Medical leadership: moving to the sunnier side

‘Medical leadership remains a minority interest on the margins of the NHS.’ So said Chris Ham earlier this year as he threw down the gauntlet to leaders in health.

I – and my colleagues in Leadership Development – have responded to this by trying to understand the roots of this issue and thus what changes we could make to support medical leadership while retaining the Fund’s commitment to developing the broader clinical and non-clinical community in the NHS. My previous blog on changing the systems of care sets out the challenges and the possible remedies.

In trying to determine how best to support medical leaders at all levels, we held an initial engagement day, followed by a series of masterclasses and then, on 6 December, our first development/network event for medical leaders from across the UK. We attended the Faculty of Medical Leaders and Managers (FMLM) annual conference and have continued to engage with leaders in our day-to-day work – for example, from our work on the views of responsible officers in London on revalidation. We have also redesigned our suite of medical leadership programmes.

Listening to the current challenges of doctors at different levels it is evident that although there is much more to do, there is also enormous optimism and a lot of positive energy that can be tapped into, which my colleagues and I are increasingly buoyed up by. This got me thinking about the language we use around medical leadership, and my wish as we move into 2014 is that we celebrate this optimism and, instead of talking about medical leadership moving to the ‘dark side’, talk about medical leadership moving to the ‘sunnier side’.

The panel of medical leaders at our development event last week had very diverse backgrounds, journeys to and experiences of medical leadership. The calibre of the participants, as well as their commitment to making a difference, was remarkable. We should do everything we can to celebrate that energy and to take forward the issues they have identified as important in increasing clinical engagement.

The challenges they identified – which reflected themes raised at other events – included: professionalising medical careers, listening to and harnessing the talent of junior doctors, and involving and recruiting more women to medical leadership roles. Several of the presentations illustrated the value of investing in medical leadership. Dr Tony Stevens of the Belfast Trust provided insight into the challenges of being a medical leader coming from a non-surgical, non-medical background. He observed that medical leaders often prefer to lead external initiatives, and he made a plea for them to focus their energy on leading their own organisation – including managing conflict and handling peers.

Dr Chris Jones, Deputy Chief Medical Officer in Wales, reminded us of the challenges presented to health professionals by the public holding up the NHS as a national treasure, and clinical leaders need to play their part in re-educating the public about the costs of and choices that need to be made about health care, especially if our vision of integrated care is to be achieved.

Celia Ingham Clark, who recently received her MBE for services to the NHS, reflected on the positives and negatives of being a woman in surgery – being referred to as 'poppet ' by a senior male leader, but also being encouraged to plan her next move by a forward-looking CEO. Although it was a difficult decision for her to step down from her role as a colorectal surgeon to become National Clinical Director for Enhanced Recovery and Acute Surgery for NHS England, her appointment is an important one in acknowledging and promoting talented and competent women into senior clinical roles in the NHS.

Probably the greatest endorsement for why we need to achieve a more positive outlook for medical leadership was the presentation by Dr Carolyn Johnston. Newly appointed as a consultant and a Darzi fellow, Carolyn reflected on what it is like to be on the sharp end of delivery, juggling motherhood and the sometimes unrealistic expectations of our youngest doctors. Her plea that we should be optimistic about what junior doctors can contribute to creating medical engagement and improving patient care should be heard at all levels of leadership in all sectors.

I started our development/network day with a quote from the late Nelson Mandela which included these words ‘...part of being optimistic is keeping one’s head pointed towards the sun, one’s feet moving forward…’  In the spirit of this quote, we must change our language and behaviour about the capability of medical leadership.

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Comments

#41284 Marc Farr
Director of Information
East Kent Hospitals

Important that we try and remain glass half full, face to the sun. Important that we embrace the intellectual challenge of doing more for less, right first time. Important to add to above that technology must be seen as central to delivery of transformational leadership, people brave enough to smash through the IG culture of saying no and insisting technology at work as simple as it is at home. Lead by banning pagers and paper

#41285 Vijaya Nath
Assistant Director
The King's Fund

Thank you Marc, really important relevant to @TheKingsFund: On Day 19 we ask when will health care catch up with digital developments? http://t.co/1yT4feFU7m #kfadvent https://t.co/xa67Ob6w6P . All leaders including Medical have to lead in the utilisation of technology .

#41291 John Byrne MRCGP
Clinical Director
SOuthern Health Foundation Trust

Participation by medics in healthcare leadership is vital, however it's not a divine right, the skills must be developed and competencies demonstrated. Crucially, it must not undermine our clinical our corporate colleagues by suggesting that medics are potential system saviours. Recent evidence suggest that it's about high functioning teams and not heroic individuals.

#41292 Vijaya Nath
Assistant Director
The King's Fund

Thank you, agree and important to recognise that there are generations of Medical Leaders, unlike their counterparts from non clinical disciplines who have not had development in management , leadership etc. As the we move into modernising medical careers , and opportunities to be developed are provided we will begin to be on more equal footing. Team working and working across organisations critical to delivering healthcare in 21st century. Taking a more optimistic view ,recognising more to be done.

#41294 Kostas Agath, E...
Medical Director
Addaction

Medical leadership should be seen in a framework that is broader than the traditional primary/ secondary care delivery system.
The third sector has provided a fertile ground to medical leadership, especially in the recovery orientated treatment of substance misuse - not many medical leaders know much about this evolution though.

#41295 Michael West
Senior Fellow
The King's Fund

Thank you for focusing on a positive vision of the future Vijaya - a future in which all working in health and social take collective leadership responsibility for achieving the goals of their organizations and for ensuring high quality and compassionate care for their communities.

#41296 Ruth Taylor
Deputy Dean
Anglia Ruskin University

Interesting blog Vijaya - so important to focus on medical leadership and great to read about the positivity surrounding the work that you and others are doing. As others have mentioned in the comments, it is vital that health professionals work together in leadership roles - what good is medical leadership without nursing leadership for example. Organisations will need cross profession leadership to prosper and to address the concerns around patient care that continue to be highlighted (as well as continuing to move forward with excellent practice - not trying to suggest that care isn't excellent in lots of areas). Leadership development needs to start early - with undergraduate students who can be leaders as they deliver care and who can help organisations to see where practice can improve as they move across and within organisations.

#41297 Vijaya Nath
Assistant Director
The King's Fund

The new configuration of health and social care will, I hope, make the contribution of the third sector even more appreciated . Marie Curie & Macmillan for example doing great work in this space as is Addaction and we look forward to supporting Medical Leaders from all sectors alongside all the professions that deliver care .

#41298 Vijaya Nath
Assistant Director
The King's Fund

Looking forward to progressing work with you and colleagues on Culture & Compassion. Collective Leadership the foundation of success

#41299 Vijaya Nath
Assistant Director
The King's Fund

Thank you Ruth , yes interdependence amongst all the professionals delivering care needs to be recognised as does the start point for each individual . Critical to success is supporting this early in in training Role design.This requires collaboration and change at Royal Colleges, LETBY & HEE and Academic providers to enable workforce which 21 st century patients deserve .

#41341 Liz Thiebe
AMIS Assistant Executive Director of Nursing/operations
Hamad Medical Corp

Ruth, you echo my experience. The solution and emphasis really is bigger than doctor leadership. It includes each of the professions and depending on the situation, problem to be solved, a different profession takes the lead. I like Richard Bohmers take on this. Sometimes the most appropriate leader of a team or effort is a pharmancist or ahp, or nurse and the doctor takes the back seat. The most successful organizations I have worked for or studied see this as the way to go.....so let's focus on what really works and keep shining a light on clinical teams

#41355 Damian Roland
Senior Registrar and Honorary Lecturer
Leicester Hospitals

Think working across health care professionals is vital especially in the context as good leadership being espoused by professionalism. Had some thoughts on this recently:
http://rolobotrambles.wordpress.com/2013/12/22/change-challenging-and-ch...

#41356 Stephen Webb
Consultant in Anaesthesia & Intensive Care
Papworth Hospital Cambridge

A positive blog, looking forward to the 'sunnier side' becoming a reality through ongoing support and development for medical leaders. Agree with Dr Carolyn Johnston's sentiment that we should be 'optimistic about what junior doctors can contribute to creating medical engagement and improving patient care'. Just look at the quality improvement that doctors in training can achieve when encouraged, empowered and given some direction through the Royal College of Physician's Learning to Make A Difference initiative: http://www.rcplondon.ac.uk/projects/learning-make-difference-ltmd

#41387 Emma Redfern
Consultant in Emergency Medicine, Associate Medical Director for Patient Safety
Bristol Royal Infirmary

We need to blow away the cobwebs and historical negatives associated with doctors in leadership positions. It shouldn't be the dark side, stuck between the coal face issues and the Board's different agenda. We need to move forward, support those willing to take on leadership roles and acknowledge the challenge.

#41388 david oliver
visiting fellow
kings fund

While we are on the subject of leadership by non-doctor clinicians, i have always found it astonishing that a staff nurse can become a ward sister/charge nurse just on the basis of an interview. The role is abosolutely critical to the quality of care in a hospital. It involves managing a 7 figure budget and 30 or more staff and so is the equivalent in responsibility of being a primary school head teacher a police superintendent or an army Captain yet in most institutions there is no requirement for any bespoke qualification or training or development. To compound this, nursing salary structures an career progression mean that excellent ward sisters/charge nurses are then incentivise to leave the bedside and enter managerial roles which may technically entail the wearing of a uniform but not any hands on care. If you compare the situation with medics who have to demonstrate a whole load of competencies, do entry exams and exit exams before getting a consultant post and who continue to practice clinically on call, on the wards, in clinics etc even when they become divisional directors there is a stark difference. However, the one time doctors dont need any formal training or sign of is.....when they take on clinical management roles. Often we are ill-prepared and have to learn on the job - so not that different from nurses who take on leadership roles after all?

David Oliver

#41419 Dr Dermot J Ward
Chairman
Society of Clinical Psychiatrists

SOCIETY OF CLINICAL PSYCHIATRISTS
www.scpnet.com

The Francis Report

Mid- Staffs: decades in the making

Response for the Society of Clinical Psychiatrists

“The essential unit of medical practice is the occasion when in the intimacy of the consulting room or sick room a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it. And because the community believes that this is the essential unit, it regards most highly those persons most skilled in consultation and personal treatment, and it rewards them accordingly. To the persons who facilitate the consultation, the medical administrators, the community is grateful as it should be, but not more so.”
Sir James Spence. The purpose and practice of medicine. 1960. OUP.pp 273-4. London.

Charles Moore's powerful piece on the Francis Report (Let's face the truth about our uncaring, selfish and cruel NHS, Daily Telegraph, February 9) should be compulsory reading for complacently shocked politicians and their appointed senior managers of the NHS. Anyone who has worked in the NHS over the past 20-30 years in virtually any capacity other than as business managers, has been aware of deteriorating hospital patient care standards.

Like, I hope some of us, he noted the surprisingly low key response in the media generally, and including the major political classes to the shamefulness, horror and cruelty , that between 2005 and 2009 up to 1,200 patients died needlessly at Stafford Hospital. He submits that a similar catastrophe, say, food poisoning from Sainsbury’s or Tesco food counters, an outbreak in an army barracks, or a large comprehensive, with similar death numbers over a similar number of years would result in the management being sacked. There would possibly be criminal charges brought. Instead we have Robert Francis QC arguing that those who were in charge, should remain in charge; that the problem was “the culture” rather than any specific bad leadership.

Surely this was most comforting to such as Sir David Nicholson, the chief executive of the NHS who had been head of the West Midlands Strategic Health Authority between 2005 and 2006. and was therefore the senior manager responsible for Stafford Hospital. A fortnight later Mr Moore’s column headline was “Sorry to harp on, but the horrors of Mid Staffs just won’t go away” . Also, inter alia, he pronounced forensically that Sir David Nicholson “should go”. That Sir David refuses to go because he declares he must see through the current NHS reorganisation beggars belief, given his track record. The Prime Minister’s clear support and stated belief he is the right person, despite his (Sir David’s) record, to continue in office has been quite bizarre.

Feeling as I do rather like a plagiarist, I will filch no more (and there is much more) from Mr Moore’s article but will repeat my encouragement to those who haven’t read it to try to do so. I am writing for a mainly medical readership. Incidentally, when I say ‘medical‘ I refer to Registered Medical Practitioners. In recent times ‘medical‘ has been used when nursing is actually the focus. I must confess freely also to detesting ‘medic‘ which to me has always meant a good person, with perhaps some first aid knowledge, helping to stretcher a combat casualty to hospital.

Why didn’t doctors do something?

As earlier reports were emerging in January 2010 about the dreadful scandal of loss of patient lives at Stafford Hospital the Deputy Editor, of the BMJ, Dr Tony Delamothe, published a thoughtful piece.
He dilated on the importance of systems failures in administration, management and nursing but it is only of the medical professionals he asks “Why didn’t doctors do something?” What follows is aimed partly at answering Dr Delamothe’s quite resonable question.

On February18, 2010 Rebecca Smith Medical Editor of The Daily Telegraph headlined “Culture of fear puts targets before patients, advisers tell NHS”, and stated that politically/managerial driven policies were put before patients according to previously unseen reports from three independent international health organisations for the Department of Health. The information had been obtained under the Freedom of Information Act. The Telegraph piece is about 10 column inches but is packed with hugely important findings. Such begins to answer Dr Delamothe’s question.

Deliberate sidelining of doctors (this applies particularly to hospital consultants) began in 1983 with NHS Management Inquiry (Griffiths Report) which introduced line management headed by a [mostly non-medical] chief executive. This displaced the triumvirate of senior consultant and matron assisted by a hospital secretary. The quondam natural leaders of the clinical team and innovators in medical policy were pushed to the periphery. It has to be said clearly that hospital consultants are the single most valuable asset in a health service; the most highly qualified and experienced in patient diagnosis, treatment and care of patients and leaders of clinical teams as well as being the most equipped to devise and implement effective forward healthcare planning. Any diminution of their role in hospital management and healthcare damages patient care standards as assuredly as night follows day.

But in the NHS perhaps the most basic tenet of general management systems theory - that those charged with leadership accountability and responsibility must also be given commensurate authority to enable them discharge their duties effectively - has since 1983 been more honoured in the breach than the observance. Incidentally, Mr Griffiths was a Sainsbury’s supermarket manager. Since 1983, doctors have found themselves practising increasingly in a world in which their accountability and responsibilities in the sharp end of clinical practise was undiminished but with more and more erosion of their essential authority clinically and in policy development . This was also aggravated by a built-in disturbance of the prior clinician triumvirate balance of consultant, matron and hospital secretary. With NHS managers, such as NHS CEO Sir David Nicholson and downwards the situation was reversed; they had power without serious responsibility as he currently demonstrates.

The managerial fish and the bicycle

Few doctors seemed aware of the profound implications business line management held for the profession and fewer managers were prepared to acknowledge the contradictions inherent in its introduction to the healthcare clinical workplace. Steele, in 1984 (Steele R. Clinical budgeting and costing - friend or foe. BMJ 1984; 288: 1549-51) a non-medical lecturer at the Department of Social Administration, University of Manchester examined the concept of line management, with general managers providing the impetus to manage an organisation. In this theoretical model the board of directors has overall control of the business, looking at overall strategy, including hiring and firing general managers. The unit manager is then responsible for the day-to-day running of the business and short-term production decisions. Within the unit a supervisor supervises the foreman, who supervises workers at the end of the assembly line where the final product emerges. A hierarchy of control is practised. Once “production” levels - the hospital - are reached however the line management analogue becomes confused. Even if the NHS has the hospital manager who will be responsible for the day-to-day running of the hospital, Steele notes that there are already supervisors and foremen in the service department to ensure the efficient running if departments like catering, laundering, portering etc but these are merely support activities to the hospitals main activity, the care of patients.

He states “this is where any NHS line management system (and therefore the theory) runs into trouble. Those on the shop floor who commit resources and make decisions are the major determinants in the system and not the minor ones envisaged in a traditional line management structure. Not only do clinicians not fit easily into the mould of line management, but, (averred Steele), their nonconformity is buttressed by arguments about clinical freedom.”

In 1985 Dr David St George (St George D. managers attempt to hijack community medicine , BMJ 1985;291: 1589-90.) illustrates further the poor compatibility of general management commercial ethos with that of medical practice...”in a hostile and competitive environment, where survival of the organisation is at stake, it is far more efficient for power to be concentrated in an individual who identifies with the overall goal of the organisation (maximisation of profits) but who can also take personal responsibility for short-term decisions”. Where the traditional medical model champions cooperation at all levels in clinical settings, general management must pursue control and competition in its goal of maximising profits.

Curiously, in 1985, even as government proclaimed the virtues of business management culture’s putative beneficial impact on the NHS with its deliberate side-lining of doctors’ influence and authority in NHS policy, the Association of Public Policy Analysis and management’s own journal published a monograph positing the medical model as especially suited to grappling with policy decisions (healthcare system were not specially addressed here though undoubtedly would qualify for inclusion) on complex systems, “since it combines practical knowledge with the findings of numerous analytic systems, and includes procedure for dealing with high uncertainty. {Etzioni, A. (1985) Making policy for complex systems: a medical model for economics. Journal of Policy Analysis and Management, 4, 383-395.}

Authority, Responsibility and Accountability

We do not claim that doctors and their teams develop only perfect policies. No, human frailty coupled with the core task of treatment and care of people who are ill or dying inevitably produces distress and dissatisfaction for patients and their loved ones and indeed involved professionals. But doctors, following long training, experience and responsibility are those least ill-equipped to lead the treatment and care of the sick.

This was endorsed (not for the first time) in the 1989 Working for Patients white paper on secondary (hospital) care which created, inter alia, hospital Trusts and began the removal of consultant NHS work contracts from regional health authorities to local Trusts. That government publication confirmed “...the key role of the consultant in the NHS in terms of their 24 hour responsibility for patient care. It is they who are the leaders of teams, responsible for all aspects of the clinical care of patients under their charge.”

However, as duties and responsibilities for patient were so clearly detailed, simultaneously the commensurate  medical authority required to discharge those responsibilities adequately was undermined at a stroke by removal of a freedom of speech clause 330 from Whitley Terms and Conditions of Service for Hospital Staff whereby:-
“A practitioner shall be free, without prior consent of the employing authority, to publish books, articles, etc., and to deliver any lecture or speak, whether on matters arising out of his or her hospital service or not.” Thus the near monopoly employer of doctors seeking to express concerns about service deficiencies and poor standards of care were thereby inhibited from speaking out and those brave souls who did so too often faced paying a high price, mentally, physically, professionally and financially.

A similar clause was included in the NHS Act 1948 whereby medical professionals had “complete freedom to publish views on the organisation and administration of the service without obtaining consent to do so.” (NHS Act 1948: The position of consultants and specialists. BMJ:1, 845-847).

Gagging and Secrecy

In 1987 Richard Smith, then editor of the BMJ (v295; 1633-4), had already adumbrated an increasingly ominous climate pervading that near UK monopoly employer of doctors, the NHS, in his milestone article, ”Twenty steps towards a ‘closed society’ on health” and the new phenomenon of gagging doctors and concern for freedom of speech. By 1994 that same journal BMJ was moved to publish a series of four related pieces under a composite title “The rise of Stalinism in the NHS” (v309:1640). These witnessed that senior doctors and nurses “were convinced the NHS was beginning to be an organisation in which people were terrified to speak the truth”.  HM Opposition in the House of Commons objected to Clause 330 removal from new trust working contracts and sought reassurance that a similar clause would be re-inserted into Trust contracts. This was rejected by government as were observations of a similar nature made by the British Medical Association, our doctors’ trade union. (Originally doctors did not want the BMA to be a trade union but government at the time insisted it should as, otherwise, it would not negotiate terms and conditions of employment with the profession). Perhaps because of its formal attachment to the NHS as putative most effective national healthcare delivery system in the developed world, its (BMA’s) activities have tended, sadly, and with doubtless the best of intentions,to be nevertheless more disapproval rather than vigorous response.

It is difficult to recall such a massive gap between original aspiration and reality as that embedded in the NHS and what that healthcare system has delivered to the population as exemplified by Mid Staffordshire under the micro mismanagement of politicians. What is also remarkable is what good clinical care doctors and their teams have achieved despite NHS politician-driven maladministration interference in their day to day work.

Perhaps the above points go some way towards answering Tony Delamothe’s pertinent question. My query is why didn’t the BMA doctors’ trade union, do more, to preserve and pursue freedom of speech for doctors. Was It too intimidated? It seemed, and still does seem, that despite earlier blatant NHS systemic flaws warnings such as Garland’s Hospital, Carlisle 2001, Maidstone and Tunbridge Wells NHS Trust, the was a blindness to the possibility of a disaster such as that of Stafford Hospital horror which is not the first, but the worst so far. The failure of the Care Quality Commission’s (CQC) “inspections” must render that organisationr as utterly unfit for purpose and an inexcusable failure especially in relation to Stafford Hospital.

Yet, Dr Delamothe’s question haunts us. Not only was the management of national health services corrupted, but the day to day patient care and work security of doctors were undermined by institutional intimidation. Those doctors who voiced legitimate criticism of flaws within existing patient care systems could be dismissed by business managers as merely self interested or “failed team players” and perhaps sent on “garden leave” with full pay; a shadow cast over them and unable to obtain posts elsewhere as they were branded within the whole NHS system. Commonly they could find application for posts elsewhere, even if shortlisted, unsuccessful although there had been no formal charges against them. There was one consultant who was suspended for twelve years before being reinstated when it was finally found she had no case to answer. The Suspended Doctors Group (SDG) was founded by the late Dr Harry Jacobs, a consultant psychiatrist, and Dr Peter Tomlin, a consultant anaesthetist each of whom had been suspended at different times. Both were found to have no case to answer but nevertheless suffered intense emotional upheaval and ostracism from many previous colleagues.The group was was formed under the auspices of the Society of Clinical Psychiatrists but suspended doctors from all medical and surgical specialties have been welcomed.The emotional trauma for suspended doctors was vast as is quite understandable. Suicides amongst suspended doctors ceased (with one exception) following the formation of the SDG and its renamed Doctors Support Group (DSG) which continues its work with Dr Tomlin as president. The advent of so-called whistleblower legislation has, to date, not been as helpful as hoped.

Healing the nations’ healthcare system

There has been much recent talk of “returning power to the doctors”. This, I submit has so far been mostly political window dressing. The following constitute some concrete proposals, rather fewer than the 290 suggested by Mr Francis.

We submit that the NHS business management system as imposed in 1983 and its subsequent development has not only failed our national healthcare system but actively damaged it by its inherent inappropriateness as outlined above. The immediate evidence, Mid Staffs, is but the large tip of an understandably larger Iceberg of patient neglect.

A freedom-of-speech clause in consultant contracts, abolished in 1989, should be restored. The present system is redolent of the now thoroughly discredited old Soviet healthcare system, an observation originally made by Mr Michael Portillo.

The restoration of essential consultant authority commensurate with their duties, responsibility and accountability in recognition of their central importance in medical hospital healthcare delivery to patients.

Restoration generally, at hospital level, of senior consultant, matron and hospital secretary/administrator triumvirate; the senior consultant being elected by peers for a limited period to be decided. The custom and practise of the ward sister or charge nurse accompanying the consultant on ward rounds should return, where it has ceased, as routine order of the day. Furthermore, the practise whereby, in some areas, family doctors have been referring patients to a “team” rather than to a named consultant should cease forthwith. It is unsafe and a patient so referred may never see a consultant for proper diagnosis and treatment plan purposes.

Crown Immunity was introduced in the early1990s for all NHS doctors without effective opposition. Prior to that doctors held individual medical defence insurance. This conferred on doctors the security of independent individualised protective legal cover for each doctor so insured. The reason the profession objected was it could mean that the local health authority could be prepared to settle out of court in a charge of alleged negligence or misconduct against a doctor because it might be less costly than pursuing it through the courts. If such were the case there could be no formal clarification of an innocent doctors reputation. Restoration to the individual medical defence insurance position would further reinforce the necessary doctor confidence and legal security which is so essential to effective patient care.

The treatment of “whistleblowers” on observed NHS system failure exposure has been both disgraceful for the whistleblower and wastefully expensive for the taxpayer. Recently, consumer affairs journalist of the year Ian Cowie, (Daily Telegraph, Whistleblowers should be rewarded, not ruined” Feb 23,2013) published a thoughtful piece (mostly he writes on financial matters) of legislation changes in the US whereby whistleblowers are financially rewarded. That is certainly a path worth exploring in the healthcare context.

The ‘friends and family test’,whereby patients will be asked whether they would recommend NHS services to people they know, is being rolled out and is sadly typical of backward government thinking. While it is important that patient complaints and dissatisfaction are appropriately addressed this Society considers that the changes we urgently recommend by improving patient clinical care would so improve the services that the number and sorts of complaints exposed in the Francis report would be much less likely to occur. There is a parallel here with W Edwards Deming’s Total Quality Management (TQM) which the US toyed with for some years in its postwar motor industry and discarded. Essentially, it involved the goal of production process perfection from the earliest to the final phase, aiming at elimination of end-failings rather than inefficient and expensive post production expensive corrections. Following the US rejection Deming, a mathematician and statistician, then sold it to the Japanese with spectacularly successful results in its motor industry while in Detroit, US motoring industry descended into near total destruction from which only now is it showing some signs of emerging.

Reinstatement of tax relief on health insurance premiums. This, was 7introduced by Mrs Thatcher’s government. Its abolition was one of the first acts of the new Labour Government in 1997. The person who takes out such insurance is more a latter day saint than someone to be despised (this has applied particularly to Labour politics). He or she has paid their so-called insurance stamp (though such insurance fund does not exist), and thereby shortens the waiting queue of those less fortunate and contributes overall more to investment in healthcare.

Restoration of Community Health Councils (CHCs) in England.The key function of the CHCs has been to represent the interests of the public in local grass-roots health service in their district. Abolished in 2003 by the Blair government they continued in Wales for reasons never properly explained by Mr Blair.

Let me end on a relevant comment on the NHS from a New York physician at a time when the worrying health economics ethical issue for doctors holding health budgets figured in the BMJ.

“New York state law may shed some light [on this] question.
Here we’re required to use our best judgement in making our medical orders. We may do neither less nor more, and we may not weigh costs and benefits. So clinical freedom is meaningless: there’s no freedom and no choice, and rightly so.
Breach of this standard is ipso facto malpractice. Furthermore responsibility for professional acts rests with the treating physician and may not be transferred to employers, government programmes, hospital officials or committees, chiefs of service, commissioners and the like. We have no professional duty to any such party; our obligation is solely to our patients.
Who, if anyone, will pay to have our orders carried out remains an entirely separate question.....if constrained by budgets and policies we fail to tell our patients what we think is best for them they’ll never know and will never be able to act in their own interest.” Carlen R. BMJ 1989: 298; 49-50.

It is an irony that a colleague from the US, a country we on this side of the Atlantic tend to regard as financially more hardnosed in health care funding, should clarify this matter so pithily for us.

Dr Dermot J Ward, Chairman, Society of Clinical Psychiatrists, March 2013

#41423 Brian Reid
Consultant in Obstetrics, Clinical Director Maternity & Children's Svcs
Royal Berkshire NHS Foundation Trust

Thanks Dermot, cheered me up no end..
Getting back to the sunnier side of leadership, I think it is most important that we encourage colleagues from all backgrounds and grades to contribute to the leadership and management of our NHS. The over-representation in medical management of middle-aged male doctors (like me) is slowly changing. That is a reassuring and refreshing trend and I suspect that events held by the King's Fund and FMLM will further enhance this.

#41426 David Levy
Regional Medical Director
NHS England

My observations from Keogh Review visits is the need to train and support Medical Directors to undertake the new role they now have.

4 of the 14 trusts visited by the Keogh process have or are changing their Medical Director.

The Medical Directors responsibilities have changed from keeping an eye on the Consultants and turning up to Board meetings to a much more wide-ranging post.

Revalidation, managing quality with the Director of Nursing, setting the culture of the organisation with others on the Board, managing Medical manpower and training of junior staff are all big tasks. However, many Medical Directors wish to remain part-time. Can Health Organisations afford part time medical leaders.

We need to offer more opportunities for trainees to experience and understand Management and develop good Leadership skills.

More importantly, having worked as a senior medical leader elsewhere in the world, we need to lose the "can't do" mentality we are labelled with by other western countries, and all do something meaningful to improve patient care in 2014

#41427 david oliver
visiting fellow
the kings fund

One thing I would add....its all very well the likes of David Prior and others saying "where were the doctors"? But if you are employed by an organisation, dependent on it for revalidation, career and salary progression and de-professionalised by having to account in a job plan for every hour of your time, with the supporting professional activities (SPAs) for training junior doctors, your own CPD, clinical audit, research, quality improvement, external leadership roles etc constrained to a fantasy 4 hours a week, this does not exactly encourage the kind of fearless, crusading, challenging behaviour that people might want to see.

On the other hand, it does little good to pine for an illusory golden age where hospitals could be run by a matron, a hospital secretary and an elected "senior consultant". The pressure on hospitals, the massive increase in emergency activity, the much shorter length of stay, the infinitely greater complexity of investigation, treatment and evidence-base mean that we can't replicate James Robertson Justice and Hattie Jacques. We also need to acknowledge that in days gone by (and I have been an NHS doctor since the late eighties) doctors as leaders were not beyond reproach. Private practice when they should have been in the NHS. Empire building. Bullying. Bristol Heart? Liverpool organ retention. No attempt to deal with patients waiting for days on trolleys. Waiting lists managed for the interest of surgeons rather than patients. Older frailer patients neglected in favour of more "glamorous" conditions affecting younger. Empire-building. High-handedness. I have seen it all and I am a hospital consultant myself. And as for the fixation with "matron" let us not forget that in a time when we could often do nothing more for patients than bed rest, when length of stay was far longer, then hygiene, nutrition and "back rounds" were all we could offer. We also had Nightingale wards, with little privacy, regimented visiting times, little respect for privacy, nurses unable to take on any "extended roles" such as iv antibiotics or catheters, let alone prescribing, vascular access etc. And hospitals were hierarchical, with junior staff feeling unable to challenge those in "authority" . There was also little focus on personal development, appraisal, patient safety etc with a "see one do one teach one" mentality. Nor were we focussed on respecting the needs and wishes of patients - with paternalism writ large. Think Buxton Chairs for instance.
So, whilst I completely endorse the idea that clinicians should lead organisations and should be in the vanguard of quality improvement, can we please abandon "golden age" notions. Its like "bring back the cane" debates. That ship has sailed.

Happy New Year

David

#41431 Vijaya Nath
Assistant Director
The King's Fund

Thank you David , I accord with your views on working on new ways of achieving medical engagement , we cannot continue in 2014 to work with the ideal of another era . The demands on all health professionals and Drs at this time requires new approaches.

#41432 Vijaya Nath
Assistant Director
The King's Fund

Pre the Keogh review Medical Leaders and MDs in acute , mental health & primary care settings moved to a realisation that their roles were increasingly needing 100% of their time. Few ,for all the reasons we have heard were prepared to step off their clinical roles . Your question re Can we afford part time medical leaders sits at the heart of the shift we need to make in developing & supporting individuals in these roles .

#41472 david oliver
visiting fellow
kings fund

It has been said that "every general makes the mistake of fighting the last war". I think we need to accept the crucial importance of clinical/medical leadership in the context of the 2014 landscape and think how we move forward constructively from where we now are, rather than where some of us might still prefer to be. And also to acknowledge that the Status Quo, pre Griffiths Report, was far from perfect, with far too much self interested behaviour from senior clinicians. For all that, I am a clinician and work with them day to day and know that they are overwhelmingly pre-occupied with delivering high quality patient care. we need to tap into this

david oliver

#41473 Claire Dow
Consultant Geriatrician
Barts Health NHS Trust

Many thanks Vijaya for an interseting blog and the thoughts provoked "below the line".
I think we do need to engage our young colleagues in how we improve systems in the hospital and move away from the "them vs us" mentality that many doctors have (including mydelf as a trainee). With some trainees only spending 4 months in a placement this can be difficult, but they often have seen ideas work well elswhere that can be applied in their current posts and ned to be encouraged to help bring about the change.
As well as the trainees we need to have systems to engage newly appointed consultants and not lose the enthusiasm that they bring to the post when appointed. Effective change can be hard to bring about and learning to take the longer view that some systems can be very slow to change whilst small incremental changes may be more effective is an area that I'm still learning as a relatively new (6 years in post) consultant.

#41476 david oliver
visiting fellow
kings fund

Dear Vijaya

With regard to the second part of your comment in response to me, I think there is a halfway house. We should be proud as doctors that we continue to be on call, on ward rounds, in clinics, in GP surgeries even though were are Divisional Directors/CCG leads etc. We have the moral high ground here because other clinical professions such as nursing abandon hands on care, and as a consequence lose credibility with colleagues and grounding in realities of frontline practice. There is a lot to be said for "do as I do, not as I say". Try watching "undercover boss" for a stark reminder of this. Look at the Army or Navy where senior officers go into battle with the rest of the troopsThe bosses end up moved and enlightened as consequence. And I would strongly advocate that senior nurses/therapists/pharmacists in leadership roles continue to practice clinically for some of the week. However, we also need to acknowledge that leadership requires selection of people with the right traits, training, development, bespoke qualifications and not "buggins turn". Though we need to remember that career health service managers fiercely resisted any attempt to move towards registration, regulation, professionalization on the grounds that "we are a trade not a profession". So we have all this focus on giving clinicians leadership skills yet are happy for lay managers - finance or HR directors accepted to "see one, do one, teach one". And we have people in charge of the whole NHS who have no background whatsoever in the service. Level playing field?

David

David

#41477 Brian Reid

David,

I agree entirely that credibility with frontline staff is key to effective leadership and for Medical Directors that is essential. However, as David Levy points out the demands on MD's are significant and a continuing clinical commitment in such posts in a large Trust may be little more than tokenism. However, a cohesive group of CD's with their feet firmly on the ground working with the MD should provide a solid framework for effective medical leadership - but it isn't always that simple.
The military analogy only goes so far - not all the officers go to war. I know; I served in the RAF Medical Branch for 16 yrs.

Brian

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