This is a question I have been asking myself more and more in recent months, sparked by a nagging worry that holding docs to account for balancing budgets or hitting targets might not be fair or appropriate, or indeed the best use of a scarce resource.
It is taken as read nowadays that medical leadership is ‘a good thing’. And it is. But what exactly should we be expecting of those brave souls who step forward?
When it all started about two decades ago, the main role was the provision of advice (often colloquially termed ‘clinical common sense’) to management. I recall though, that as clinical management became established, a view developed that without budgetary control, there was no real power. Power lay with the one who held the purse strings, it was believed, and all aspiring medical leaders were told ‘make sure you have control of the budget’.
This did happen, but interestingly it was normally managed day-to-day by the manager. And if it became overspent, it was normally the manager who was held to account. A similar thing happened when targets were introduced – the clinical director was nominally responsible but the manager was usually the one who was performance managed, and suffered the consequences if achievement was not up to scratch!
And it has largely remained this way, so that presently we have a rather illusory situation whereby the clinical director nominally holds the budget, while the manager manages it and is held to account over it.
My current view is that generally it is not a good use of a doctor’s time and expertise to ask them to take on the role similar to that of a senior general manager. After all, we have managers who are specifically trained to do this. And in fact, holding the purse strings confers only one sort of power, and it is a sort that soon vanishes when times are hard and the need to save outweighs the ability to spend.
Real power comes from respect and credibility, the intellect to understand complexity, and the ability to influence colleagues, superiors, and subordinates in a constructive way. The truly effective medical leader can understand the clinical issues, scan the clinical horizon widely and far forward in time, and understand the implications for their own service or organisation. They can then go on to devise a strategy, gain support and buy-in, and oversee the implementation of it.
Clinical strategy is therefore a key role for medical leaders, and a vital one in these changing and uncertain times. Another one must be the achievement of good clinical outcomes. The effective clinical director will be measuring and monitoring valid indicators of clinical efficacy, and working with colleagues to understand areas of weakness and bring about improvement.
Finally, senior management cannot run a successful organisation without sage advice from doctors. Insight into future developments, help in understanding health issues and how to address them, advice on best use of resources, and an understanding of where the ‘clinical view’ lies on big issues of the day. And ‘yes’, advice on those budgets, and in particular how to stretch them still further without creating adverse consequences for safety, care quality or patient outcomes.
A very different beast then to a general manager. A complementary role that can underpin a very effective partnership between clinician and manager.
Have I got this right?
This article was published on HospitalDr on 21 August 2012
John
Always a good read Mark, thanks. I just want to add a couple of points if I may.
The first is to say that the much desired and urgently needed transformational change is almost certainly made more difficult to achieve by the incessant churn of senior staff. While this may be unavoidable, the maintenance of a steady strategic course is endangered by this – in seven years or so, my hospital is (including significant interims) on its fifth CEO, its fourth DoF, and its fifth Head of Governance.
Most incoming Execs, understandably, do not see their future success and promotion prospects optimised by a policy of ‘steady as she goes’, but the result for the organisation is yet another REorganisation, with the crucial middle tiers of managers (whether clinical or not) being moved into altered structures and new titles. By the time that has become embedded, the next Exec is usually hoving into view, fully equipped with their own – probably different – ideas!
The second point is to do with the Emperor’s Clothes, and I will not labour it here. It is, simply, that it may be about time to begin to recognise that there will not be enough money to fulfil unstoppable public and political expectation, and the sooner this is explicitly recognised, the sooner that expectation can be managed. That is not a pretext for failing to pursue improvement with every bit of commitment we can muster, but we need to do it in the real world rather than on Planet Lansley.
Oh, and isn’t it about time that the NHS stopped rewarding senior failure by re-deployment and re-emergence?
MarkN
Hi John, thanks for commenting. The problem of ‘senior churn’ is a difficult one, particularly for maller organisations. I wonder though, whether the problem is the lack of a viable and positive/exciting strategy? I suspect that a clear and forward-looking strategy, developed and supported by the Board, would be a compelling reason for ambitious execs to stay longer. After all, there are names and reputations to be made for those who ‘pave the way’, whether in small or large organisations. Also, I have noticed that smaller organisations (not yours particularly) do seem to be more concerned about independent survival than anything else, and this may not always be compelling for those with out an overriding ‘local’ interest?
Norman Briffa
Excellent Post as usual Mark. I suppose one of the roles of the clinical leader is to communicate financial issues to clinical staff and therefore maybe God Forbid share the burden of cost cutting with the manager. The general manager being the focus and target of opprobrium as the chief dicer and slicer of services is not helpful at all. They are solely expected by CEOs and CFOs to deal with cost cutting and they do this in the fastest way they know best – cutting beds and stopping recruitment. If clinical leaders and by implication clinical staff were on board then maybe the smart reorganisation or redesign of pathways/services that needs to happen before the slicer starts whirring may actually happen.
MarkN
Thanks Norman, I agree entirely. Somehow, we have to move away from simplistic cost-cutting and on to genuine service transformation. It’s difficult, spinning plates may fall in the meantime, and docs and other clinical staff need to be involved. But I cannot see any other way forward given the broader economic climate and the continually rising demand?
David King
Great post, thanks Mark,
Perhaps one role of a good medical leader is their ability to act as a bridge between their clinical colleagues and the wider organisation, helping to surface and champion good ideas and people. So they will need some awareness of the business processes (finance, strategy, governance, operational management, etc) in order to to engage with the body corporate and make progress.
But, in general, I agree with your point – medics are a scarce resource and the emphasis should be on developing a shared approach where the talents of all the professions are used to best effect.
MarkN
Thanks David. I agree, the bridging role is a crucial one
Simon Dodds
Hi Mark,
Excellent post! In general doctors are not trained as managers nor managers as doctors – so some form of collaboration is needed – irrespective of who is leading/following/responsible/accountable. For this there must be some degree of common ground, shared language and understanding. It feels to me that there is an unstated assumption that between them the doctors and managers have everything that is needed. I’m not convinced this assumption is valid and I have some evidence for this. I am currently reading a book called “The Leader’s Handbook – Making things happen and getting things done”. I was attracted by the pragmatic title and the subtitle “A guide to inspiring your people and managing the daily workflow”. It is by Peter Scholtes and was published in 1998! It is exactly what it says on the tin – a “detailed how-to guide” and I have to say that I have almost never heard doctors or managers talk in the terms he does. If I had read this book a few years ago it would have saved me a lot of time – and I guess that may be is true for others too. Doctors and managers. Maybe we all have lots to learn?
MarkN
Thanks Simon. You are right we do tend to assume that, collectively, we have all the skills that are needed. This is unlikely to be true and maybe we overlook this aspect?