Should clinical experience be a precondition for a job in NHS management?
Authors: Caroline Kamau
Journal: Journal of the Royal Society of Medicine (2015)

As England approaches the elections this spring, politicians should pledge to increase the numbers of medical doctors and other clinically experienced staff within NHS management. The NHS is a popular point-scorer in electoral debates because of the ongoing crisis it faces in funding, strikes, under-staffing and disruption in hospitals. One problem that is not being sufficiently addressed is that NHS governance is out of touch with medical doctors and other frontline staff. A survey in 2008 showed that 87% of senior doctors and NHS managers want doctors involved in business planning, and 78% want doctors involved in budgeting, finance and resource allocation. Clinical staff are still excluded from core NHS decision-making, such as spending large sums of public money on management consultancies, restructuring and other non-essential expenses. In 2013, the NHS spent £210,000,000 on getting advice/help from private management consultancy companies such as Ernst & Young, McKinsey and Pricewaterhouse. The reality that many NHS managers have no first-hand experience of working with patients or clinical teams could be blamed for this sort of poor decision-making and the inappropriate application of models from the business world. The British Medical Association has questioned the use of efficiency targets that are not clinically evidenced, the erosion of clinical staff as a way of making efficiency savings and the exclusion of clinical staff from NHS decision-making. Billions of pounds in NHS ‘efficiency savings’ have come from cuts to the numbers of clinical staff with dire consequences for patient care. Some hospitals are resorting to desperate measures such as postponing all nonemergency operations and asking non-clinical staff (e.g. HR/IT staff) to work on wards. The lack of clinical prioritisation in NHS spending is compounded by government funding cuts, and the result has been the current funding crisis. Twothirds of hospitals in England are now in deficit, with an estimated £500 million shortfall accumulated by NHS England within just the first three months of this financial year. Pay freezes and worsening working conditions due to under-staffing prompted NHS health personnel to embark on nationwide strikes in 2014. The latest planned strike (due to take place on 29 January) was called off when the government improved its pay offer. Increasing staff pay, public spending on the NHS and ward staffing levels will, however, not solve the problems if there remains under-representation of clinical staff in NHS management. In one hospital, an entire team of accident/emergency consultants resigned at the same time because of chronic staff shortages and the hospital’s management reported reluctance to listen to suggestions about how to improve the department. Clinicians cannot play a central role in NHS decision-making because the current structure gives them a peripheral role – they are consulted if need be; for example, clinical senates were introduced after the NHS acknowledged the need to gain their advice before making decisions. There are 12 clinical senates across the country and they comprise doctors, nurses, allied health professionals, patients and others. The problem is that the structure of the NHS isolates clinical senates. It was intended that they will advise clinical commissioners, Health and Wellbeing boards, the NHS Commissioning Board and others, but it is not clear how they can systematically influence decisionmaking while being geographically restricted and while potentially competing with clinical networks to fulfil the same advisory function. In the case of clinical commissioning groups, the requirement is that there should be at least one doctor per group but this is not enough and it is not surprising that only 38% of general practitioners in non-leadership roles within clinical commissioning groups feel that they and their colleagues’ views are properly represented. The idea of clinicians as people who should be consulted occasionally on an ‘if need be’ basis is not an approach that has worked. The alternative option, whereby clinicians become integral to the running of