If a trust has a bad night, the on call manager is expected to account for it and justify their own actions. The expectation on managers reflects the dominance of ‘management to targets’, writes Robert Royce

Thirty years ago my nights on call consisted primarily of listening to justifiably irate junior doctors complaining that they had no bed linen in their on call rooms (neither did the patients as the laundry kept breaking down) and receiving and making plaintive calls for hospital diverts.

Invariably these were refused, and even when accepted, appeared to make no difference.

‘It was very much in the hands of junior staff and out of sight, out of mind’

That feature of on call has remained, but other things have changed.

Back then there was no four hour target, no hospital coordinators or bed and site team, no operations centre, and while you were on your own (you weren’t expected to bother anyone else out of hours short of a major incident), the expectation of how the hospital would perform was also lower.

It was very much in the hands of the junior staff, and was out of sight and out of mind.

Management to targets

The expectation today of what will be undertaken by managers on call reflects the demands and dominance of “management to targets”.

The priority is to try an ensure four hour breaches are minimised.

Robert Royce

If the trust has a bad night the on call manager is expected to account for it and justify their own actions (or lack of them). 

In pursuit of this it is often the case that on call managers are expected to be on site for much of the weekend and to be up half the night on weekdays.

Although hospitals now employ bed and site/operational coordinators, and most emergency departments have senior nurses and consultants/senior middle grades on each shift, the on call manager is now seemingly indispensable to the hospital delivering to the expectations of the chief executive or chief financial officer, and is responsible if it does not.

This description is both a simplification and caricature, but only in part.

The ‘tough it out’ trend

It also illustrates a persistent trend in NHS management - the deployment of “back stops” to try and compensate for staff not doing the job you thought you were paying them to do in the first place.

It is quite common for managers to be put on the on call rota based on their grade rather than their operational experience - this is arguably even more the case at director level - and despite the organisations’ significant expectations of what those on call managers will achieve, any training for the role is very much the exception rather than the rule.

‘“Back stops” are deployed to compensate for staff not doing the job you thought you were paying them for’

Managers are expected to just “tough it out” and learn on the job - an attitude characteristic of medicine 30 years ago, but much less so now.

As we increasingly regulate the hours and work of doctors, we appear to be taking the opposite position with managers.

For them it is “as many hours as is necessary to meet the needs of the service” while a large portion of the rest of the NHS are working to the set hours and conditions of Agenda for Change.

The simple truth

This reflects a simple truth: the system will lean hardest on those staff groups it feels are most responsive to pressure.

Managers have proved less resistant to such pressure than nurses, who in turn are more compliant than doctors. This is often reflected in who gets questioned most closely about the clinical performance of a department/hospital.

What is most interesting about this is not that the four hour target (unsurprisingly) dominates the management agenda, but rather the expectations we have of different groups of staff with regard to the same issue.

‘The system will lean hardest on those staff it feels are most responsive to pressure’

We end up with managers on call coming into the hospital in response to long wait times in A&E, while consultants may refuse to do so on the grounds that this is not a patient safety issue.

Leaving staff leave aside for one moment, the vexed question as to whether a full A&E with patients waiting hours for treatment and some not yet assessed by a doctor can also be a safe department tells us much about power and culture in NHS hospitals.

This also highlights a fault line that has run through the NHS from day one between the priorities of clinicians, and that of management and their political masters.

This became more pronounced once increased funding got linked to more ambitious performance targets.

The on call challenge

The increased funding may be a thing of the past, but the targets are not.

I have heard these described on many occasions by clinicians as “management targets” and by implication something separate from the real business of the hospital and worthy only of begrudging concern.  

This lack of alignment about what is important - and also what gets rewarded within each professional group - is one of the defining characteristics of the NHS.

‘The last 30 years has got increasingly onerous for managers’

There isn’t the space to argue the rights and wrongs of the respective positions on display, but it highlights a gulf that has to be addressed.

The failure to do so is a major driver of the bullying culture (both real and claimed) - now a persistent feature of stories concerning the NHS.

Being on call was never enjoyable, but over the last 30 years it has got increasingly onerous for managers. Is that the case for everyone else?

Robert Royce is an independent healthcare consultant