Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: A clinicians v managers blame game is a false dichotomy

BMJ 2023; 382 doi: (Published 25 August 2023) Cite this as: BMJ 2023;382:p1957
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

The case of Lucy Letby, a neonatal nurse who has just been given a full life sentence for the murder of seven babies and the attempted murder of six others, has dominated recent headlines and caused widespread shock.1 Much of the early discussion in the media after the verdict has focused on whether NHS managers mishandled concerns and suspicions raised by doctors about the sudden deaths of babies and potential criminal actions—and has labelled the doctors raising those concerns as the problem.23

But a polarised narrative of doctors versus managers won’t help resolve many underlying systemic issues in the NHS. Many managers are themselves current or former clinical practitioners, so the divide isn’t sharp. Many of the serious problems currently affecting culture and morale in the NHS workforce happen with doctors, nurses, and other clinical staff in influential leadership and management roles. Simplistic and politicised talk of “pen pushers,” “bureaucrats,” and “too many managers”4 ignores the fact that many of the people in charge have clinical qualifications.

Clearly, as doctors we don’t control everything, but we control more than we sometimes acknowledge. And we do need to look in the mirror. NHS staff satisfaction is at its lowest point since data have been routinely collected.5 We still too often have a culture that deters frontline clinical staff from raising concerns or challenging hospital bosses on safety, staffing, or working conditions,67 and our own professional peer groups are not exempt from responsibility. And how often do we see senior NHS managers—including those who are clinically trained—speaking out openly to criticise the government, or NHS England, or the Care Quality Commission, or flagging serious risks to patient care or staff welfare? Too often the culture is one of silence, hence complicity.

In the Letby case, and in some other recent high profile scandals and external reports—for example, around a bullying culture at University Hospitals Birmingham8 or maternity services at East Kent,9 Nottingham,10 or Shrewsbury and Telford11—senior managers with clinical backgrounds were part of the problem. Although it will take a full inquiry to establish the full facts and lessons in the Letby case, paediatricians who worked on the unit at the time have said on the record that they repeatedly raised concerns about the number and pattern of unexpected deaths and their concerns about Letby; that they asked for the police to be involved and yet were themselves warned and made to apologise.1213 The Health Service Ombudsman has already called this a “cover-up.”14

Interests and reputations

The NHS Confederation’s 2022 report Is the NHS Overmanaged? cited research finding that one in three clinically trained staff engaged in management activities of some kind.15 Around 15% of people in formally designated management or executive roles were doctors—many combining this work with clinical practice and 30% were nurses or allied health professionals—who were far less able to continue clinical work. NHS Providers reported in 2017 that a third of NHS chief executives had clinical qualifications: mainly nurses but some doctors.16 And every board will have executive nursing and medical directors who often in turn have deputies and divisional leads.

So, as clinical professionals we are not without agency, influence, or power. It follows that many of the problems affecting patient safety, service quality, the working lives and morale of staff, and organisational culture are partly in our gift as doctors and nurses to challenge and solve. And yet, doctors who raise concerns so often seem to be labelled as “challenging” or “troublemakers,” despite the notional protections of the Public Interest Disclosure Act, the “freedom to speak up,” and the General Medical Council and Nursing and Midwifery Council’s guidance on a “professional duty of candour” when things go wrong.171819

This month’s updated Good Medical Practice guidance from the General Medical Council20 says that doctors in management and leadership positions must “create an environment in which people can talk about errors and concerns safely” and that the rest of us “should raise concerns if patients are at risk from inadequate premises, resources, equipment, processes or systems.”

It can never be right that people who qualified and worked as doctors, nurses, or allied health professionals forget their original values and codes on taking up senior management roles—prioritising corporate interests and the reputations of employing organisations, positive public relations, or “managing upwards” to please national agencies, rather than helping staff keep their own working practices and their patients safe. This still happens far too often for my liking.