Most acute hospitals in the UK are subdivided into directorates with each directorate taking care of one or more specialities.
Directorate management team typically includes an accountant, head of nursing, general manager and is headed by the clinical director.
Clinical directors often are an experienced consultant, though increasingly younger consultants are being appointed because of their interest or qualifications in the medical management. Although some hospitals have struggled to appoint clinical directors as the workload deters potential applicants, in other trusts, clinical director’s post is a truly competitive appointment.
Clinical directors are able to use their knowledge, experience and understanding to facilitate day to day working and medium to long term planning. They are responsible for the clinical, operational and financial outcomes and as such are required to ensure systems and processes to guarantee corporate and clinical governance are in place.
Many hospitals in UK have strengthened directorate management structures through elimination of business managers and its replacement with more high profile appointments at general manager’s level. General managers come from a variety of backgrounds including nursing, finance, human resources to name a few. Many of the general managers are internal promotions and increasingly have business qualifications or are in the process of acquiring such qualifications. Like clinical directors, general managers are responsible for the directorate outcomes.
Being clinicians in the first place, clinical directors tend to concentrate more on the clinical structures, processes and outcomes. General managers tend to concentrate more on operational and financial outcomes. There is invariably some overlap between these areas, and the degree of the overlap varies according to knowledge and experience in the relevant disciplines and need to cover each other at the times of leave, sickness etc.
In many places such as my trust these arrangements work very well. In other places, there are tensions created by need to invest in clinical services and balance the books, needs to deal with clinical activity at a speed determined by contracts and demands, which may not find favour with clinicians and need to have safe staffing levels, only met with by paying for expensive agency staff.
The way GM and CD are appointed puts GMs under a greater pressure as the failing CD can still have his/her full time consultant post. GMs may not have such luck and may have to look for post elsewhere or take a less attractive and less well rewarded role.
In order to get the best out of directorate management teams, the team needs to work together and meet regularly. All contentious issues need to be brought to the discussion table, and realistic and affordable solutions agreed. This process is quicker if consistent solutions are applied to commonly occurring problems. It is not always possible to have a solution agreed at the first airing and some of the best solutions are a result of hard work and grafting by the team members.
It is important to know that the directorate management team does not always know the answer to all the questions posed. Both CD and GM should be prepared to seek advice from within or outside the directorate. Better solutions sometimes take time and both CD and the GM have to be prepared to give time and space for a good solution to emerge. Communication within and outside the team is the ultimate key to success. The time spent communicating is worth every second
One of the tasks delegated to the directorate management team is to align the trusts objective with that of the directorate. Well functioning executives are best placed to guide and re-route such a process if derailed, through regular review meetings. Executives need to ensure that trusts have induction processes for the newly appointed CDs and the GMs. In some cases, attendance at external courses should be facilitated through paid study leave. There are many such courses available for the aspiring and newly appointed CDs, though there is a gap in the market for clinical orientation courses for the GMs coming from the non-clinical backgrounds.
The NHS is going through the most difficult period in its history and there is no guarantee that efficiency savings will be any less in the future. There will be an additional pressure on the trusts having to live on the best practice tariffs and it would not be a surprise if GP consortia decide to tight financial belt further. The directorate management teams, particularly clinical directors and GMs, need to work together to survive and prosper.
Dr Pervaiz Iqbal is clinical director of medicine at Chesterfield Royal Hospital Foundation Trust