Rock and role

Published: 27/03/2003, Volume II3, No. 5848 Page 20 21

As England's chief medical officer - a medic turned manager, no less - Professor Sir Liam Donaldson has strong views on how managers and clinicians can work together.He wants to see more managers providing leadership and inspiration to their medical colleagues, thereby unlocking doctors'creativity.

And then who knows how fashionable health service management might become?

On the day of HSJ's interview with Professor Sir Liam Donaldson, I am woken by the reassuring tones of the chief medical officer. The country's senior medic is fulfilling the traditional CMO role of playing the nation's GP, issuing sensible advice on the To d a y programme - in this case about the spread of severe acute respiratory syndrome to Europe.

It is a role Sir Liam has not chosen to prioritise - though he performs it well. He understands that providing healthcare now requires a more sophisticated approach than the 'doctor knows best' model, prevalent when he entered medicine over 30 years ago.

And HSJ has come to talk to him about one of those complexities: the relationship between clinicians and managers.

Sir Liam is in no doubt that there is a problem. 'There has been a breakdown in the relationship between doctors and managers and those leading the service at national level, ' he acknowledges.

However, he does not believe this breakdown flows from 'a fundamental rejection of the concept of management in healthcare' by doctors.

HSJ's reader survey (see news focus, page 15) suggest many believe that difficulties arise from the clash of managerial and medical cultures. Sir Liam, while not suggesting this has completely disappeared, believes that this battle was fought nearly 20 years ago - over the Griffiths report and the introduction of general management to the NHS.

Today he claims the fact that so many doctors have entered management - himself included - makes it obvious that the two disciplines can and should co-exist.

Rejecting mutual incompatibility as the reason for the breakdown in the relationship, Sir Liam instead suggests the tension arises from the 'climate' in which medics and managers find themselves working. It is this, he suggests, that has created the real problem - the worldwide pandemic known as unhappy doctor syndrome.

In the UK, the CMO believes doctors' morale has been affected by two factors. First is the media 'bashing' they have received in the wake of high-profile scandals such as Bristol and Alder Hey. Tellingly, Sir Liam adds: '[Doctors] haven't felt they have had too many friends in the management camp standing up and defending them.'

Managers, of course, may counter that doctors are rarely conspicuous in their support of management colleagues when the press indulges in one of its regular maulings of 'NHS bureaucracy'.

The second reason for doctors' unhappiness, according to Sir Liam, is a combination of high workload and a feeling that much of it is being created by politically driven targets.

The CMO rejects this allegation: 'The targets are not politically inspired as such. They represent, on the whole, what the public wants.'He does acknowledge that, 'maybe doctors haven't been as engaged as they could have been in helping to set targets' and that fears over autonomy are often likely to make doctors wary of targets. But he argues that, 'with the right kind of communication, you would get agreement [on targets] from many doctors'.

'If you had talked to doctors in the mid-1990s when they were very dissatisfied with the direction of travel of the NHS, they would have pointed to long waiting times, for example, in coronary artery bypass surgery. Doctors wanted reduced waiting lists - now that has happened. And I would argue that had we not been clear about where we wanted to get to and mobilised effort behind it - in other words created a target to challenge the system - we would not have got there.

Targets are a focus for discontent, rather than a real difficulty.'

So much for the diagnosis, what about the cure? Sir Liam briefly mentions national initiatives like Improving Working Lives and reforms to even out the workload across the medical workforce.

But he makes it clear he believes it is the responsibility of health service managers to lead their clinical colleagues out of this fog of fear and confusion.

His stint as a health service manager came during the 1990s, when he was first general manager, then a regional director, in the North West.During that time, he says, he 'came to have a deep respect for many health service managers'. He also began to understand how difficult it was for some managers to deal with doctors.

'On one of my visits around the region, I sat with a manager over a cup of coffee. He opened his heart to me and admitted he was frightened of the doctors who worked in his hospital. He told me: 'These doctors are highly educated, highly skilled, socially very polished. I am in awe of them.' He was a decent, decent man, but found himself out of his depth.'

Most HSJ readers would hope that Sir Liam's colleague was a throwback to the old subservient days of the hospital administrator - and the CMO stresses that he, too, believes times are changing.

He claims that not only are the management 'handmaidens' of the 1960s and 1970s disappearing, but so are the bullies of the 1980s and 1990s 'who thought that relationships with doctors could be based on giving orders'.

Instead, he says, more managers are becoming 'true leaders' who 'do what you would expect a leader to do in other industries that have very diverse workforces, like those that include scientists'.

A 'true leader', in Sir Liam's eyes, 'inspires, motivates and tries to set a path for service delivery which everybody buys into'.

'One I always pick out - with admiration and awe - is Bill Murray [chief executive of South Tees Hospitals trust]. He has created a happy family of doctors, managers, nurses and others.And he's a tough guy.He wants his targets hit, his doctors accountable, but they go there with him because he inspires respect and motivates them.'

Sir Liam acknowledges that healthcare has had to become more managed over recent decades, and this trend is likely to continue. He also suggests that doctors, despite their unhappiness over reduced autonomy, have shown considerable capacity to deal with tighter control.

'We have seen, over time, their autonomy being reduced, not only by management accountability within a hospital or primary care service, but through tighter professional standards laid down by the General Medical Council and the royal colleges.'

Many managers believe doctors should be more accountable to them. Sir Liam disagrees: 'If You have got the kind of leadership that Bill Murray displays, accountability flows from there.'

'There needs to be considerable subtlety in the relationship between doctors and managers, 'he says. 'The nuts and bolts of accountability can be mediated through job plans, contracts, annual appraisals etc - but there has to be a recognition that medicine is different to many other things that are being managed.

'You are asking doctors to have the skill, experience and judgment to take life and death decisions. Management accountability can't infringe in that area - because there is not the technical competency.'

Mr Murray is a very experienced manager and it is to the lessons of experience Sir Liam suggests the service should turn, illustrating his point by the way of an idiosyncratic story. 'I was sitting in a restaurant in Islington [north London], the tables were very close to together and I overheard a conversation between the couple next to me. He said: 'Cookery's the new rock 'n' roll, is not it?' She replied: 'No, history is the new rock 'n' roll'.

'Well, We are not good enough at looking back and seeing the lessons of the past. The lessons in healthcare management are all about the right leaders.'

Sir Liam says those leaders - clinicians and managers - he has always looked up to were all good at their day jobs, but also 'wanted to make a wider contribution'.

He remembers one colleague who used to tell the young Donaldson: 'I get up in the morning and I want to change the world.'

'It is those inspirational models we need to draw on, ' says the CMO.

'Managers can't just sit down with their doctors and say, 'We have had the latest target from Whitehall: here's a piece of paper that disaggregates it to your clinical service.

Go away and deliver it please'.

'They have got to sit down as a team and explain why these targets may improve quality of care.

Work out as a team how they are going to do it - whether it means plugging a resource gap or re-engineering services.

'Doctors are often very creative people. If their creativity is unlocked, they will find solutions to things we haven't found before.

The skill of management is to unlock that creativity.Overworked and disillusioned doctors are not going to feel creative.

'Managers must help doctors not to be cynical about change - help them see the opportunity and not the threat.'

Of course, managers will only be in the position to inspire and lead if the Department of Health lets them. Doctors are not likely to follow those they believe are simply political puppets.

Sir Liam suggests that the growing role of strategic health authorities will be significant in removing Whitehall's grip on the throat of local services.

'I have been very, very impressed by the extent to which they're starting to influence the agenda, ' he says.

It will also be necessary for medical schools to give doctors a better understanding of the management role, claims the CMO.

'If we want a greater understanding between medicine and management, we need to build that in at an early stage.'

Young doctors with a respect for management, SHAs providing a barrier to central control, inspiring leadership and shared goals.

Sir Liam's vision is very attractive, though not - as he would no doubt admit - one without some significant question marks.

But if it does come to pass, the NHS will deliver much improved patient care and, who knows, Islington diners may then decide it is health service management which is really the 'new rock 'n' roll'.