17 08 2009

Few people can have missed the American Republicans’ disastrous approach to the healthcare discussion straying beyond normal political posturing into farce, exaggeration, lies and the plain ridiculous when it comes to using the NHS as an example of how bad healthcare can be. One of the expressions of annoyance at this criticism of the NHS has been a spontaneous twitter campaign #welovethenhs, even supported by the Prime Minister himself.

But I believe there is something we can learn from American healthcare.  Am I aligning myself with Conservative “maverick” Daniel Hannan? Not in the slightest. My point is to echo a line from a paper by Reinertsen (2007) at The Institute for Healhcare Improvement. They have tried to address some of the difficulties in engaging clinicians in a quality agenda and ways to improve it. I have to confess to having a physical reaction on reading this paper, which for me and management science must count as a first:

 “Administrators need to stop regarding clinicians as customers and start treating them as partners in the delivery of healthcare.”

There is a lot clinicians have to learn about management and the whole topic of engagement I suspect will never be fully analysed. I accept there are dramatic differences in funding and organisation (sic) of American healthcare but this I believe is something they have correct.  I believe it sums up a fundamental difference that both offers solution and defines some of the difficulties. Clinicans are not overspending budgets, failing to make cutbacks, having shortfalls in clinic returns rates. Clinicians are dealing with patients. With the patient at the centre of this debate and the ONLY reason for the service being there each side may stop regarding the other with suspicion and regard each other as partners in the delivery of healthcare.

The reasons why we are currently at this juncture may contribute to our learning and progress from here. That I suspect will be my thesis.

Reinertsen, J., Gosfield, A., Rupp, W., & Whittington, J. (2007) Engaging physicians in a shared quality agenda. Institute for Healthcare Improvement, Cambridge, MA.

Clinical Managers are like web sites.

22 04 2009

The more I thought about the last post and Sue Llewelyn’s analogy of clinical managers as two way windows, the more I realised it was wrong. For me at least.

Certainly a clinical manager can allow and transmit vision (knowledge) to and from both sides of the “divide”, the insights one being more apparent to the other. But there I think the analogy starts to fail. Once again I accept that this may be due to my experiences but if an analogy is to be worthwhile it must work beyond simply those who describe it.

If one is inside a building looking out, no matter how big the window, the view is limited by the window itself. Similarly, no matter how close one gets to the window only one room inside the building will be visible. that is if the window is even on the ground floor! I’ll let you make your own translations into the experience of managers and clinicians.

My proposal is that clinican managers should be like a website.

It’s all about communication and information, accessibility, and development. And if the website isn’t working properly, or providing the right information, the appropriate support or communication portal, it can be upgraded and added to. It doesn’t have to be all singing and all dancing with java apps and downloads everywhere; it has to be personal and effective, professional and online.

What sort of website are you?

Ballad of a Thin Man

12 04 2009

On the encouragement of another reader, (thanks Lee!) I have taken my inspiration for this post from a hero of mine; Bob Dylan.

In the surrealist song taken from the album “Highway 61 Revisited” “Ballad of a Thin Man, ” he sings;

You walk into the room
With your pencil in your hand
You see somebody naked
And you say, “Who is that man?”
You try so hard
But you don’t understand
Just what you’ll say
When you get home
Because something is happening here
But you don’t know what it is
Do you, Mister Jones

The meaning behind this whole song is still being debated by Dylan fans many years later. Who is Mr Jones and what is he doing that he doesn’t understand?

Some commentators feel Mr Jones represents a music critic who just didn’t get Dylan, his (new) musical direction or even his songs. Mr Jones appears to be an establishment figure, one of authority or presumed superiority yet he displays his misunderstanding of his situation and the lesser people within it, ultimately being rejected by them, “how does it feel to be such a freak?”

Mr Jones is the wrong man in the wrong place at the wrong time.

What purpose am I trying to fulfill by posting this? I suppose partly to highlight my own confusion over things management and my place within it as well as addressing some of the confusion surrounding me and my opinions of all this.

You raise up your head
And you ask, “Is this where it is?”
And somebody points to you and says
“It’s his”
And you say, “What’s mine?”
And somebody else says, “Well what is?”
And you say, “Oh my God
Am I here all alone?”
Because something is happening here
But you don’t know what it is
Do you, Mister Jones

I appreciate that I present a very negative view of management. This comes from my own, ongoing experience and therefore is subject to my own interpretation. As the vast majority of this is negative it should come as no surprise that my representation of the issue is necessarily thus. It is neither a stance of nihilism nor criticism, merely repeated disappointment and undoubtedly confounding mis-interpretation. As a critique however it cannot be denied. Whether it makes sense or not, like Dylan’s sword swallower and his offer to return your borrowed throat, is not actually the issue.

Some have criticised my position suggesting cynicism and “wrongheadedness”. That logically comes from an alternative stance, one with a positive understanding or experience of management that is not mine to share. The two stances cannot be mutually exclusive and so both parties have to accept that this confusion is actually highlighting the problem rather than explaining it.

Medical management must be effective; without it the clinical practice as defined and prescribed by government and society simply would not exist. What is clear however is that the vast majority of clinicians view management as understandable as Mr Jones or his behaviour. Clinicians go to work, perform their duties and leave with very little direct influence or interaction from management other than in a coersive or regulatory sense. This develops the negative viewpoint.

To to deny or allocate blame in this is neither helpful nor appropriate. To chose to develop and progress the relationship clearly is the responsibility of both parties, recognising the divide and working towards reducing it. Surely no organisation can be at its most effective if it is so clearly dysfunctional.

Because something is happening here
But you don’t know what it is
Do you, Mister Jones

I’m not saying I’m Mr Jones or the commentator, I’m just saying this is actually quite surreal.


First, do no harm. Primum non nocere

21 03 2009

Regular readers will know of my hesitancy in becoming significantly involved in medical management. Some of this is due, on my part, to a lack of education and understanding of the complexities of the role. Partly however this is also due to deeply held, negative views regarding the overall aims of management compared to those of a clinician. I struggle with the different mindsets required to fulfill the two roles as I find the goals are not complementary but may often be totally divergent.hippocrates2

Now, as any good Greek scholar will know, “Primum non nocere” (first do no harm) is NOT part of the Hippocratic Oath. Primarily of course, the phrase is in Latin and Hippocrates was Greek! Secondly, even rough translation of his original treatise does not reveal a section that could even be mistaken for this now clichéd phrase. There are various interesting thoughts as to the genesis of the myth but the most common is that  in Epidermics, Book 1, section XI, Hippocrates wrote,

“Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm.”

The concept is however true that a physician, by whichever oath or code they practice, regards the health and care of their patients as of paramount importance. The scope for debate within that statement is huge but in the sternest of interactions between clinicians and management the power of that phrase and its interpretation underpins the behaviour of clinicians.

The news yesterday of yet another hospital; Birmingham Children’s, being severely criticised for its lack of care for its patients leaves every clinician with a feeling of shame. No matter the management edict, the targets or the funding issues, clinicians will struggle, often against the odds, and yes, even against the management, to provide the best care they possibly can. My sadness is further increased that this is yet again happening in the face of a current Healthcare Commission Report of apparently excellent (measured) standards and the award of Foundation Trust Status for delivery of these standards.

What does all this mean? It shows the gross inaccuracy of  heuristics applied to patient care, it shows that management are repeatedly willing to sacrifice patient care on the twin pagan altars of targets and foundation status and all this depresses me. These situations are clearly a failure of management and whilst the reasons for this failure may be complex, unknown or even unknownable they are contrary to our basic premise; “first do no harm”.

Do I want to take on a management role and prevent this happening? Is it possible to prevent this in the face of management pursuing goals at such expense?

A world of difference.

17 03 2009

Two stories are currently dominating the news reports; Mid Staffordshire NHS Trust and Royal Bank of Scotland. Two stories of management pursuing goals deemed laudable, each receiving recognition within its own field of “success” only to have revealed the ultimate costs of those achievements.

Sir Fred Goodwin and the Board of the Royal Bank of Scotland are not the cause of the current financial “downturn”. There is no doubt that behaviour such as theirs contributed significantly to the failure of the Group and the subsequent, some would say required, major Government support of the Bank. Mr Goodwin received a knighthood, “for services to banking” and is currently involved in some discussion, shall we say, regarding the value of his pension/pay-off/ severance/reward from the company. Currently, the financial reward for his “services to banking” is to be paid probably tax free to a value that has as many digits as my mobile phone number. He has simply “retired”.

The management group of Mid Staffordshire NHS Trust strove through their actions in the three years leading up to 2008 to fulfill the Government standards regarding financial probity and clinical targets. The Trust was given the accolade of Foundation Status in recognition of its efforts in achieving those quality standards.  The “Annual Healthcare check” from the Healthcare Commision for 2007-8 can be found here. A snapshot of their performance is below.


Impressive eh?

Today, it is being widely reported that the Health Commision has found that the management pursuit and achievement of their stated goals was at the expense of clinical care. During this same three year period it is reported that there has been significant failures of management and clinical governance lead to unnecessary suffering and a significant number of deaths. How exactly this fits with the report issued last year is open to conjecture.

I’m sure we’re all pleased to hear that the senior managers of this Foundation Trust have “retired” too.

There’s so much I feel about this whole situation and its wider context that just breaks my heart.  Perhaps leaving it unsaid speaks louder than any words.



17 01 2009

Sheep aren’t particularly clever animals. They gain safety in their herd as they have no means of self protection and spend most of their day ambling from one bit of grass to another.

Seth Godin coined the phrase sheepwalking to describe this sort of behaviour in our work places. A placid acceptance of the way things are, recognising that stepping out of the herd is both dangerous and unlikely to be successful such that following each other around, almost aimlessly, will get the job done to a moderate degree of satisfaction all round.

Shepherds (and managers) like this sort of behaviour as they know that if they leave the sheep out on the moors one day and comes back the next, the sheep won’t have gone far but will have achieved what they needed to have done. If a sheep wanders out of the herd either the herd bring it back in or the shepherd and a bit of implied threat from a sheepdog restore normality. Occasionally the sheep are rounded up and directed on to a new task or better pastures. When the weather is particularly bad the shepherd brings the sheep in and make sure his flock are protected.

It’s not compulsory you know?

Structure of Clinical Management in NHS

23 12 2008

The military is the basis of some of our concepts of leadership. The British Army currently has the following structure.

A Corps

  • two or more Divisions
  • commanded by a Lieutenant-General.

A Division

  • two or three Brigades
  • commanded by a Major-General.

A Brigade

  • three Battalions
  • commanded by a Brigadier.

A Battalion

  • around 700 soldiers
  • made up of five companies
  • commanded by a Lieutenant Colonel


A Battlegroup.

  • mixed formation of armour, infantry, artillery, engineers and support units
  • formed around Armoured Regiment or Infantry Battalion
  • 600 and 700 soldiers
  • under the command of a Lieutenant Colonel.

A Company

  • about 100 soldiers
  • in three platoons
  • commanded by a Major.

A Platoon

  • about 30 soldiers
  • commanded by a Second Lieutenant or Lieutenant.

A Sectionarmy-march1

  • about 8 to 10 soldiers
  • commanded by a Corporal.

Think about a conflict that this Army might be involved in. The overall goal will be well defined, tasks and responsibilities are clear. There are likely to be many good leaders whose efforts may not recognised by any except those closest to that action and the ultimate outcome of the conflict may not reflect the leadership skills of those lower down the structure. What is paramount however is the acknowledged and understood practice of followership.

Now, I’m not suggesting that it should be the same, but can anyone explain the concepts of the structure, aim, chain of command and function of clinical management in the NHS?

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