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Policy responses and statements
- Name of organisation:
- King's Fund
- Name of policy document:
- Commission on Leadership and Management in
the NHS - call for evidence
- Deadline for response:
- 15 December 2010
Background: The financial and management challenge facing the NHS
is considerable. The government's focus has been to reduce management
costs to protect front-line services, but it is clear that a system
as complex and unwieldy as the NHS needs to be well managed and led
if it is to deliver change on the scale that is required. The King's
Fund launched a Commission to:
take a view on the current state of management and leadership in the
NHS
establish the nature of management and leadership needed to meet the
quality and financial challenges now facing the health care system
recommend what needs to be done to strengthen and develop management
and leadership in the NHS.
The Commission on Leadership and Management in the NHS is chaired
by Professor Chris Ham, with members including Professor Ross Baker,
Dame Jacqueline Docherty, Dr Peter Hockey, Lord Tugendhat and Professor
Kieran Walshe. Nicholas Timmins will act as Secretary to the Commission.
The Commissioners will be considering a range of evidence, including
an analysis of trends in management and the role of clinical and managerial
leaders in improving performance.
The Commissioners sought evidence from interested individuals and
organisations who were invited to submit views both on the current
state and future needs of management and leadership in the NHS.
COMMENTS ON
KING'S FUND
COMMISSION ON LEADERSHIP AND MANAGEMENT IN THE NHS:
CALL FOR EVIDENCE
The Royal College of Physicians of Edinburgh (the College) is pleased to respond
to the King’s Fund’s consultation on Commission on Leadership
and Management.
The College considers that management and leadership in the NHS currently
provides good value for money relative to other international systems. However,
there are a number of issues to be addressed. The College has set out
below what it considers to be some current issues with NHS leadership and management,
and how these may be addressed.
- Communication
There is widespread evidence of a communication breakdown between managers
and healthcare professionals. Managers are criticised for failing to
involve doctors and other healthcare professionals sufficiently in the day-to-day
management and delivery of services and making arbitrary decisions, for example
in relation to the boarding of patients, the organisation of waiting lists
or the delivery of other targets. Clinicians are cited as having a poor
appreciation of the role of managers. This poor communication is detrimental
to all parties and the health service more generally.
Related to this issue is the growing separation of management from clinical
advisory structures and the reduction in the number of clinical academic staff
involved in advisory and management structures. It is imperative that
clinical academic staff contribute to service development.
To address these issues, both managers and clinicians need to develop a greater
understanding of each other’s roles and motivators to ensure they work
together towards a common end. Communication skills also need to be developed
to ensure that all parties can discuss, on equal terms, a shared understanding
of how the service can be delivered more effectively and efficiently.
In addition, managers must embrace the notion that their main role should
be to enable clinicians, nurses and staff on the ground to do their job effectively.
- Autonomy
Greater autonomy is needed at a local level to empower management. A
recent study undertaken by the McKinsey & Co, London School of Economics
and Political Science and Centre for Economic Performance’s found that
hospitals that gave managers higher levels of autonomy were rated more highly
in terms of effective management practices than lower-performing hospitals.1
McKinsey and Monitor recommend a ‘Service Line Management’ approach
which views clinical departments as analogous to business units in a commercial
organisation, necessitating the provision of greater control over activities
and input into long-term goals to clinical directors.
The College supports this notion, when combined with training and development
to build the management capacity of lead clinicians. It is noted that
there appears to be commitment to change in this direction in England.
- Training
It is considered that doctors can make effective leaders but most require
education and development and this is not covered in current curricula.
To address this, the Academy of Medical Royal Colleges and the NHS Institute
of Innovation have developed competency frameworks for medical leadership. The
application of these frameworks more widely in the training and development
of doctors would assist in ensuring a succession of competent clinical leaders. Training
in finance, health economics and service planning could also become required
components of Core Medical Training from an early stage. Additional
training options will also assist in the development of a clear medical management
career path.
In respect of lay managers, it may be beneficial them to receive training
in evidence-based medicine. Understanding the evidence-based drivers
of doctors will assist managers to influence their behaviour. Improvement
methodology appeals to clinical staff, generates data that can be used for
the improvement of the service, and demonstrates full engagement of healthcare
professionals with the management as well as the delivery of the service.
- Development of Career Path
The McKinsey & Co survey found that hospitals with clinically qualified
managers were associated with better management scores.2 The
study also found that a relatively low proportion of UK managers have clinical
expertise. The UK sample had the lowest proportion of managers with a clinical
degree of the seven countries surveyed, suggesting that the UK could
gain much by encouraging more clinical staff into management. This supports
the development of medically lead clinical directorates with clinically qualified
managers as well as lay managers in support.
It is noted that doctors often “fall” into management positions,
rather than being consciously selected for positions. The appointment
and development of clinical leaders should be a conscious decision based on
skills and ability and should be properly performance managed. There
is a real need for the development of systems to identify, cultivate and provide
clear career pathways for clinical leaders and managers. Medical management
needs to be promoted as a genuine career option, with incentives and recognition
to attract good those with the appropriate aptitude.
Such incentives and recognition also need to exist to attract clinicians to
assist management, for example, on consultative committees. Much activity
at a local level in terms of leadership of services, service development, advisory
and planning committees is undertaken by clinicians out-of-hours. It
is important that the current review of Clinical Excellence Awards does not
disincentivise such participation.
- Management of conflicts of interest
There is evidence that medical management often faces conflicts of interest,
as it must balance clinical and management responsibilities simultaneously. For
example, responsible officers have obligations to both Trust boards and the
General Medical Council in relation to revalidation of doctors. There
is a need for this issue to be considered further and discussed openly
so that guidance can be provided to ensure actual, potential or perceived
conflicts are appropriately identified and managed.
- Medical management models
Despite studies such as the recent McKinsey & Co paper, there is a lack
of evidence surrounding the effectiveness of various medical management models. Further
assessment needs to be undertaken to determine how best to ensure the successful
convergence of management and clinical advice.
In conclusion, given the current financial climate, it is essential that resource
savings from within senior management are delivered in a fashion that prevents
management paralysis and upheaval.
The College welcomes the involvement of the King’s Fund on this important
matter and would be happy to discuss any aspects of the above comments further.
1
Dorgan S, Layton
D, Bloom N et al. Management in Healthcare: Why good practice really
matters, 2010, p 3 http://worldmanagementsurvey.org/wp-content/images/2010/10/Management_in_Healthcare_Report_2010.pdf
2 Dorgan S, Layton
D, Bloom N et al. Management in Healthcare: Why good practice really
matters, 2010, p 3 http://worldmanagementsurvey.org/wp-content/images/2010/10/Management_in_Healthcare_Report_2010.pdf
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[15 December 2010]
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