Abstract
Will shifts in policy lead to more doctors managing the NHS? Michael Day reports
It's not just patients who might benefit from more doctors but the service itself, according to the UK National Health Service's chief executive, David Nicholson. He told the annual conference of staff grade and associate specialist doctors in June, “Within two years, we want a doctor applying for every chief executive post advertised. Where clinicians and managers work together,” he said, “There is almost nothing you can't achieve.”
Leading doctors have welcomed the call for more clinical input in the running of the NHS, although many have raised doubts about whether Mr Nicholson's two year deadline for getting medical applications for all chief executive posts is remotely realistic.
None the less, after the Conservative party's pledge to do away with central NHS targets, the pressure on the government has increased to give local clinical concerns higher priority.
Mr Nicholson is relying on the appointment within the next two or three weeks of the first NHS medical director, to speed up the process. He is understood to be reluctant to comment further until the medical director has had a chance to establish his or her position on what has become a key policy area for the NHS.
Doctors prioritise safety
Other senior figures in the NHS have praised David Nicholson's calls for more medical chief executives, however. Gill Morgan, a former doctor and chief executive of the NHS Confederation, the representative body for NHS organisations, said, “It would be very good indeed to have more doctors in NHS chief executive positions.”
According to Dr Morgan, “Doctor-managers that I've known tend to prioritise patient safety and see the importance of engaging other clinicians in management decisions.”
Another doctor, Jennifer Dixon, head of policy at the King's Fund, an independent think tank, says, “The more doctors as chief executives the better because so much expenditure is done at the level of doctor and patient, and if you really want to boost quality and efficiency you have to push this agenda forward.”
Awkward surgeons
She adds that doctor-managers are better at discharge planning and better at dealing with awkward consultant surgeons. “Unfortunately there are some surgeons who simply won't listen to other people if they're not doctors,” she says. “And in general terms their [doctor-managers'] medical knowledge allows them to make informed decisions about the doctor-patient interface.”
Tom Smith, a senior policy analyst at the BMA, says, “Where doctors and managers work together, the quality of care is much higher. I certainly think it's a good thing to have more doctors in chief executive posts.” He adds, however, “I think David Nicholson has misunderstood what we really need.”
The gulf between chief executives and consultants was memorably illustrated in Can Gerry Robinson Fix the NHS? In this television programme from BBC2 and the Open University the management guru Gerry Robinson tried to help reduce waiting times in Rotherham NHS Foundation Trust, a relatively successful NHS hospital. The programme showed how it was necessary to get consultant surgeons to change their work practices to boost productivity.
Gerry Robinson did not come out strongly for or against greater use of doctors in management. But he does think that management skills are to a large extent something that people are born with, and as such should be highly rewarded. “I think management skills are a relative rarity . . . and unless you're prepared to pay for that capacity, you're not going to get it. You're really not,” he said, reflecting on the programme.
Same baggage
Tom Smith fears the response of government and senior civil servants to such problems will be to shove as many doctors into NHS posts as possible—and see them weighed them down with the same baggage that NHS chiefs have currently. “I've been a senior NHS manager, and it's hard to overestimate the level of top down influence from Whitehall. It's there all the time, like a spectre.
“There are three approaches you can take. You can turn doctors into managers, or you can try and make management more clinically sensitive, or you can try to recast NHS management making sure that clinical priorities form the basis of all decision making. The mistake that Nicholson might make is that he seems to be opting for the first choice, in that he wants to simply turn doctors into managers.”
Some observers note, however, that there is not much danger of this given the current paucity of doctors running trusts or health authorities. With just two or three medically qualified acute trust chief executives and fewer than 10 holding equivalent posts in mental health units and health authorities, doctors currently form a marginal presence among the most senior health managers.
Rationing and balancing
Gill Morgan thought that a few changes were happening at the top of some NHS organisations that meant it was almost impossible to be precise about exact numbers.
She has worked as a doctor and the chief executive of a health authority and admits it would be naive to think that most doctors would aspire to running a hospital—or would have the aptitude for the job.
“There is a real issue about whether every doctor wants to be a manager. I'm not sure every doctor has the skills to be a senior manager—or the desire,” she says. “The job requires a different kind of contact with people and is much less immediately rewarding.” The key challenge, she says, is to find doctors who are willing to accept the very different challenge of dealing with rationing and balancing the needs of one group of patients with those of another.
Too little power
Currently, every acute trust has a medical director, who is supposed to bring clinical expertise to bear on such decisions. There is, however, a widespread sense that this group of managers has too little power and influence.
“Medical or clinical directors are usually the most unhappy group in many hospitals,” says Tom Smith. “They're stuck in the middle. They see the worst of the clinical and management behaviour.” Morgan concedes that this is often the case: “Often they don't have the training and support they need, and they're chosen for the job simply for their seniority as clinicians not because they have any desire or aptitude for being senior managers.”
Robert Naylor is the non-medically qualified chief executive of University College London Hospitals NHS Foundation Trust. He claims that unlike most chief executives he has effectively devolved the running of the hospital to his three medical directors.
“Unfortunately, a lot of places have medical directors that just play at being managers. They don't have budgets; they're effectively advisers. This needs to change.”
He too wants to see more doctors in positions of power: “I agree with David Nicholson that there are far too few examples of doctors in these positions. But I think that the medical profession itself in the form of the royal colleges and the BMA has a responsibility to change things.
“It needs to recognise that doctors represent the greatest untapped pool of intellectual and managerial resources in the NHS, and that many doctors can make a greater difference to the health of individuals by adopting these roles than they can by treating individual patients.”
Training for undergraduates
As such he welcomes moves to incorporate management training into undergraduate medical courses. The project is being run by the Academy of Medical Royal Colleges and the NHS Institute for Innovation and Improvement, which is supported by the NHS Confederation.
Patricia Hamilton, president of the Royal College of Paediatrics and Child Health, is chairing the project's steering committee. She hopes that by March next year the results of the “enhancing engagement in medical leadership” project will be presented to the General Medical Council and Postgraduate Medical Education and Training Board for approval.
The plan is to begin teaching management and leadership skills to undergraduates and continue into postgraduate education. “This won't be an optional extra,” says Dr Hamilton, “Everyone will do it, and I think everyone will benefit. All doctors need to exhibit leadership skills sometimes.
As much of a difference
“But the project is also aiming to find the leaders of the future—the doctors with the ability and desire to be senior managers. The new courses will show these people that they can make as much of a difference being managers as they can being clinicians.”
The proposed changes to medical education have not been costed yet, but Dr Hamilton says they need not be very expensive. “This is not going to be about sending people on special courses. It's about changing attitudes and priorities.” She says that both medically and non-medically qualified people would be involved in teaching management skills.
Stephen Smith, dean of the faculty of medicine at Imperial College, London, is creating a programme that combines training as a medical doctor with a masters degree in business administration.
Gill Morgan says, “We're never really going to change things in the NHS unless you ensure that in every room where serious decisions are being taken there's a doctor with a senior management role and proper responsibility, who has serious management skills and an interest in management.”
But will big changes take place within the two year timescale mentioned by Mr Nicholson? “That does sound very optimistic,” says Dr Hamilton. “I wouldn't like to put a time frame on it, but hopefully within five to 10 years we will see big changes. I think we are starting to move in the right direction.”