A decade of the national clinical directors - aka the czars

As the first medical experts at the Department of Health in addition to the chief medical officer, their appointment remains a dramatic move.

But their roles must now fit a new financial era and a changing medical leadership landscape.

When first envisaged, the czars were to prioritise three areas: cancer, heart disease and emergency care. Until then, these services had been planned at a local level and had lacked national policy direction.

On his appointment in 1999, the first czar, national clinical director for cancer Mike Richards, was asked by chief medical officer Sir Liam Donaldson to name one service that had been systematically improved across the country.

“I could only think of one, cervical screening, which was turned around by [now NHS chief knowledge officer] Sir Muir Gray, who in many ways was a forerunner for a czar,” he recalls.

“But there is no doubt over the past 10 years that these services are improving.”

Royal College of Surgeons president John Black agrees there was a “vacuum”, but suggests national service frameworks - with clinical directors to oversee them - became more important as a result of NHS devolution and the purchaser provider split.

While the arrival of the czars resulted in national standards, questions have arisen about how their roles have been defined.

“Whether or not we have ever had job descriptions, one can discuss and debate,” says Professor Richards.

Dame Carol Black, president of the Academy of Medical Royal Colleges as well as national director for health and work, a post based in the Department for Work and Pensions with a strong connection to the DH, says the roles are “neither fish nor fowl” - with one foot inside the government and one out.

She says: “You are there to be able to bring genuine comments and ideas from the outside. It enables the centre to understand what the periphery is thinking.”

The important interest groups for clinical directors are doctors and their representatives. Professor Richards says: “If I felt I lost the confidence of the clinical community I do not think I would be able to go on doing the job.”

Sir George Alberti, national clinical director for emergency care from September 2002 until this May, says the reaction to his work has been “on the whole positive”, but adds: “If you were making good recommendations which they did not necessarily agree with, you got some bad reactions as well.”

Difficult position

Mr Black is enthusiastic about the good the directors have done. But he says his college’s current cause célèbre, the European working time directive, demonstrates the limitations of the roles.

“The directors are in a difficult position because they work in a political environment. The advice they give has to fit with ministers’ political position, and the government has committed itself on the directive,” he says.

Despite their success, the loose definition of czars’ roles means their continued presence is never assured. Some are on fixed term contracts and their influence has grown and waned dramatically depending on the health secretary.

A cull was mooted as recently as 2007 but it failed to materialise and the next stage review’s emphasis on clinical leadership and quality endorses them.

The DH is advertising for a replacement for Sir George, who says: “I think we were good forerunners to the quality and Darzi agenda. We did push the DH in that direction on the value of having clinical leaders.”

The directors have recently been brought together under NHS medical director Sir Bruce Keogh with the strategic health authority medical directors, suggesting they could take on a regional leadership role in addition to their national remit.

They all meet monthly as an NHS medical board. NHS East of England medical director Robert Winter says: “Our clinical backgrounds cover nearly the whole waterfront of specialties, so there is enough there to be able to have a pretty authoritative opinion on an issue.”

In another vote of confidence, NHS chief executive David Nicholson told HSJ the directors were one method of engaging clinicians with the steep spending cuts mooted. They have recently been asked to identify programmes that save cash while also improving care.

Dame Carol says: “In a sense it is more important to have these roles [as spending is cut]. It may be more necessary to say, ‘How do we deliver a high quality service within the resources we have got?’”

But this brings with it another risk. The creation of clinical directors and now strategic health authority medical directors were moves by the DH to bring the medical community within the corporate NHS at the top level, and reach out to the lower echelons.

The tension created - colleges “hated” the clinical directors in their early days, one source said, while they continue to receive very short shrift on medical websites - may be intensified by spending cuts.

Sir George cautions: “Our strength was that we were not arguing from a financial point of view. Obviously finances matter, but equally clinical directors will lose value if their starting point is not quality and safety from a clinical standpoint.

“You then have to be realistic about what is affordable and how quickly you can get there.”

In March, Sir Bruce warned professional groups against reverting to a “status quo” adversarial stance with management in response to efficiency demands.

If successful, attempts to spread to lower levels the national clinical director approach, of having one foot in the corporate NHS and one out, would ease this problem.

One example is the challenge handed to advisory board Medical Education England to build an association with the corporate NHS at an earlier stage of doctors’ training.

Sir Bruce explains: “If you do not know how the system works how can you feel loyalty to that system?

“We have a problem where the primary loyalty of a large part of the workforce does not link with their employing organisation.”

Local limitations

Mr Black is enthusiastic about having local clinical leaders who have the desire, power and time to improve services, as clinical directors have done.

But he admits to not being fully signed up to the rhetoric - “my eyes glaze over when people start talking about leadership” - and blames some of the existing limitations of local medical managers on the system.

“Desperately struggling with your financial targets and waiting list targets is 95 per cent of the concern of trust medical directors,” he asserts.

“This leaves little time for engaging with national improvement strategies, which often also threaten trusts’ income. The culture in a trust is a desperate struggle to survive.”

National clinical directors’ success in surviving the financial squeeze may depend on extending the balance they have achieved nationally to a local level, which itself could turn on a shared understanding between the DH and the professions of what medical leaders should be doing.