The latest research from the Nuffield Trust provides a fascinating assessment of the state of the relationship between doctors and managers. The fact that we continue to look on them as two separate tribes probably says it all, but I would recommend reading the whole thing. I was particularly struck by the finding that chief executives are the most optimistic group – which either shows that they have a true understanding that things will get better or a delusional belief in their own abilities to bring about change, depending where you sit.
Undoubtedly this relationship is at the heart of the NHS and must be nurtured if the service is to survive and improve in these hard times for us all. The patients are at the centre of everything we do and that is worthy of a constant reminder to everyone. Together we can make great things happen.
It is true that doctors and technically-skilled managers do see things differently. The skill is to harness those differences and combine them as a chimera so that the whole becomes greater than the sum of the parts and our new management beast combines the best of both organisms. I believe that allowing the two to work as closely together as possible is the true route to success. But how?
The times when medical management was described as 'the dark side' must surely now be past, with many examples now recorded of systems led by clinical managers that have bridged the gap and made things work. Without a doubt, developing a clear clinical strategy and then jointly working to implement that vision is a good start for everyone. Using patient journeys to understand the details of pathways and flow is a powerful tool. Clear and open systems of business case development and honest appraisal for implementation and allocation of resources are essential. That is called management. To understand health care as a business and the financial consequences of clinical actions may seem uncomfortable for some clinical purists, but without that no one can manage to improve.
New ways of working will certainly need new ways of managing. As we blur and erase traditional boundaries between organisations, both within the NHS but also out into local government, relying on the traditional (rather Luddite) “trust me I'm a doctor” approach to developing a hierarchy is bound to fail. We need a grown-up conversation about what we are trying to achieve for our patients with shrinking resource and how we can work together to provide that.
A good starting point is always the simple question 'is it safe?' That can expose a whole range of shaky planning and poorly thought out ideas. My other favourite test of the state of doctor-manager relationships is 'does this team have a Christmas party or ever socialise together?’
Doctors are often considered a difficult group to manage; this is true, so the trick to counter that is to give them the skills and develop ways of working to let them manage themselves. Most clinicians will rise to that challenge. Responsibility must come with accountability, but for most that is a fair deal. It should not be about control, but rather having agreed ways of moving towards a joint goal.
Incentives for change can be important, but as highlighted in the Nuffield’s report, perverse incentives against necessary change can be considerable. It is still possible for clinicians to hunker down until it all goes away – that needs to change.
Since this report was written, the Secretary of State has announced plans to create more clinical CEOs, supporting them with six months' training at Yale. Hunt’s initiative will start to bring the NHS in line with international practice. The Medical Leadership Competency Framework produced by Professor Peter Spurgeon some years ago gave a set of international comparators for how medical managers function across the world. The UK is an obvious outlier.
In most of Europe, medical management is a recognised, valued and supported career choice – usually made at the equivalent of the UK’s ‘Specialty Trainee 2’ (two years post-graduation). The training programme provides not only technical knowledge but allows an element of apprenticeship learning, although the UK will find it difficult to replicate this as there are currently so few role models available. Medical management roles are supported and well remunerated, and there is a level of stability and a tradition of permanence.
In the UK, however, the existing NHS CEO average tenure of 49 months seems unlikely to draw people away from standard clinical practice – that will need to change. There is also an unspoken disincentive to this in areas where private practice can provide a more appealing add-on to NHS practice.
David Evans is Chief Executive of Northumbria NHS FT. Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.