first person

When a psychiatric registrar shadowed the chief executive of his trust for a week, David Oyewole was amazed to discover that she shared many of his concerns as a clinician - and that she worked rather hard

What management experience have you had?', my clinical tutor asked during one of my annual appraisals. I mumbled something about thinking of going on a well-known management course in the next few months, but he wasn't impressed. 'Have you ever thought of shadowing a senior manager for a week?' he asked. 'Shadow a manager?' I thought. 'What could I learn from that? How tedious. I've never heard of it. Anyway, knowing how secretive they are, they wouldn't want to be shadowed.'

I was left with this idea until shortly before my next assessment. To my horror I realised I still hadn't attended that well-known management course and decided my only way out was to organise some shadowing.

My plan was to start at the top and work my way down until I found someone who agreed to 'have' me. I contacted the chief executive of my trust and an adjoining one. To my surprise, the secretary of one of them called me back within minutes, suggesting different dates to start shadowing; the other called me herself. I accepted the invitation from the chief executive of my trust to shadow her during a particularly busy week and began trying to get a week's study leave - at very short notice. Luckily, my consultant was going to be around during my week away, so it was approved.

On my first morning I was asked to arrive at 8.30am. Managers don't start work that early, do they? On getting through the door of trust HQ, I was on the lookout for those leather sofas, special china and famous tea ladies. To my surprise, trust HQ was bustling, and the chief executive's secretary gave me a copy of that week's agenda. Soon I was immersed in my first meeting of the day. It was short and to the point, dealing with the previous weekend and the agenda of the week ahead. I was surprised by some of the clinical issues being discussed - and here I was thinking that managers were only interested in budgets. We spent the morning going through serious- incident forms that had been filled in by ward staff, forms which I had always imagined to have been stashed away in a cupboard and left to the woodworm. In fact, these forms did have a use, particularly in putting forward ideas on how to remedy these incidents and avoid further ones. Someone asked for one form to be passed to the trust's PR department in order to help resolve a dispute with some 'difficult' relatives. Other issues, such as increasing nurse numbers, were also considered. Soon after, I found myself in another meeting - between the health authority deputy chair and my chief executive. Tea was provided, but we had to make it ourselves. The rest of the morning surprised me further. How adamant our chief executive was on how funding should not be cut in certain areas. For the first time I realised that we were on the same side. At last, I understood the intricacies of the purchaser-provider split. Later that week, I had first-hand experience of the negotiations between the trust and HA about the implications of clinical governance. It became apparent that in future, interaction with GPs would be central to the trust's healthy development.

That same afternoon, we rushed to a meeting with the director of social services to discuss the difficulties our trust had been having with getting placements for patients, thus lengthening the already formidable list of bed blockers. It was interesting to see how having separate budgets for mental health and social services sometimes allowed illogical scenarios to develop - for example, a fully recovered patient remains in a£300- a-night hospital bed instead of transferring to an£80-a-night hostel.

One of the most enlightening mornings was spent with the head of the public relations department, going through recent complaints from patients and relatives.

It became clear what a difference it made when a prompt and courteous response was provided when things had gone wrong and relatives or patients had found it necessary to complain. These matters were resolved much more easily when experts were involved.

There were structured meetings throughout the day, every day, and I was surprised by the number of consultants I saw at these meetings. The content ranged from planning and implementation of new initiatives to the monthly lunch with the chief executive, where consultants were able to air their grievances on existing policies, as well as exchanging gossip.

I realised that the ward round was not the only place where consultants played a major role. In fact, I discovered that a lot of their time was spent tackling tough management issues. There was one consultant who seemed to be at most of the meetings. He surely couldn't have enough time left for much clinical work? I later found out he was the medical director.

Over the next few days I rushed from meeting to meeting and from site to site, learning a great deal but with no time for meals. I found myself longing for those previously scorned free lunches provided by the drugs companies and having to settle instead for the odd sandwich grabbed on the way from one meeting to another.

Towards the end of the week, I was lucky enough to catch a trust board meeting; this is the one where the chief executive is held accountable for the progress of the trust.

These meetings were open to the public to come and observe and to voice their concerns. I expected multitudes to arrive; no-one did. Perhaps it was because the meeting started at 7pm. My ideas of managers' nine-to- five days were in disarray.

The week rounded off with a meeting with the trust solicitors. I learned that their services are available for all where mental health issues are concerned, and that I no longer have to feel frustrated when unable to interpret the grey areas of the Mental Health Act.

Now that I have attended that 'well-known management course', I see how ill-prepared I would have been for the practicalities of joining a trust as a consultant had I not done my week of shadowing.

Not only were the myths about the goings-on in management laid to rest but, more importantly, I at last grasped how the trust functions both on a day-to-day basis and in the bigger picture of the NHS. It is only from behind the scenes that one really sees the work that people do and what needs to be done to keep the hospital wards and community services going forward.

Historically, doctors have failed to recognise that clinical excellence needs to be paralleled with an understanding of the environment in which clinicians work. But it is increasingly important for doctors to learn how to deal with managers. NHS managers make up an untapped resource which should be incorporated into medical training.

It seems that managers, for good reason, are here to stay. Management will be a major commitment for consultants in the future, so it is worth our while trying to gain some experience in this essential area.

We need to bridge the gap between 'us and them' in a more practical way. Perhaps managers should shadow junior clinicians as a regular feature of their lives. And we should make an effort to learn from managers in preparation for our future as consultants. Understanding how a system works enables any necessary change to be brought about much more easily.

Dr David Oyewole is a specialist registrar, department of psychiatry, Charing Cross Hospital.