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Published: 26/09/2002, Volume II2, No. 5824 Page 10 11

In the final part of HSJ 's three-week series examining the NHS's progress in this financial year, we look at the pressures on senior managers and consider how they are coping with the pace of reform and the often conflicting demands on their time from patients, politicians and staff Managers want to be inclusive and developmental, but the constant demands of a target-obsessed government are skewing their priorities.Tash Shifrin reports Go on, own up: just how target driven are you? And have you any idea how target driven you are meant to be, what with the need to be strategic, a good partner, a leader and - just possibly - see your family and friends from time to time?

Fears have been voiced that the pressures of the star-rating system and intense political, public and media interest in high-profile waiting-list targets are distorting clinical priorities or preventing senior NHS managers from drawing breath and taking a more strategic overview.

But then again, if the targets are important perhaps it is right that they are the focus of activity. One trust chief executive obtained that precious third star - and its attendant freedoms - by concentrating on hitting the targets specifically highlighted in the star-ratings system. 'I have personally got involved in project managing it... right down to individual patients, ' he said at the time.

This chief executive put in place an escalating warning system that meant he could be personally 'woken up at 4am if there was likely to be a long trolley wait' in accident and emergency.

NHS Confederation policy manager Nigel Edwards points out that the third star could be 'worth a million quid' - no small incentive. But he is planning research into what chief executives actually do, whether they are able to do the job in the way they want to, and - with entertaining potential - what other staff think chief executives do or ought to.

'There are probably different versions of what chief executives do. I am interested in how people are defining it and whether the environment is affecting it, ' he says.

'I believe the environment in which most of our leaders work forces them to focus up and out rather than in and down.'

He adds that the message coming across from many chief executives is that they 'wanted to be developmental, democratic and bring people on', but instead under pressure 'they're resorting to hierarchy and instruction - the kind of behaviour they do not like when it is done to them'.

Southern Norfolk primary care trust chief executive Mark Millar says he knows 'a number of chief executives up and down the country' who are personally managing target-hitting at a very detailed level. But at his PCT, 'we haven't got quite the same line 'control' as an acute trust. In terms of [improving] access to primary care, we have to operate by influence and persuasion.'

This is why he says it is 'very important to get round' to often far-flung rural GP practices, though this is time-consuming.

'To travel east-west across the patch is an hour, or an hour and a half. North-south, It is at least an hour, ' he says.

Acting director of the NHS Leadership Centre Penny Humphris says the short-term 'must-dos' are 'something you can never take your eye off '. And case management by chief executives is common. 'Lots of people do it by taking a cohort of named patients.'

To make sure no-one is waiting more than 12 months, for example, you look at anyone put on a list before March 2002 who must be seen and treated by March 2003. 'You have a report each week about which have been knocked off the list, ' she says.

'It is the micro-detail that many chief executives are having to manage within, ' says Ms Humphris, an experienced NHS manager whose last job was running a health authority. 'It is very much how the trusts and we at the HA were working to make sure we hit targets.'

But Ms Humphris' national post has shown her that chief executives' roles are 'very different in different parts of the country, with different challenges'.

One acute trust chief executive says: 'A big issue in mid-year is performance. I am spending a lot of time on that at the moment.

That is compromised by, every couple of days, the centre wanting a bid for this... and we have to get a team together to look at that.

'There is a lot of disruption. As a chief executive you work through other people. But There is a huge amount of dislocation in the system at the moment.'

And everyone is making demands - often the same ones - simultaneously. 'The PCT and strategic health authority also want to know about our performance.

It is very crowded, very amateurish.'

He says chief executives' priorities will depend on where they are in the star ratings. But changes in the assessment system meant noone knew what the criteria would be, leaving some managers disoriented. 'A lot of the work people put in was a complete waste of time.

No-one minds putting in 150 per cent performance to hit the NHS plan. But when you are doing it in the dark, it gets a bit panicky.

People's careers are on the line.'

Commission for Health Improvement communications director Matt Tee says: 'Beyond the core, usual business there are some things that appear to take chief executives' time up.One of those is merger, any sort of merger.

'Private finance initiative projects are another example where it takes up a huge amount of time - on business cases, beauty contests for potential PFI partners and so on.'

What Mr Tee calls 'recovering form things' - in particular financial recovery plans - also vacuums up management time and attention.

By contrast, Mr Tee says the pressure of waiting-list targets is 'a bit more historic'. Trusts have more successfully devolved this sort of work to general managers in surgery and directors of operations.

Clinical governance and quality are getting there, he says. 'It is beginning to be seen as important.

Part of the wash from the last stars was people realising that it wasn't just the basket cases where the CHI report could make a difference.'

Kettering General Hospital trust chief executive Geraint Martin explains his method of prioritising and making sure areas such as activity targets and clinical governance are linked.

'We have taken the white noise of targets - the 400 targets in the NHS plan - and boiled them down to 15 key ones, where if we reach those, we can reach them all.

We are also trying to make the targets make clinical sense.

'A lot of my time is spent managing the tension between what clinicians think we should be focusing on and what the targets say we should be doing. I am spending a lot of time managing the message as well as the process.'

Neil McKay is chief executive of the 3,000-bed Leeds Teaching Hospitals trust, formed after a merger four years ago. The trust has two stars but was recently criticised by CHI for focusing on performance targets and its financial deficit to the detriment of clinical governance. This is something Mr McKay acknowledges.

'Any trust chief executive who ignores the importance of clinical quality in search of delivering quantitative targets does so at their peril because the job is about all those things and, if anything, the pursuit of high clinical quality comes top, ' he says.

But he adds: 'It is impossible to imagine you can do everything.

You have to be brave enough to devolve and decentralise decision making.' He urges junior staff to 'stop asking for permission'.

Leeds is now setting up a network of clinical management teams with their own budgets.

The trust HQ will 'intervene only when necessary'.

Mr McKay rejects the 'cynical concept' of politically driven targets. NHS managers are there to work within a framework of policy decided by a democratically elected government, he says.

But he adds: 'Part of the job of the chief executive is to put up an umbrella to protect the organisation from unnecessary targets.'

Like Geraint Martin, he has 'distilled' a lot of targets into a few key ones. 'And then [you] protect the organisation from other extraneous requests.'

Those extraneous requests may be the least of the problems for PCTs, whose agenda has expanded rapidly, often outstripping management capacity.Many PCTs have struggled through their early days with key posts, such as finance director, unfilled.

Research fellow Bernard Dowling of Manchester University's national primary care research and development centre says some of these problems are easing along with an increase in the number of finance staff.

But he adds: 'When you look at the trends of staff employed, the trend has been upwards. But when you look at the number of targets, that trend has been upward too. I think PCTs are uncertain whether the gap between targets and capacity is getting narrower. A number would say it is widening.'

Mr Millar points out that PCTs face 'a squeeze before you start'on management costs. The money from the old HAs has been topsliced to fund SHAs - now covering some of the remit of former regional offices - and topsliced again to fund savings and the cost of transition to the new system.

'The money has been taken from the service to fill the gap left by regional officers. I do not know of any PCT who wouldn't need to spend more on management than dropped out of the HA, ' he says.

Management capacity is important but it is 'difficult selling that to the board, the public, the health secretary and Uncle Tom Cobleigh', Mr Millar says.

This adds to the challenges new PCTs face - but they are developing in very different ways (see overleaf).

This is a point CHI's Matt Tee echoes. 'There is a lot of variety.

They are at different stages of development and are doing bits of their work in different ways, partly because of managers' different backgrounds, and partly to do with groups of PCTs doing things in different ways.'

There may be no template for chief executives or other NHS managers to follow and there may be no evidence base - yet. But the variety and creativity of their approaches is surely a good sign. l