Health tsars
Authors: H. Burns
Journal: BMJ (2004)

In 1999 the Department of Health in England appointed its first health “tsar.” In doing so it broke with its long tradition that only civil servants worked with ministers to develop and implement policy. Since Mike Richards became the cancer tsar (more properly, the national cancer director) a further eight health tsars and one “champion” have been appointed to shape a variety of services, including primary care, heart disease, mental health, diabetes, and services for children and older people.

Although secondment of practitioners is not new in other departments of British government—the Ministry of Defence relies heavily on advice from serving military officers, and Treasury officials often work with seconded economists—the use of clinicians to direct change at a national level in health was new for England. The initiative has not been without its critics.

Tsars tend to be appointed because they are noisy and attract attention. They are usually outspoken and passionate in advocating change in the way their patients are managed. In this respect they are no different from many others working in the same specialty. Inevitably, when one eminent clinician is given the opportunity to change the face of a specialty, equally eminent colleagues might be disappointed not to have been chosen themselves. Being a health tsar can therefore provoke hostility for no reason other than jealousy. Given the seniority of those appointed, the chances are they can cope with a bit of envy.

The public also can seem a bit dismissive of tsars. A recent article in the Times said that the government appoints a tsar “whenever it sees an electoral liability brewing.”1 This view is unreasonably cynical. Whatever might be said of the way in which tsars are selected, their arrival in the health service is an honest and welcome attempt to involve health professionals in redesigning care from the bottom up. Newspaper sub-editors also tend to poke fun. Diet action coordinators become “food tsars,” healthy living programmes are directed by “fat tsars,” and teenage pregnancy projects are headed by “sex tsars.” But, however doubtful the general public might be, health professionals are certainly taking tsars seriously and seem convinced of the value of having one of their colleagues sitting at the Department of Health's top table. The key factors in being seen as a successful tsar are to be open to ideas and to have money to spend.

In a quick, and admittedly non-random, telephone survey of managers and clinicians that I carried out, one of the most common sentiments encountered was: “He's good because he listens.” My survey complements that carried out for the BMJ by Katherine Burke (see p 126).2 The synergy of tsars working closely with professional colleagues in a consensual way has been identified as a powerful source of benefit for patients.3 Where tsars were seen to be more autocratic, their value and impact were met with less certainty. Charisma and communication style were also seen as an important determinant of success. David Colin-Thome, the primary care tsar, is seen to be particularly good at working an audience. The other important characteristic by which a tsar is judged is the amount of money he is perceived to influence. Innovative ideas and an effective way of communicating them are all very well, but money talks in the modern NHS, and without it no one is listening to you.

NHS colleagues are anxious that tsars might be prone to two particular temptations. The first is that of becoming a creature of the civil service and just another element in the central control system of the health service.4 Obviously, to be listened to within government tsars need to be seen as helpful. Open criticism of government policy is not likely to increase their influence with ministers. However, they should remember that the lifespan of a tsar is finite, and someday he or she will be back working with colleagues as a coalface clinician again. If a tsar tries to defend the indefensible or support policies that are clearly politically convenient rather than evidence based, then his or her professional standing with colleagues will suffer. I can find no evidence that any of the tsars are doing this but plenty of evidence that colleagues think it a risk of tsardom.

The second temptation is to try to cling on to power too long. It seems as though no tsar's contract will be extended beyond five years. This is a good decision. They are employed for their innovative thinking and should leave the post before staleness sets in. In my own case as a cancer tsar (or lead clinician, as the post is called in egalitarian Scotland), I ended my secondment after the publication of the Scottish Cancer Plan in 2001, after three years in the post. In shaping the plan I had done what I felt comfortable in doing and thought it best to leave implementation to others. Tsars should choose when to go, not be forced out by a palace revolution.

Ivan the Terrible was the first Russian prince to be called “Tsar.” After the death of his first wife his reign became increasingly marked by senseless cruelty, and whole cities were massacred to assuage his paranoia. Peter the Great, while no stranger to murder and intrigue, was seen as an imaginative reformer who opened up Russia to Western ideas and trade. When he decided to develop a navy, he disguised himself as a carpenter so that he might learn at first hand how ships should be built. He seems to have been convinced of the benefits of a bottom-up approach to reform. Our health tsars seem more like Peter than Ivan. On the whole they seem to be doing a good job, with colleagues generally supportive of their efforts and the Department of Health seen as more responsive to clinical pressures as a result of their influence. The message for prospective tsars is to listen to colleagues and hold fast to principles of evidence based medicine. If all else fails, success is likely if you make sure you have a ringfenced and, preferably, large budget.