'Stop squeezing middle managers'

Published: 16/06/2005, Volume II5, No. 5960 Page 20 21 22

Speaking on the eve of the NHS Confederation's annual conference, chief executive Dr Gill Morgan says the NHS can prosper - but only if key questions about the future direction of the service are answered

'There is a real crisis in middle management', declares NHS Confederation chief executive Dr Gill Morgan.

'They are the people who are accountable for the targets and who have the strongest interface with clinicians; they are also the people who get attacked and vilified for poor standards.' It might seem an odd message to send out on the eve of the confederation's annual conference, but Dr Morgan's eagerness to address the problems facing the service head on appears to stem from a deep-set confidence about the organisation's growing role and influence.

Three years after taking the top job at the confederation, Dr Morgan is also recognised as a key player herself.

She was one of four people who new health secretary Patricia Hewitt phoned on her first day in office.

From this corporate and personal position of strength Dr Morgan sets out a clear line: the NHS will only prosper if a number of urgent questions are answered.

One of these is the iniquitous position of middle managers, squeezed between the rock of government priorities and the hard place of medical resistance - and facing public censure as a result.

A recent survey by HSJ showed that most managers were pretty unhappy with government policies (page 16, 28 April). But the confederation has been broadly supportive of the direction of travel.

'We represent boards, ' says Dr Morgan by way of explanation. 'So It is not surprising that as the leaders of organisations their perspective is different [from middle managers'].' That said, she acknowledges a need to meet the needs of those lower down the hierarchy: 'We need to do more to get our message through to that level.' She wants to make the confederation's briefing information more widely available to middle managers and says the organisation needs to ask: 'how do we bring them into our structures?' Dr Morgan also admits that not everything is rosy with NHS boards.

She believes the combination of targets and performance management has left many board members feeling sidelined.

'Without doubt some chairs and boards feel very disempowered.

They do not feel their skills, ability and commitment are being used.' Dr Morgan says this was shown by assessments carried out by foundation trust regulator Monitor, which revealed a lack of corporate responsibility at board level.

'We have got to get that responsibility back. The corporate board is not about execs over here and non-execs over there, which is how many boards operate at the moment. It is something that is more than the sum of its parts. The only way you'll get good and sustainable health services committed to continuous quality improvement is when it is the job of the corporate board to deliver that.' Dr Morgan rejects the suggestion that many non-executives might not be able to cope with the more demanding environment created by foundation status, payment by results and other schemes: 'You can't answer the question until You have put in the proper development programmes and support, ' she says.

Equally, she cautions against the mass importation of non-execs with identikit commercial skills.

'I am against the idea of off-theshelf non-execs that all look the same - that would be a disaster. It is important we do not have a simplistic view of what a good chair or nonexec looks like - it varies. We have got to much better at helping boards identify what range of skills they need now 'To be an effective primary care trust non-exec some of things that are not valued now - like community involvement - may be absolutely fundamental to a primary care trust undergoing structural change and needing to be embedded in the community.' As befits a qualified doctor, it is the relationship with clinicians that Dr Morgan wants to discuss in greatest detail.

She says the main reason behind the 'massive clinical disengagement' affecting the service is a result of government and senior managers failing to tell a 'compelling story' about how reforms will improve oneto-one interactions with patients.

A case in point is the national programme for IT, which potentially offers huge leaps in patient safety and clinical time-saving. Earlier use of the powerful clinical advocates who are now being employed would have produced a 'different understanding at the front line from what We have currently got, ' she says.

Dr Morgan is also worried about the use of 'managerial language', which jars with how doctors 'feel' about their work and the growing belief that clinicians' worries are not being addressed.

'Some of their concerns, about independent treatment centres and medical training for example, are simple to deal with. But we have appeared not to listen. When people are passionate about the things they care about, which they feel are crucial for their profession and patients, It is felt as if We have pooh-poohed them as being unimportant.' Asked what is changing to resolve the problem, Dr Morgan praises those 'senior people in the [medical] colleges and the British Medical Association' who have taken responsibility for driving forward 'radical' ideas, such as the hospital at night proposals designed to deal with the implications of European working-time directive.

Any attempt to convince the public that NHS reforms are working is likely to run into smack into one very highprofile objection - the increase in healthcare-acquired infection.

The government has responded to this concern by proposing an inspection regime that could, in theory, see managers being prosecuted. Dr Morgan appears relatively relaxed about the idea.

'In a previous incarnation I inspected hospital kitchens before crown immunity was removed and found some very dirty conditions.

[But since its removal] I can't remember any NHS hospitals having legal action taken against them over dirty kitchens - people responded to the legislation.' However, while understanding why the government would want a similar approach to wards, she believes most NHS organisations would 'already meet any external inspection standards were put in place'. The few that did not could be supported to come up to standard before the legislation came into force.

'I do not believe there will be any prosecutions' states Dr Morgan. 'This act is to boost public confidence rather than make much difference.' Another issue on which the confederation is trying to exert its influence is the future of primary care trusts. Dr Morgan preaches the gospel of flexibility. 'To commission effective secondary care you need bigger constructs. You need the leverage of a population of at least 100,000 - but probably significantly more.

'On the other hand, with social services you need to be related to local government boundaries - though not necessarily one-to-one - that would work in cities, but not in Devon.' The answer lies in a series of niche solutions 'designed around individual circumstances' and subject to 'change over time'.

Dr Morgan also warns that the PCT debate has been 'distorted' because of the focus on their ability to commission secondary and specialist services.

'The exciting future is non-hospital care. It is about managing changes in primary care and integrating with social care. These challenges need different skills from contracting.

'The danger is that we forget that and take PCTs so far away from the other organisations they have to relate to, to produce integration that we will have another disconnect.' The successful introduction of practice-based commissioning is also key to local (and clinical) engagement, according to Dr Morgan.

'Part of the problem around commissioning of secondary care is that - if you stereotyped it, and I know this is not true in the majority of cases - you have had one group of accountants talking to another group of accountants about how GPs will work with consultants. And guess what? You do not get the behaviour that matches the contracts.' But she warns: 'I would regret - and think it would be difficult to run - a system that was entirely practice-based.

The sum of individual decisions doesn't add up to proper strategic thinking within a tax-generated, financially capped system.' Dr Morgan returns to the importance of 'non-hospital care' when she addresses payment by results and the lack of incentives to minimise acute admissions.

She does not believe the incentive system developed for long-term conditions 'will look like payment by results as we currently have it'.

Indeed she believes that unless that is radically redrawn it could 'distort entirely' the government's own policy objectives on long-term conditions.

Rather than having a system that rewards episodic care and therefore encourages activity, she hopes for something that recognises the integrated nature of long-term care.

'It might look like a year-of-care budget, ' she says, 'in which a fixed sum is provided for the care of someone with a long-term condition, including mental illness, over a 12-month period.' Dr Morgan claims that sharing any savings resulting from the use of alternatives to hospital care among commissioners and providers would provide the right incentives and ensure that 'everybody wins'.

On both practice-based commissioning and payment by results, Dr Morgan's over-arching concern is that the NHS is treating their implementation as a task rather than as chance to use these new tools to change service delivery.

She acknowledges that managers in the majority of NHS organisations can struggle to find the 'intellectual space' to do this while they are delivering the overcrowded policy agenda. Yet despite this, she believes the need to achieve change is particularly pressing.

HSJ's April survey showed that managers' biggest concern was whether NHS funding will continue at above inflation rates beyond 2008. Dr Morgan claims this will only be achieved if the NHS can prove its case.

She says the NHS must show that it has made effective use of the new 'tools' it has been given, including realising all the benefits of the national IT programme and the GP and consultant contracts, as well as making sure that the Modernisation Agency's 10 high-impact changes are all in place.

'As I go round the country I am urging people to think about this, because then we will be in a strong position to make a coherent argument that going back to receiving [funding] growth at inflation is not going to let us tackle issues like the aging of the population or sustain the type of service we want to see, ' she says.

The CV

2002-current: chief executive, NHS Confederation

1995-2002: chief executive, North and East Devon health authority

1996-1998: chair, then president, Institute of Health Services Management

1990-1995: director of public health, Leicestershire health authority

WHICH WAY NOW?

THE FUTURE OF THE CONFEDERATION

Dr Gill Morgan's original vision for the NHS Confederation was 'a safe home' for organisations that provided services funded from NHS money.

The type of organisations doing that has expanded significantly and the confederation now has around 40 affiliate members from the private and voluntary sectors.

Full membership is not yet on the cards, through the proportion of members who would countenance such a move has grown significantly.

'A lot people who were opposed have changed their minds because they've seen some real opportunities for innovative ways of doing things that deliver the best of the NHS and the commercial sector, ' says Dr Morgan.

'When we ask the membership again, we may be in a very different position. We might want to bring the private sector in as full members, but we are increasingly working in a much more federal way. That seems to be where the council feel most happy.' Rather than being 'a lobbyist for any one bit', Dr Morgan says the confederation can bring primary care trusts, foundation trusts, the private sector and other players together to discuss themes that affect them all.

She also sees it as the confederation's role to help set the 'rules' that would allow this 'collective group of organisations' to deliver the best services for NHS patients - for example, what actually constitutes a level playing field between public and private sector providers.