The general management ‘mistake’

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The general management ‘mistake’

This post is from The King's Fund Blog

Reflecting on the small proportion (less than a third) of NHS chief executives from a clinical background, Jeremy Hunt questioned ‘whether the NHS made a historic mistake in the 1980s by deliberately creating a manager class who were not clinicians, rather than making more effort to nurture and develop the management skills of those who are’.

The development of general managers in the 1980s followed the Griffiths Report, which argued that business-like principles were required in the NHS to oversee ‘planning, implementation and the control of performance’. Griffiths’ vision was that significant and lasting change in the NHS was possible only with management techniques found in industry. Although Jeremy Hunt suggested that this policy distanced clinicians from management responsibility, the report was actually quite clear that doctors would need to take on these roles if they were to keep the freedom to choose how to investigate and treat patients.

While there are undoubtedly some cultural and structural issues that get in the way of clinical leadership, has the medical profession allowed itself to become detached from management in hospitals? Established doctors can consider a number of directions for career development, including research and education – well-trodden routes to respect, recognition and reward. Clinical leadership roles, however, have less obvious benefits and may even place doctors in conflict with their colleagues (over allocation of resources, job planning or disciplinary action, for example). As Nick Timmins described so eloquently, the drawbacks are all too apparent to clinicians thinking of making the move to ‘the dark side’.

So what would change this? We know that paying doctors more money to carry out these management roles is rarely a positive way forward – most are not motivated by extra money once they reach a certain level of pay – so perhaps the satisfaction of using resources better to improve patient care is key. Part of the difficulty for clinical leaders, though, is that they do not always have the skills to carry out the job as well as they would wish (which can be demoralising in itself). Understanding management, as opposed to research and education, is not usually one of a doctor’s core skills.

While organisations like The King’s Fund have long offered development and training to clinical leaders, the medical profession is now starting to address this issue more systematically. The Academy of Medical Royal Colleges’ has provided welcome backing for the Faculty of Medical Leadership and Management, which is attempting to professionalise the clinical leadership career path through research, training and support. Additionally, the role of the NHS Leadership Academy will expand to include an international clinical leadership development programme – starting with 30 students attending Yale – and an NHS MBA has been established with leading British universities. However, the benefits of a medical leadership specialism are less clearly articulated, and may even be counter-productive if it reduces the doctor’s clinical credibility with colleagues.

There are obvious advantages to clinical leaders being close enough to the action to have real influence. Clinicians who are engaged at this level are far more likely to add value to their organisations by being more productive and innovative (and far less likely to harm their services by showing features of burn-out, such as cynicism). It’s right for clinical leaders to accept responsibility for making difficult decisions – about financial expenditure, location of services, workforce changes and the allocation of resources – but to frame this in a professional value-based context that acknowledges our task is to make best use of the resources to benefit patients. These ideas aren’t new; in 2008 Lord Darzi (citing McKinsey’s work in the United States) described how clinical leaders with the power to make decisions improve both the quality of care and the effective use of resources. The King’s Fund has helped to promote this argument through its work on delivering better value in healthcare.

While Jeremy Hunt focused on the role of national bodies in supporting clinical leadership, individual trusts are also exploring what they can do. Within my own trust (Sandwell and West Birmingham) there are opportunities for clinical staff to learn general skills – for example chairing meetings, giving presentations or preparing a project – as well as more specific ones, such as handling staff investigations, dealing with sickness absence and improving recruitment. After Jeremy Hunt’s speech, Simon Stevens has reminded us that most management is in fact carried out close to the patients, typically by nurses and doctors who still have predominantly clinical roles. Far from being a mistake, the creation of general managers has brought valuable skills and expertise to the NHS. The error has been in failing to address the issues that prevent clinicians from maximising the value of their management roles.

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