Wednesday, January 21, 2009

Turning Doctors into Managers

Please refer to the NHS Glossary for explanation of abbreviations and acronyms mentioned in this post.

The UK parliamentary Health Committee's review of Lord Darzi's NHS Next Stage Review (NSR) raises many issues and concerns - too many for me to discuss here.

But one section of the committee's report, "Measures to improve he leadership and workforce of the NHS", is worthy of comment.

Firstly, the Health Committee notes the MTAS clinician training fiasco of 2007 about which it has already commented in a previous report.

Now let me quote from the Health Committee's current report into the NSR:

Turning doctors into managers

167. The NSR recognises that "in parts of the NHS, competing interests between clinicians and managers has, on occasion, been against the best interests of the patient". At the heart of Lord Darzi's proposals for improving leadership is his aspiration to bridge the gap between the two groups and to encourage doctors to become managers. Mr David Nicholson claimed that:

We are quite unusual as a health system in this country of having relatively few clinicians in the most senior posts and I think it shows in terms of the focus of our work.[209]

According to the NSR, the new Leadership Council will identify and train talented and suitable doctors who will become senior SHA managers of the future. According to Mr Nicholson this could be achieved fairly speedily:

Our aspirations are that within three years on every shortlist for a chief executive job in the country there will be at least one appointable clinician who will be available for appointment.[210]

Doctors who become managers will be required to keep their clinical skills if they wish to re-enter medical practice. Although some may abandon medical practice, others will wish to remain clinicians first and managers second. This will mean both time and funding will have to be made available so that clinicians can maintain their skills.

168. Witnesses agreed that it was desirable that more doctors should become managers in the NHS. However some had concerns about certain obstacles in the way of achieving the proposal. Dr Hamish Meldrum, of the BMA, argued that:

Unfortunately, and I think it probably happened because of successive changes and reorganisations and everything else, there is a feeling that in some areas the quality of management is not very good and that clinicians who get involved in that—I hear expressions like they have gone over to the dark side or they have sold out or they could not hack the day job.[211]

Dr Meldrum also claimed that the debate sometimes overlooked the point that "The main reason we went into medicine [was] to be doctors and clinicians, not to be managers".[212]

169. The reluctance of doctors to take on managerial roles might help explain why previous attempts to increase the number of clinician-managers had been unsuccessful. The King's Fund for example told us that:

The last three attempts to secure a national approach to developing the most senior leaders has been marked by less than impressive outcomes.[213]

We were informed that there was little reason to be optimistic that the NSR would succeed where other initiatives had failed:

This policy is ironic as during the Blair years it was proposed to create a NHS University to meet these problems. This was abandoned expensively. Will these proposals thrive where the NHS University failed? The need is obvious but the policy drive has failed in the past![214]

Furthermore, the NSR states the DoH "will identify and support the top 250 leaders in the NHS", and establish a new NHS institution for both managers and clinicians to develop training schemes for all NHS employees.

I am concerned.

Doctors are good managers. They are good at managing my healthcare. They are good at diagnosing my condition, prescibing my medication. Kezia's consultant, John Grainger, has been bloody marvellous. He is a trained paediatric haematologist. I assume he does not have an MBA.

Here the Minister of Health in successive governments (we've had several) has been a clinician with no training in management. Dr Lima, the only orthopaedic specialist in the country, who sees every broken/fractured bone in a population of 160,000, and is well-received and respected. Two or so governments ago he was made Minister of Health but he insisted on continuing his orthopaedic work at the country's only general hospital.

If John Grainger, our trained paediatric haematologist, is invited by the government to become one of the 250 and will need to be trained as a manager, and will need to keep up his clinical skills if he ever wants to continue treating kids such as Kezia, which was surely his primary motivation to enter the medical profession, then ... how will he be compensated and how will kids such as Kezia be treated

A good General Practitioner practice in the UK has a non-clinician practice manager.

I think Lord Darzi's recommendation that clinicians are trained to be managers sucks. My own experience in a completely different field of work is that a technician (which a doctor is) does not (always or necessrily) make a good manager or supervisor.

The NHS managers, if they were good, would be working in the private sector or would be working in he NHS through theire public service conscience.

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