Doctors and nurses may have great clinical skills but they are often unprepared for the more general but equally pressing duties of management, writes Liz Saunders
Health service management. A concept? A role? An aspiration? An insult? Sometimes with the focus on clinical leadership, management can feel like an underground activity. At best something to be tolerated − a necessary bureaucracy; at worst something to be found and destroyed.
So what is the business of management? Planning, budgeting, organising, staffing, controlling and problem solving. Pretty crucial activities. Part of the challenge of management in general, but particularly in the context of the NHS, it’s an activity that’s akin to that of a stage manager.
If it is done well the “show” will unfold without mishap, everyone will be where they need to be, have the equipment and facilities they need and can get on with their jobs. You only really notice it if it is not working well.
Setting the stage
It is incredibly difficult for clinical staff to offer truly patient centred care if they don’t have the right facilities, equipment or staff to do so. The NHS is a system populated by human beings − human beings offering compassion to one another.
‘The assumption that a good nurse will make a good manager is flawed’
Offering compassion to patients is made all the more challenging if staff are exhausted, there are too few of them and they are dealing with systems that feel deliberately set up to make life more difficult. Effective and sensitive management, with an acute awareness of quality improvement science, should make this situation much less likely.
Given that the work of management is “backstage”, those not undertaking management tasks often won’t appreciate the difficulty and complexity involved in doing it well − assuming it’s something anyone can do.
The phenomenon of clinical staff making their way through the clinical grades and ending up as a manager is one seen regularly in the NHS. Yet the assumption that a good nurse will make a good manager is flawed. The NHS ends up with people in management roles, with great clinical skills and qualities, but little understanding of how to do their new role − how to be a really effective manager.
Don Berwick’s review and his accompanying presentations started to signal a change. It is no longer acceptable to complain about the systems. The job of everyone working within the system, says Professor Berwick, is to improve it − that’s not a “nice to have” addition. It is part of the day job.
Looking at the Berwick review it is clear that a lot of his recommendations are around valuing the skills of managers, whether those that reside in an individual with the job title of manager or in clinical staff. He recommends that all staff should have at least a rudimentary understanding of improvement skills − including understanding systems and operating within teams. Maybe it is time for managers to help clinical colleagues see some of the work that goes on backstage.
‘Doctors are expected to manage budgets, calculate staffing levels, improve patient pathways and navigate the endless complexities of the system with hardly any training’
Clinical education provides a challenge. While in some curriculums there are moves to introduce clinicians to concepts of management and leadership at an early stage in their career, for many this remains an area that is largely unexplored. And then they are expected to be competent at it.
For example, take the role of a consultant. An anaesthetist describes how it felt to make the transition from specialist registrar to consultant: “You spend 10-15 years of your life training to be a doctor. You work hard to understand what you’re doing and you’re looked to as the expert. Then you get a consultant job and you realise that the clinical world is about a third of what you’ll be doing and at best you’ve had a week’s course on the rest.”
This is an intimidating position to be in. Yet doctors and other clinical professionals are expected to manage budgets, calculate staffing levels, improve patient pathways and navigate the endless complexities of the system − all with hardly any training.
This presents multiple challenges to the professional manager:
- They are engaging with colleagues who, in many cases, have a limited understanding of the world they inhabit. While they are resident in the same building, their experience of what it means to deliver healthcare can be miles apart. If we are talking about “clinical engagement” this mutual lack of understanding is much more likely to lead to tension and discord than an appreciation of, and desire to engage with, other perspectives.
- The emotional and psychological impact of feeling incompetent on professionals who are perceived to be at the pinnacle of their career can lead to defensive behaviour that is difficult to penetrate. For example, as a manager, if a clinician comes to you angry that their business case has not been taken forward it is difficult at that stage to take a step back and begin a rudimentary explanation of payment by results.
- To value those backstage you need to understand what they do. Managers so often recount experiences of attempted changes to service delivery led by clinicians that end with “if only they’d involved me earlier”.
Health service management is not recognised as a profession in itself. There are many who think it should be, but there is recognition that it would be a complex and arduous process. There are, however, many clinical professionals who would benefit from increased expertise in management and many expert managers practicing in the NHS for them to learn from and work with.
If the recommendations of the Berwick review are to be taken seriously, management skills need to be firmly in pre-performance planning and post-performance debriefs. They need to be valued as an integral part of delivering high quality care.
‘The temptation, especially in the often pressurised environment of healthcare, is to lead from the front’
It falls to educational institutions to take action and undoubtedly the core programmes being launched by the Leadership Academy will do much to raise the profile of these skills among the clinical community. But it’s up to practising managers to share their art, expertise and passion for these skills.
There are many examples of good practice already: partnering programmes between doctors in postgraduate training and junior managers; managers making it their business to be known in clinical areas; in-house development programmes to help new consultants understand their organisation. There’s always room for more as well.
More than a manager
Perhaps the role needs to be reframed. Managers, at their best, are not just stage managers but producers, directors, coaches and mentors. Engaging the workforce in improvement of patient care means sharing skills and ideas, and building productive relationships where members of the team can be honest about what they know and don’t know.
The temptation, especially in the often pressurised environment of healthcare, is to lead from the front − to get on with it rather than looking around to see where others are at. Do they understand what’s going on? Are you showing them how you’re doing what you’re doing or just presenting the result? What is their role?
Engagement makes the biggest difference to how a team performs. Managers, and the skills of management, are too valuable to stay backstage if the wonderful show, the NHS, is to go on. Our patients are relying on it.
Liz Saunders is senior consultant at Hay Group’s healthcare practice