Management trainee Tom Smith thought the NHS was his chance to make a difference. His experience proved a rude awakening

I have had an unusual but extremely rewarding experience on the NHS management training scheme.

After a year in a London teaching hospital, I spent an elective period with the Nuffield Trust, and a second placement in Cardiff examining ways to improve the interface between the university hospital and college of medicine. Throughout the scheme, and in deciding if NHS management was for me, I have struggled with its negative image and striven to find a shared positive articulation of its aim.

I was delighted to be accepted on the NHS management training scheme. I came from the London School of Economics with a left-leaning heart-and-mind passion for the NHS. The LSE had tempered my romanticism with the imperative of optimising impact, and I hoped, perhaps naively, that NHS management might be my vehicle to make a difference.

But it was a rude awakening to discover the complexities of health management, particularly the extent to which the NHS is handicapped by professional and cultural barriers.

I was disheartened by the fragmentation between roles and the antagonism towards the managerial agenda.

It felt enormously disabling to attempt to work with people for whom ideals and ideas are a non-starter for management. I became frustrated that the focus was unclear, aims ill-articulated, and that the expedient always squeezed out the important.

NHS managers lack a positive, clearly perceived purpose. The value and major contribution of NHS management is a demonstrable focus on improvement, attained by emotional intelligence and an analytical mind.

Change forms a constant backdrop and the complexities of change are the reason managers are so important. Without fluidity there would be no need for managers.

Management without a clear focus on service improvement is defensive and negative. It is disappointing to hear some managers complain about change, often seen as an upheaval.

At a session on clinical governance at the 1999 Institute of Health Services Management conference, I was struck by the discussion's negative tone. The audience had a narrow view of clinical governance, seen as a mechanism for identifying poor clinical practice and deflecting scrutiny. A weary discussion ignored the huge potential for positive change, and was largely dismissive of its articulated aims as unrealistic aspiration. I am not surprised that managers who have been battered by change are cynical, but clinical governance is of enormous importance for managers.

Management is synonymous with ideas and thinking, or, as Alistair Mant puts it, 'useful intelligence'.

Mant sees management as 'a broad-based intelligence which understands the complex systems of our organisations and societies'. If management has been identified with unwelcome reform perhaps it might, in time, be credited as the agent of change towards a patient-focused service targeted on improvement.

Clinical governance provides an ideal vehicle for management to shift its emphasis. The NHS, led by managers, will have to change to harness improvement as a shared value base and to widen its capacity for information and ideas.

Information has the potential to be a positive basis for dialogue with clinicians and the public, to repair confidence. Are managers ready and able to manage a knowledge-based service focused on ideas and improvement?

I have been surprised by a lack of engagement with nondirective thinking. A symptom of the present culture is that managers are inundated with workplace reading material and have little opportunity to read around.

The investment in the production and summary of a knowledge base has not been matched by an equivalent effort to ensure that this information is accessed and used. While there is something of an academic interface for policy, it is underdeveloped at the operational level.

In my time on the scheme I have wavered between wanting to stay in the NHS, where there is little time for ideas, and working in academia without necessarily making a difference. Management and academia need to take implementation seriously.

For management to be focused on quality, it needs an evaluative loop between theory, policy and implementation. I worry that the opportunities of the new NHS will be lost without investment in the managerial capacity to deliver them.

REFERENCE

1 Mant A. Intelligent Leadership. Sydney: Allen & Unwin, 1997.

Tom Smith is a Nuffield Trust associate.