even an organisation where every
individual was motivated purely by the public good would not necessarily
deliver optimal care to its patients. Organisations are far more complex
than a simple sum of their parts and unless they are well organised the
good motivations of their staff may deliver poorly coordinated and low
quality care to their patients. Professionalism, altruism, and the public
sector ethos are not enough. In the real world where not everyone is an
angel, it is much worse than that.
Besides, clinical judgement is sometimes just plain wrong in what it
thinks is good for the patient. One of the most criticised targets in
health is the 4hr A&E target where many clinicians argued interfered with
their clinical judgement (by which I think they meant that speed wasn't
important for patients). It has always been clear that the public did care
about how long they waited (and the target improved their view of A&E
immensely) but just last week this journal published yet another
confirmation that longer waits are really bad for patient outcomes (BMJ
2011;342: d2830 doi:10.1136/bmj.d2830).
It isn't markets that impinge on clinical freedom but the need to
coordinate many clinicians and other staff to deliver high quality care to
all patients. There are many ways to coordinate and organise people and it
is not easy to work out which is best. That is what markets are good at.
In the NHS the ideal is for providers to compete on outcomes and
efficiency (profit is not the point, spending the limited resources
available to the NHS effectively is). We need to find out which ways of
organising healthcare work best and make sure they spread across the
system. Why should we support out local incumbent supplier when others
offer a better service for our patients?
The idea that markets will destroy coordination and prevent
cooperation is not just wrong but ridiculous. We are surrounded by profit
making markets where companies that achieve enormous feats of coordination
to deliver us ever cheaper and better goods and services. No car or
computer would be built, no phone call made unless a great deal of
coordination existed. Yet that coordination exists between competitors. No
large building would ever get finished if hundreds of firms did not
collaborate closely to build it. Yet they will all compete to be part of
the team.
Peedell also wants to argue that the motivations of markets and
profits would corrupt any medic who participated in them. But, again,
experience in other markets doesn't support this. Consumers don't assume
that a car manufacturers' desire for profit will result in them getting an
expensive lemon: when competition exists the car manufacturer has to
satisfy the customer or they won't get his custom. Customers don't assume
that supermarkets offer us dangerous food and make profits by cutting
quality: if consumers don't trust them, they don't use them and the
profits evaporate. Doctors who can't be trusted wont keep their patients
if there are other more trustworthy doctors competing with them. Far from
undermining the doctor patient relationship, the possibility of patient
choice might actually reinforce it (even if profits are involved which
they mostly won't be).
The profession should not be antagonistic to all reform because of
Peedell's parody of what is proposed.
Competing interests: No competing interests
I thought Peedell's analysis was brilliant and that it should become
compulsory reading for all policy makers. He clearly identified the
tension between the medical profession and the policy makers. However it
was a a pity he could provide no other solution than a return to the pre-Grifffihs set up. (HC84 13 refers).
Competing interests: No competing interests
The insightful editorial by Shapiro and Rashid resonated with common
sense and traditional clinical values. The difficult change we have to
bring about in the NHS requires enhanced leadership supported by
responsive management. In the recent past, management has been able to
finesse the periphery of clinical care to achieve imposed process-related
targets that have generally been helpful in forcing through minimum
standards of service in some clinical areas. The majority of the difficult
work we have ahead of us, however, requires a different approach involving
responsible, informed senior clinical leadership at the centre of
necessary change. What has been difficult to achieve in the past is
tackling some of the more fundamental problems in our health care systems.
Such a 'long-term gain' approach may often require 'breaking a system'
before repairing, regenerating and reinvigorating it. The cost of such an
approach is perceived 'failure' against short term process-driven targets
that superficially condemns an organisation as failing. I would argue,
however, that this approach more accurately demonstrates insight and
recognition that some key objectives may take a finite time to deliver,
particularly when it involves a change in culture of clinical staff to
bring about that change. Such change can only be realistically and
sustainably achieved with transparent and strong clinical leadership.
Those strong clinical leaders are within our workforce now but there
remains frustration that their voices are unheard and that management only
wants to hear views that support a predetermined direction of travel. The
challenge now to clinicians is to stand up and be counted, raise your
heads above the parapet and engage to bring about change the right way, by
leading from within!
Competing interests: No competing interests
"Without clinical leadership, major health reform is doomed to fail"
[1]. Followership is just as crucial, hence the importance of engaging
clinicians in order "to see things our way".
Shapiro and Rashid suggest encompassing the notion of "ownership" in NHS
leadership to enhance clinical engagement and performance. However, their
analysis shows a profound misunderstanding of how market based NHS reform
has impacted upon the medical profession over the last 20 years.
Clinical engagement requires trust, shared values, and a shared
vision of the direction of NHS reform. However, the last 20 years of NHS
reform has seen all 3 main political parties in England support a market
based vision for public service delivery. The Labour MP and former cabinet
minister, John Denham summed this up well:
"All public services have to be based on a diversity of independent
providers who compete for business in a market governed by Consumer
choice. All across Whitehall, any policy option now has to be dressed up
as "choice", "diversity", and "contestablity". These are the hallmarks of
the "new model public service"" [2]
This pro-market neoliberal ideology supports the view that the market
is the most efficient and effective mechanism for delivering public
services. At the heart of this belief lies a concept in market theory
called Public Choice Theory, which uses the theories and methods of
economics to analyse the behaviour of public servants. Thus, all public
servants are seen as "utility maximisers" or "rent-seekers" driven by self
interest rather than the public interest.
Public Choice Theory therefore rejects the idea of professionalism and the
public service ethos, and views privatised public-service markets as
necessarily the route to optimal efficiency in production. Julian Le
Grand's work in this area using the "Knights, Knaves, Pawns and Queens"
metaphor has been particularly influential on policy making favouring this
approach [3]. Public choice is a major factor in the rise of New Public
Management (NPM), which favours narrow economic priorities and micro-management practices (e.g audit, inspection, performance indicators,
league tables, monitoring and centrally imposed targets) over professional
judgment. [4] Thus, all the things that Shapiro and Rashid highlight as
problems to achieving good NHS leadership and clinical engagement are
fundamentally related to the school of public choice and pro-market NHS
reform, which is set to increase under the proposed legislation enshrined
within the Health and Social Care Bill. I'm afraid that the idea of
"ownership" in leading NHS change will not sit well with the medical
profession, when medical professionalism itself is undermined by the
changes being implemented. This is one of the reasons why the proposed
reforms are so unpopular within the health professions. There will always
be a tension between doctors and market reforms because medical
professionalism presents an obstacle to the market because "medical
sovereignty" exerts control over the market through a combination of
cultural authority on patients and political influence over policy making
[5]. In addition, doctors like to work collaboratively to build high
quality local services. What could be more anti-market than supporting
your local incumbent provider? This is why the proposed legislation has
aimed to enforce the market on doctors through the powers of Monitor and
compulsory membership of GP Consortia for all GPs. Forcing change is
clearly not a good way to enagage or encourage ownership.
Another key point about markets, is that they undermine the social
contract between doctors and patients and damage the doctor patient
relationship, because decision making becomes increasingly based on
financial concerns rather than patient needs. Thus, the chair of the BMA
GPC, Dr Laurence Buckman, has rejected the idea of performance related
bonuses ("Quality Premiums") for GP Consortia. He stated at the BMA LMC
conference last week that:
"we will not agree to anything that gives patients the slightest
perception that we might be making money out of reducing care to patients.
This is utterly unethical"
It is no coincidence that the American medical profession lost public
support faster than any other profession during the rapid
commercialisation of the US healthcare system in the 1970/80s [6].
In summary, the authors have understood the importance of engaging
clinicians in NHS leadership, but they have simultaneously failed to
address the issue of public choice theory and market ideology and its
negative effects on medical professionalism. I would therefore ask them
this simple question: Why should doctors engage in NHS leadership roles to
deliver a market based NHS, which fundamentally undermines the public
service ethos, medical professionalism and the doctor patient
relationship?
In my view, the inability to get the medical profession onside in NHS
leadership and followership, is yet another example of market failure in
healthcare. The best solution to get effective NHS leadership is the
abandon the failed market based policies of the last 20 years.
References:
[1] Ham C. Engaging Doctors in Leadership. A review of the
literature. Available @
http://www.hsmc.bham.ac.uk/work/pdfs/Engaging_Doctors_Review.pdf
[2] John Denham MP, former Health Minister quoted in 2006
http://www.chartist.org.uk/articles/labourmove/march06denham.htm
[3]. Le Grand J. Motivation, Agency, and Public Policy. of Knights,
Knaves, Pawns and Queens. OUP 2006
[4] Bottery M. Education, policy and ethics. Continuum. New York,
2000
[5] Starr P. The social transformation of American medicine. Basic
Books, New York.1982
[6] Blendon R. "The public's view of the future of medical care" JAMA
1988 259: 3587-3593
Competing interests: co-chair NHSCABMA CouncilBMA Political board
The last Conservative government introduced the concept of a
purchaser-provider split in the NHS. This was reinforced by Labour and
will be even more so under the current so-called reforms.It seems that
this concept is no longer questioned, on the grounds that it is more
efficient in some ways that no-one seems able to measure. Many of us
working in the NHS are unconvinced of the benefits of this approach.It has
gebnerated another layer of bureaucracy involved in commissioning, often
consisting of people with little or no experience of patient care. It also
introduces a potential conflict of interest, in that the purchasers may
have an incentive to purchase less to safeguard their budgets and indeed
their own incomes. A further negative effect is localism, where
organisations seem to go out of the way to do things differently from
their neighbours and patients remain afflicted by the notorious post-code
lotteries in terms of treatments and referrals. Despite NICE this is a
problem more prevalent here than anywhere in Europe. Several generations
of healthcare professionals have been brainwashed into believing that this
is an inevitable state of affairs but of course it is not, just the
imposition of dogma by health economists who know little about health and
apparently not much more about economics. A government which does not seem
to understand what it is doing is no help. and of course we cannot expect
the leadre sof our profession to jeopardise knighthoods by speaking for
real reform.
Competing interests: No competing interests
Am I the only primary care doc who cannot understand what these guys
are talking about? Maybe anyone involved in administration should be
required to use words of only 1 or 2 syllables and be able to make their
points intelligible to 10 year olds.
Competing interests: No competing interests
Re:Markets are not always evil and doctors are not always angels
There are some glaring flaws in Stephen Black's arguments in favour
of the marketisation of the NHS.
Not all public servants are angels. But then neither are competitive
private companies, whose track record is blighted by greed and
catastrophic management failures (e.g. the Hatfield train crash).
Black mentions supermarkets. Convenient for sure, but they have
blighted many of our communities by taking trade away from our city and
town centres. Where is the competition there?
It's all very well having competing providers for procedures like hip
and knee replacements, but I really can't see how private providers are
going to see stroke care as profitable.
Caring for the elderly or people with learning disabilities? The BBC
has shown only recently how private companies have in some cases failed to
provide care that meets the basic standards of common humanity.
Black is right to say that well-meaning clinicians need to be well
organised so that their contributions provide optimum care. But is
marketisiation the best way to provide this? I suspect not.
Applying market forces to healthcare was clearly a disaster in the US
on a gigantean scale. Can't we learn from this?
Competing interests: No competing interests