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. 1998 Apr 4;316(7137):1091.
Working in management
NHS managers have fundamental duty to put patients first
Editor—Many doctors find that solving management problems appeals to
their creative talents. Some have found the experience so rewarding
that they wish to continue. For others it is an emotionally draining,
and at times nerve wracking, experience. This, it seems, is what Ayres
has found, for he has emerged with a truly fanciful notion of the role
of the manager.1
The quality of the product of health care is determined by the expert
skills and knowledge of the front line workers—the clinicians—who, by
every decision they make, commit whatever resources are available. The
non-clinical managers cannot directly control their activity. Yet they
are in place to take responsibility not only for effective use of
resources but also for implementing all other aspects of government
health policy. This demands a skilled, sensitive management team,
drawing on the skills and leadership qualities of the medical and
nursing staff and pulling the decentralised clinical teams together to
form an effective, corporate whole.
Ayres concedes that operational management staff will always be
needed in the NHS. Healthcare provision, however, demands an extremely
high calibre of leadership, in addition to “operational
management.” It is difficult, but essential, to devolve power,
authority, and budgetary responsibility while at the same time
delivering health objectives such as improved health status, equity,
equality of access, and quality standards.
In one respect though, Ayres and I are of one mind. It seems to me that
NHS managers, as well as all NHS staff, have a fundamental duty to put
patients first. Tensions between professionals and managers are
inevitable. Misunderstanding of each other’s role and conditions of
work removes the likelihood of responsible and informed management
decisions. The public, to whom we are accountable, demands and deserves
top managerial skills to lead and develop its most valued institution.
Yet, says Ayres, the NHS is “already cheap and efficient” and
if the other 94% of gross domestic product was as well spent we would
be leading Europe on education and public health services as well as on
health. What an accolade for the achievements of general management in
the NHS. Many thanks.
References
1.Ayres R. A year in management. BMJ. 1997;315:957–958. . (11 October.) [Google Scholar]
Editor—It is unfortunate that Ayres learnt so little in his attached
year in management.1-1 Pejorative comment and stereotyping
are no substitute for reasoned discussion. Some managers, it is true,
earn £55 000 a year or more, but most don’t. An appointment at a
grade that is generally only one step below board level pays about
£32 000, or the same as that paid to a second year senior house
officer on 20 additional duty hours with as little as three years’
experience. All consultants earn £55 000 but most much more, as do
most general practitioners. Trust chairmen are limited to a stipend of
£20 000—no extra fees, court work, private work, and so on. Most of
the doctors I know have sharp suits and mobile phones and drive
above-average cars. Perpetuating the stigmatic view of managers as
“fat cats” is both pointless and hypocritical.
Ayres is right that public health is important and that the
internal market is nonsense. Neither of these was caused or wished for
by NHS managers, who on the whole agree with him; they were caused by
political dogma and a medical profession that had no new ideas other
than to spend more money. How does he think things can be changed other
than by high level operational and strategic management, led by
clinicians supported by high quality managers?
Finally, though the NHS is efficient, the idea that no wasteful
clinical activity remains is hopelessly naive. Every issue of the
BMJ contains examples. Incidentally, management costs in
the NHS have been falling consistently for several years and are among
the lowest in any developed healthcare system. Ayres should go back and
try again, with a more open mind. Managers, clinicians, and patients
share the same objectives. Working together, instead of abusing one
another, we might stand a better chance of achieving them.
References
1-1.Ayres R. A year in management. BMJ. 1997;315:957–958. . (11 October.) [Google Scholar]
BMJ. 1998 Apr 4;316(7137):1091.
Having public health doctors as managers is not the solution
Editor—Ayres makes a heartfelt plea for changes in the management
in the NHS.2-1 His personal view contains several
statements that many doctors will at first readily identify with,
but they merit closer attention.
He implies strongly that all managers of secondary care services,
besides those involved in menial administrative tasks, should be
medically trained. There are a few problems with this. Where are these
would-be medically trained managers? Are enough doctors willing to give
up what they have been trained in to do something they haven’t been
trained in? The author himself lasted but one year. More importantly,
why should someone who is medically trained automatically be a better
manager than someone who is managerially trained? General practitioners
and primary care teams almost invariably appoint as a practice manager
a person who is not medically trained; why should secondary medical
care be any different? Surely the best people to manage health services
are the best managers.
To a degree the author tries to circumvent this by urging public health
doctors to take up the task. Again, several problems arise. There
simply aren’t enough public health doctors to do this while there are
just 600 consultant posts nationally, and recruitment is being reduced.
Even if there were enough public health doctors. why should they wish
to restrict themselves to managing healthcare services? Public health
is about much, much more than healthcare services, and public health
trainees learn that quickly. With the recent appointment of a minister
for public health we in public health are looking forward to increasing
our joint working with the many agencies outside health services in
order to improve the public’s health. To me, the thought of being
restricted to managing healthcare services—whose impact on health,
though important, is restricted—fills me not with enthusiasm but with
dread.
References
2-1.Ayres R. A year in management. BMJ. 1997;315:957–958. . (11 October.) [Google Scholar]
