Abeda Mulla and Jonathan Shapiro
When Roy Griffiths wrote his letter about general management in 1983 to the Secretary of State for Health Norman Fowler[i], he could hardly have imagined its impact on the NHS over the next thirty years. Although the note urges the involvement of clinicians in the management of their organisations, the introduction of managers with discretionary decision-making powers actually created a deep gulf between these new managers and clinicians: the stereotype became that managers only worried about the money, whilst clinicians were only concerned with protecting their professional corners.
As this dichotomy became more and more pronounced, the notion of the clinical manager began to emerge, someone whose background was all about patients, but whose expertise included an understanding of organizational dynamics, combined with an ability to manage autonomous, professional staff. Thus, clinical directors, medical directors, and nurse directors started to appear, all intended to bridge the gap between the two halves of the perceived divide.
Some of these clinical boundary spanners (or boundroids, the term used by the inimitable June Huntington) engaged enthusiastically with management even as they experienced considerable role tension[ii] because they needed to be accepted as ‘one of us’ by both of the groups with whom they worked. Others felt they had been pushed into management and disliked the new role[iii] from the start.
Subsequently, the more talented and enthusiastic boundroids were encouraged to become leaders more explicitly. ‘Clinicians are expected to offer leadership, and where they have appropriate skills, take senior leadership and management posts… and change the system where it would benefit patients’[iv]. Despite this mantra, very little real progress has been made in increasing the presence of clinicians at the strategic levels of NHS Trusts[v] with few cases of clinicians becoming the chief executives of their organisations; compare this with the USA where having a medic as the chief executive of a hospital is relatively common, and the combination of management expertise with clinical credibility is almost expected.
Unsurprisingly, clinical leaders are beset by similar pressures as clinical managers, where role tensions and levels of legitimacy[vi] are concerned. The situation is worsened by limited definitions of the leadership concept itself, which often takes no account of the situation or the realities of leading clinicians in the NHS, including the culture of the individual organization or the personality of the boundroid[vii].
In our forthcoming publication[viii] we describe how clinical leadership was manifested in three different Birmingham and Black Country Acute Trusts, including the role played by the political context of the NHS and its culture. We show that the pervading organisational culture of a Trust determined how it responded to external directives. Furthermore the value given to and approach taken of clinical leadership varied over time, depending on the strategic priorities of each organization. The 2012 structural reforms to the NHS[ix] afforded Acute Trusts some level of stability, which could have been used for internal organisational development. However, at the Trusts we studied, the desire to develop clinical leadership remained for the most part rhetorical, as explicit plans for developing clinical leadership were limited; capable clinical leaders seemed to be expected to emerge unbidden and rise within individual clinical management structures, to be facilitated in their progress by the relevant (but perhaps unbriefed and untrained) managers or Executives, and whilst there were examples of this, it was hardly the norm.
We found that at the Trusts we studied, clinical leaders generally accepted their organisations’s performance management regimes, providing that they were allowed to retain their own sense of autonomy; the recent resignations from two clinical Chief Executives following criticisms from regulators on their organization’s leadership and performance[x], demonstrates how tensions continue to exist in this area even for very senior clinical leaders.
Linking management and leadership to clinical accountability can be an effective NHS strategy, but only if the measures chosen have clinical merit. If we expect our clinical leaders to ‘think like a Clinician, act like an Executive’ (to borrow from Simon Stevens) and still at the same time retain credibility with clinicians, the Board, and the external world, it is paramount that the political, regulatory, strategic and clinical objectives are all aligned so as not to turn away these talented clinical boundroids from corporate leadership. And anyone who can deal with so many masters, genuinely deserves a medal…
[i] Griffiths R. (1983) NHS Management Inquiry Report, London: DHSS
[ii] Huxham, C. and Bothams, J. (1995), "Bridging the Divide - the Duality of Roles for Medical Directors and Clinician in the New NHS", Public Money & Management, Vol. 15 No. 2, pp. 27-34.
[iii] Forbes, T., Hallier, J. and Kelly, L. (2004), "Doctors as managers: investors and reluctants in a dual role", Health Services Management Research, Vol. 17 No. 3, pp. 167-176.
[iv] Department of Health (2008), “High Quality Care for All: NHS Next Stage Review” Final Report, London.
[v] Veronesi, G., Kirkpatrick, I. and Vallascus, F. (2013), "Does clinical management improve efficiency? Evidence from the National Health Service", Public Money &Management, Vol. 34 No., pp. 35-42
[vi] Storey, J. and Holti, R. (2013), "The contribution of clinical leadership to service redesign: a naturalistic inquiry", Health Services Management Research, Vol. 25 No. 3, pp. 144-151
[vii] Howieson, B. and Thigarajah, T. (2011), "What is clinical leadership? A journal based meta-review", International Journal of Clinical Leadership, Vol. 17 No. , pp. 7-18.
[viii] Hewison A, Mulla A, Shapiro J (2014), “The importance of clinical leadership in service redesign- Experience in three English National Health Service Hospitals” International Journal of Leadership in Public Services Vol 10 pp1-16
[ix] Health and Social Care Act (2012); http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted
12 “Think like a patient; act like a taxpayer” http://www.england.nhs.uk/2014/04/01/simon-stevens-speech/