Published: 14/07/2005, Volume II5, No. 115 Page 30 31 32

An HSJ survey has shown that more and more PCTs are appointing medical directors. But what do they do and how do they differ from PEC chairs? Ann Dix reports

Two years ago, when GP Doug Russell was appointed medical director of east London's Tower Hamlets primary care trust, he was a rare breed.

'Where medical directors existed they tended to be in PCTs who had an army of community consultants. I was very unusual in that I have a GP background.' Since then PCTs have matured, with an increasing number employing medical directors, although the role varies.

An HSJ survey of PCT chief executives showed that of 73 respondents nearly half (48 per cent) had a dedicated medical director, with a further 12 per cent planning to appoint one. Another 27 per cent of PCT chief executives said the medical director's responsibilities were part of another person's role, while a quarter of PCTs still had noone performing the role. Over two-thirds of PCT medical directors were GPs. While a fifth of posts were classed as full-time, nearly two-thirds of medical directors were still in clinical practice.

Dr Russell believes one of the reasons for the increase is the emphasis on tighter regulation of GPs following the Shipman case. 'The various Shipman reports have concentrated minds, ' he says.

But while he believes that PCTs with no medical director 'put themselves at risk' because their procedures for identifying and dealing with poorly performing doctors are likely to be less robust, he adds: 'It is a great mistake if the post just becomes about performance issues.' West Hull PCT medical director Dr Mark Williamson believes every PCT should have a medical director. 'Because we are publicly accountable bodies who commission and provide medical care for a population and spend huge amounts of money, there should be accountability for medical input into that, ' he says.

In north London, Islington PCT medical director Dr Peter Reader, who also facilitates the NHS Alliance professional executive committee chair network, says there are probably two breeds of medical director: those who stick with the 'nominal, stopping the buck' role, and others like himself 'who are doing and evolving the job into more of a clinical leadership role'.

He stresses that this is not 'a challenge or an alternative to the leadership of the PEC', but is about providing clinical leadership on the executive management team - especially now that clinical engagement is high on the political and management agenda.

NHS Alliance chair Dr Michael Dixon agrees.

Given the right leadership skills, the PCT medical director and PEC chair 'could be a very powerful combination, ' he says.

At a time when there is a national debate on the effectiveness of PECs (see feature, pages 2629), 'really good personal leadership from the PEC chair and the medical director could help make up for lack of leadership from the PEC itself', he believes.

But as medical directors are quick to point out, there is often a lack of clarity between the roles. A big difference is that, unlike the elected PEC chairs, medical directors are executive directors, accountable to the management board.

But some believe the role of medical director can be seen as unnecessary or 'subsumed' into that of the PEC chair because of the 'ill-defined and variable nature of the PEC's role', says Dr Mark Williamson, medical director of West Hull PCT.

Back in north London, Camden PCT medical director Kathy Hoffmann found her role changed with the arrival of a new PEC chair: For three years, the medical director role defaulted into leading the process of change.' The election of a new PEC chair, who is strong on clinical leadership, means she is 'trying to retreat from all that'. But she adds: 'You do not become a medical leader because someone has given you the job.

People have to develop trust in you.' But becoming a PCT medical director is not always a happy experience. GP Nick Summerton, who recently resigned from Yorkshire Wolds and Coast PCT, describes himself as a 'failed medical director' because he wasn't able to convince his PCT of the broader potential of the role.

He says he emphasised from the start that his interest lay in service development, not clinical governance. But once in post, 'the PCT wanted me to deal with governance, appraisals, regulation of GPs and to act as their GP rubber stamp'.

'They wanted me to cut referrals and say what they wanted me to say - not develop clinical services.' He has now gone back to running a practice and seeking to develop a commissioning group. 'I feel the PCT wasted an opportunity. There is a need to get frontline clinicians engaged, and that could be through the medical director route.' He adds: 'The practices were warm to the approach I was trying to take, ' but the PCT 'could not accommodate the GP perspective'.

Now he says he 'would not touch a medical director job in a PCT again because it could have done me a lot of harm with my GP colleagues'.

Since Dr Summerton left the PCT, some management functions have been integrated with those of East Yorkshire PCT. This includes the establishment of an integrated medical directorate and PEC.

Kate Ireland, director of service improvement for both PCTs, says: 'When Dr Summerton was interviewed for the job it was with a clear job description, ' which included performance management and service improvement. 'Dr Summerton left by mutual agreement', after a short time in post.

East Yorkshire PCT chief executive Andrew Williams is now leading the new integrated management team. Ms Ireland said that service improvement plans include a programme 'initiating and promoting clinical engagement' led by the new medical director. 'We are trying to move the organisation from a difficult patch to a new future, ' she said. .



Ask Camden GP Kathy Hoffmann why she chooses to be a primary care trust medical director and she says she loves the challenge.

Much of her job centres around performance management and providing education, training and support for GPs and other clinicians.

But it is also about providing clinical leadership, a large part of which is 'making people feel needed and valued'.

'It is about helping people recognise the challenges and then drilling down and supporting them.' But she adds: 'It is also about taking people out if they can't do the job. I quite enjoy that.

'People probably perceive me as tough and quite scary, ' she admits, although this is not how she sees her role in the organisation.

'A large part of my job is to make the system more trustworthy. I am surprised at the trust people put in us and I find it unacceptable as a professional when that is abused.' 'I was talking to a whistle-blower the other day who was quite worried about it. I asked: if your children or any of your family were patients at the practice, how would you feel then?' But while troubleshooting is an important part of her role - from dealing with fraud and poorly performing doctors to sorting out practice disputes - she stresses that her main job is to be supportive.

This means understanding why problems have arisen, getting individuals to take responsibility and providing the right support to remedy the situation, she says. 'Only when we have exhausted all these avenues would we take more serious action.'

A former primary care group chair, she works two days as a medical director, dividing her remaining time between managing a GP practice, seeing patients and minor surgery.

Juggling the demands of management with her clinical practice can be a nerve-wracking experience: 'I am nervous that it means I can't focus on either job.' But she sees it as essential. 'You can have all these ideas round the boardroom table, but It is important to stay in touch with the real world. You need to understand what It is like to be in a shitty surgery where people come in with complex problems... If I worked as a medical director full time, I might lose that sense of, there but for the grace of God go I.' She also finds the 'hierarchical and topdown model' of PCT management very trying.

'I hate it. I struggle with it ... I think It is a bad form of management.' While she is 'constantly looking for new challenges', she will never cease being a GP.

'I know in my heart that the thing I am and will always be is a doctor. That relationship with patients is something I never want to give up.'



Dr Peter Reader was formerly a professional executive committee chair before moving to Islington in north London to become a primary care trust medical director. He made the change because, 'I wanted to work full time in clinical leadership'.

He works four days for the PCT and one day as a GP, in a new practice in an underdoctored area. 'It is about keeping up my clinical skills and being in touch locally.' At one stage his PCT considered making him PEC chair as well as medical director, but it was decided that it would be hard to combine the role of chair with performance management. 'It is difficult to pull together both of those things, ' says Dr Reader.

As well as GP appraisal and performance management, his role is to provide clinical leadership and support for practices. He manages independent contractors such as dentists and pharmacists, and is responsible for clinical governance and effectiveness and implementing National Institute for Health and Clinical Excellence guidelines.

'The PCT also wanted someone to provide primary care leadership on the management team and support to the PEC, ' he says.

He adds: 'I would recommend all PCTs to have a medical director who is interested in service development and clinical engagement.

'A lot of clinicians think I am slightly mad.

They think because I am no longer self-employed I am less in charge of my fate. But what feels like security is actually potentially restricting.

'The great difficulty about being a PEC chair is trying to juggle the role with being a GP. Cutting the umbilical cord has been very freeing. I can move job to reflect how I wish to develop.'



GP Doug Russell became a primary care trust medical director 'to make difference'.

'I wanted to be involved from the inside rather than chucking brickbats from the outside, ' he says.

He took up his post with Tower Hamlets PCT in east London two years ago. 'It has been a tremendous culture change, ' he admits.

'Everything takes much longer, but when you change something It is on a much bigger canvas.' Formerly he worked in a series of advisory and GP development posts at family health services authority and health authority level. He now works four days for the PCT and one day as a GP.

His practice is outside Tower Hamlets in a neighbouring PCT, which he says helps avoid conflicts of interest.

'There is a perception that doctors close ranks.

So that separation is quite useful.' Although performance management is an important part of his role, he insists: 'It is not just slash and burn.

'It is about creating a developmental environment. I like to think that 80 per cent of my work is supportive and 20 per cent is dealing with problems.' 'The big motivator for GPs is not carrots and sticks, ' he says. 'It is peer comparison.' He is also a primary care 'advocate' on the management executive, which includes arguing for greater investment.

The professional executive committee 'dreams the dream' and 'it is my job to translate it into policy', he says.

'What I hope the PEC gets from me is analysis, feedback, and challenge to their opinions.' Becoming a medical director requires you to be thick-skinned, he says.

'To many GPs you are a turncoat. Equally I get other managers saying I am the poacher turned gamekeeper.' Dr Russell does not have as much contact with the front line as he would like. A big problem, he says, is that 'once you are an executive member you are overwhelmed by committees'.

At 54 he sees this as his last management job.

'After that I'll probably go part-time and take over a clinical practice.'



Dr Mark Williamson's first medical director role was working for five primary care trusts in Leeds, 'each with their own perspective on the medical director function'.

'It was great really - but the 120-mile round trip was unsustainable, ' he says. After two years in the job he moved to take up his current post as medical director of West Hull PCT.

Before that he had a variety of roles, including working for the local medical committee and being a health authority nonexecutive. 'I learnt in my 30s to have political nuance and lightness of feet, ' he says.

He works four days for the PCT and one day as a GP. His other roles include being regional adviser for prison health and supporting the strategic health authority on the national programme for IT.

As PCT medical director, his responsibilities include performance management, clinical and professional leadership, clinical governance, and developing clinical services. But he is also working at a more strategic level on areas such as National Insitute for Health and Clinical Excellence implementation.

He describes the main motivation for what he does as 'to be the bridge between the medical profession and managers of the NHS'.

But he adds: 'Developing an effective relationship with the PEC chair is a major key to success.' Ultimately his ambition is to be an Department of Health adviser. 'I wish to be effective as a clinical adviser at the highest level possible.'

To contribute articles to HSJ's clinical management section, e-mail ann. dix@emap. com