Clinical leadership and management in the NHS
Authors: Margaret Turner Warwick
Journal: Journal of the Royal Society of Medicine (2011)

I share the editor's confusion1 about ‘clinical leadership’ and ‘management’ of the NHS. Leadership and management have overlapping attributes, both are professional, but they are not synonymous and it obfuscates discussion of the issues to use them interchangeably. There is no harm in calling ‘dustbin men’ ‘waste management operators’ if it raises their morale and self-esteem. However it is sad when honest to goodness management of a magnificent national organization find it necessary to indulge in such self-aggrandizing terminology. Clinical leadership qualities are needed in a wide variety of roles in the NHS but management is only one of them. Clinicians who wish to take on senior management roles (either in commissioning or in hospitals) are vitally important, there should be more of them and the training programmes which have been developed are absolutely necessary. When we wish to discuss the optimal qualifications and training of management skills, let us say so and keep the terminology clear.

Notwithstanding all this, ‘clinical leadership’ training initiatives have become a euphemistic flavour of the month. Courses, diplomas and masterships abound. Even the notion of a Faculty is gaining ground and for good reasons – but the name should be accurate. These training opportunities have been set up largely (but not exclusively) to encourage clinical professionals particularly doctors and some nurses to acquire management skills, on the premise that professionals in frontline clinical practice are better placed to improve the operation of the NHS. Of course their input is vitally important but the question is, how can they be used to best advantage? Indeed searching for the holy grail of optimal management of the NHS has a substantial history.

Before the NHS, medical superintendents in charge of small hospital organizations were common and often successful. In the early years of the NHS, doctors treated patients and there was no expectation for them to take heed of the costs. They were supported by small numbers of relatively poorly paid non-clinical administrators, some of whom had received some training at a Staff College and others who learnt on the job. Some were very good. However as the potentials for treatment expanded and the cost of the NHS got increasingly out of hand, government accepted the Griffiths report in the early 1980s in which he proposed that the NHS required high quality captains of industry with business and financial experience in order to improve the efficiency and productivity of this increasingly complex and expensive national business. They became the Chief Executives of the NHS, rightly commanding substantial salaries. Over time policymakers were keen to increase the authority of these managers and that of the clinical professionals with responsibility for patients diminished, to one more akin to that of ‘hired artisans’. This created an increasing professional/management divide; clinicians' morale fell, patients unmet expectations caused concern to politicians and the costs continued to rise. Not surprisingly as the NHS was moved once again into an open market environment, the model promoted by Lord Darzi of getting frontline doctors to manage the costs as well as the service to patients was welcomed by policymakers and governments alike. Cynics might suggest that its attractiveness was in part based on the fact that if and when it failed, the professions alone would take the blame. There is still considerable doubt, as discussed by Ham and colleagues2 as to whether such a model run by self-styled ‘keen amateurs’, even after attending a ‘clinical leadership’ course, is the best way to run the vast and complex NHS operation. Many doubt whether it can work at all.

It is inevitable that the costs of the NHS will always outstrip resources. The challenge is to use those available (whatever they are) in an optimal way. While it should take advantage of good business-like principles and practice, the NHS is not a business and patients with their life and death, common and uncommon problems, cannot be handled or discarded like unprofitable commodities. Thus conventional market practices will always fail.

The knowledge and experience of the clinicians are crucial but are quite distinct from the skills brought to the table by those from the financial and business world, regarding efficiency, productivity, value for money and financial solvency. The underlying principles and operation of the NHS are unique and it requires a unique management system.

Logic therefore dictates that a new model should be explored where there is an equal partnership between the clinical profession and those with business and financial experience who each can bring their own skills and can learn enough of each others profession, not only to gain insight but also to gain mutual trust and respect. It is common experience among those who have worked in the NHS for a long time that those Hospital Trusts or Foundations which have been run successfully (and there have been quite a number of them in spite of the inevitable financial constraints) have succeeded because the non-clinical managers have understood and respected the clinical needs and views of patients and the professional doctors and nurses caring for them, and the leaders of the clinical profession who have taken on managerial roles, have reciprocated by understanding and respecting their non-clinical managerial colleagues. Notably where this partnership has been successful, morale throughout the organizations has risen and even difficult financial decisions have been accepted and supported.

All this indicates that the current enthusiasm for the training of some clinicians in management principles is essential and should be applauded, but it is only half the story. It is equally crucial for both senior and junior non-clinical managers to receive complementary training in understanding the principles and limitations of medicine. Such proposals have received considerable support from individuals and have been explored in some depth at Green Templeton College in Oxford, by the Royal Society of Medicine and by Surrey University.3 Sadly they have so far failed to advance, not least due to a singular lack of enthusiasm and financial support from either the Department of Health or the NHS executive.

In summary, it is not so much a Faculty of ‘Clinical Leaders’ which is needed but a Faculty of ‘Management of Health Services’ where management is dependent on an equal partnership between clinical and non-clinical professionals and where complementary and appropriate training programmes can be trialled and promoted. Such a Faculty might allow the exploration of a new model of management which has a real chance of successfully tackling the singular problems of the NHS, which have eluded policymakers for so long.