With almost all healthcare expenditure driven by doctors’ decisions, it is only natural they should be involved in NHS decision making, argues Rajan Madhok

The NHS is probably the most challenging management assignment in the entire public sector. With its politicisation, constant structural changes, and rising public expectations fuelled by targets and intense media scrutiny, it is not for the faint-hearted.

Now, with the Health and Social Care Act and stringent efficiency targets, the going is getting even tougher. NHS chief executive Sir David Nicholson has described the reforms as the biggest change programme in the world, so big it can be “seen from space”.

Given all the turmoil, why bother to be a manager or even a doctor in the NHS?

I came from overseas to work for the NHS, and my view is that when working well the NHS is an excellent health system. If you have seen the anxiety and helplessness of people suffering ill-health in less fortunate countries, you appreciate the security provided by the NHS.

But my main point is that there are good reasons why doctors, in particular, should get involved with policy making and management.

Doctors are able to judge the need, quality and safety of services through direct clinical observation. Almost all healthcare expenditure is ultimately driven by decisions made by doctors. They can and should, therefore, inform decisions about the planning, procurement and delivery of services - it makes sense to put them in a position to influence and take responsibility for these decisions.

I have had a long career in medical management spanning three political eras - Conservative, Labour and now coalition. Here, I want to share what I have learnt about medical leadership during this time.

I believe that doctors are natural leaders. Here are the 10 qualities associated with a good doctor:

  1. Asking questions Finding out what is wrong with the patient.
  2. Listening The patient will tell you the diagnosis.
  3. Empathy Seeing things from the patient or carer’s point of view.
  4. Decision making Arriving at a diagnosis despite uncertainty.
  5. Commitment Getting the best for the patient.
  6. Ingenuity Finding ways through for the patient when you seem to have run out of options.
  7. Value for money Using resources well. For example, ordering tests only when needed.
  8. Team working Being part of multidisciplinary teams.
  9. Curiosity Seeking to develop through life-long learning and CPD.
  10. Crisis management Taking charge in an emergency.

If I said my career has been fun all the time I would not be telling the full truth. Of course, there have been frustrations. After a while in medicine most things become routine, but there are still moments of suspense and exhilaration.

Similarly in management there are dull or disappointing times, but also good times when you know you are going to make a big difference. What always kept me going as medical director was the thought of major system change, with its potential to touch not just one life but many.

Here are the 10 key lessons I learnt as medical director:

  1. Passion Unless you believe in what you are trying to do, progress will be limited.
  2. Perseverance Passion needs to be complemented by staying power, also known as “the harder I try, the luckier I get” phenomenon.
  3. Courage Do not fall into the “mortgage and school fees” trap. Security is tempting but can shackle. Have the courage to challenge things. Although it is not easy in the NHS to question authority I found that if you do it well, you acquire more power.
  4. Act sooner Sometimes it is only apparent with hindsight, but there is a right time to act. Consider timing explicitly, and act when you think you are right.
  5. Do not seek permission Sometimes you may need to, but not always, and undue deference to authority can be damaging.
  6. Do not complain Work with the cards you have been dealt, rather than wishing things were different. Anybody can lead when things are perfect - leadership is about making it work despite problems.
  7. Respect Enjoy working with colleagues. Most of them want to do a good job, and need some recognition. Empower others, and you will be surprised at how much you get back in return.
  8. Use change I am struck by the fact that the Chinese put together the words danger and opportunity, “wei-chi”, to make the word for change. Leadership rarely involves resisting change - it is about turning it into an opportunity. Be ready to compromise up to a point, and buy time.
  9. Work-life balance Make time to smell the roses. Do not think that you can be good at work but ignore other aspects of life. Most people who are successful in their career enjoy their life outside work, too.
  10. Invest in yourself If you do not constantly improve yourself you will not be effective. Over the years I have been through the Judge Institute’s International Health Leadership Programme, the King’s Fund-led Realise Your Potential Programme and the Common Purpose Matrix Programme, plus many psychometric assessments and other self-development courses.

I am conscious that I may raise eyebrows by singling out doctors. What about nurses and other clinical professionals, who can be equally good? They can also claim the above qualities.

Moreover, there are concerns doctors are not interested in, or not trained for, management. Indeed, some say doctors have too many vested interests and cannot be impartial.

I do not wish to upset other clinical colleagues or managers and I value the contributions of all parties. But the survival and success of the NHS in the 21st century depends on medical leadership, and doctors can and should rise to the challenge.

It is worth noting that many successful healthcare organisations, for example in the US and India, are led by doctors. I am told that when Roy Griffiths introduced management in the NHS he hoped that doctors would take the lead.

Albert Einstein famously said: “The thinking that got you into this mess won’t get you out of it.” This is very apt for the NHS, and the solution lies partly in strong medical leadership.

My advice to aspiring medical leaders is get involved, use your natural skill as a doctor, surround yourself with good colleagues, delegate properly and hold people accountable. You will be surprised at what can be be achieved.

Rajan Madhok is a former medical director at NHS Manchester. He can be emailed at rajan.madhok@btinternet.com.

The views in this article are personal and not of any of the organisations Mr Madhok is associated with.

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