MACHIAVELLI A BLUFFER'S GUIDE TO MANAGING THE NHS

Every health service manager must learn early how to control and manage doctors.

Never forget that - after the politicians - doctors are the people who decide your destiny. Don't believe me? Then name any chief executive who has survived a vote of no confidence by their medical staff committee for more than three months.

The way to deal with very junior doctors (pre-registration house officers and senior house officers) is to bully and/or ignore them. They won't complain to their consultants because they want a good reference, and don't want to blot their copybooks or get a reputation as a barrack-room lawyer.

Lest you feel this is an unnecessarily sadistic stratagem, let me point out that it is a favourite of consultants. No single group bullies junior doctors more effectively than consultants. Don't believe all the modern touchy-feely stuff: consultants are ruthless. They shout, make impossible demands, vilify and belittle their juniors in front of others, then threaten them with a bad reference if they complain. The bad reference is the medical equivalent of a thermo-nuclear device:

both bring promising careers to a shuddering halt.

The manager's best form of control is to restrict the supply of white coats. Consultants always get the posh starched ones, registrars get clean but old ones, juniors get the crumpled and grubby, or even none at all. So when the consultant asks Dr Wimp why his coat is dirty, crumpled or non-existent and he meekly replies that 'management' won't let him have one, the consultant will point to the blue-white fresh crispness of his own and say: 'Well I can get a clean one. Why can't you?'

Junior doctors hate this sort of thing.

The clear and pragmatic reason for making young doctors fear managers is simply so that they have a personal interest in doing what the manager wants, which is to discharge patients from hospital - unless they are all working for a primary care group, in which case their main role is precisely the opposite.

Any hospital with an accident and emergency department will always be busy. Patients crowd the A&E corridors and wait quietly in admission departments for a bed. The point is that any fool can agree to admit a patient, but it takes guts to send them home instead. Hence junior doctors admit people willy nilly, when they should be wandering the wards slinging old biddies out into the night because they look OK.

Discharged patients get knocked off the waiting lists; discharged patients stop costing money; and discharged patients make room for really ill people so that either (a) waiting lists go down even more and/or (b) you can cope with even fewer beds in the hospital.

Consultants only worry about discharging patients in two circumstances: first, if they are surgeons, and second, if they have a particularly interesting case they want to get in tomorrow. Of course, this only applies in the NHS. In the private sector, patients are kept for as long as the insurance company will stand it, although if a more lucrative case turns up, discharges can take place even faster than in the NHS.

Now this is all fine, except the manager on duty overnight will have distraught sisters phoning every 20 minutes in the small hours because there are no beds for a diabetic patient. In these circumstances the equally hard-pressed junior doctors are the key asset.

Get them to discharge anyone who is still showing signs of life, promise to support them on the morrow. . . and go back to bed .

But how to control consultants? You don't control consultants - you divert them. This is surprisingly easy. Don't get clever and try to bribe them with new electro-medicals (a stratagem only for the direst emergency when cost is no object).

Join the golf club and learn their nicknames. Golf is less important than it was but still garners wide interest, while freemasonry is largely redundant as an entree because the masons now take almost anyone.

Consultants crave exclusivity.

The alternative is to become expert in manipulating complex share portfolios, but you risk costing your target money if you get it wrong: not a good way to curry favour. So golf and nicknames it is.

When Professor Balderdash booms some offensive heckle at you, just say: 'Hello Buffy, old chap. How was the Colorado sun for the handicap?' It never fails.

This is the first of four articles by Machiavelli. Michael White's column will return at the end of the parliamentary summer recess.