Line management led by donkeys

Dr Dermot Ward

You may have overlooked a BMA and The King’s Fund debate held on April 28 last. The motion was “This House believes doctors (in the UK) have failed in their duty to lead health services change“.  The BMJ had showcased the event in its April 25 paper journal. There were allegedly “50 senior doctors, healthcare leaders and policy makers in the expert panel of 2 for 2 against. I was seized by a bout of incandescence and fortunately short notice anyway prevented my presence. Now, a vote before the debate (a practice which has taken root here) had the motion carried, 63% to 37%. Following the debate it was only narrowly defeated, 49% to 51%.

But why my incandescence I hear you ask. Partly of course l am as one of Pavlov’s dogs in my low paranoia threshold when I find our profession under vacuous attack and let me tell you why in this instance. Doctors in Britain seem to have a longer term memory problem.  A large segment of medical society seems to have forgotten that up to 1983 doctors were the sapiential, de facto leaders of the NHS because there was general acceptance that their medical education, skills and hands-on practice reached a depth amongst public and professionals allied to medicine that this was the natural order of the healthcare and illness treatment world. Next to doctors stood a nursing profession, hugely respected also for its then mainly female membership. Most of the health care team (yes, contrary to recent propaganda we did have properly functioning teams then) accepted this informal hierarchy, maybe, like life, a bit fluffy at the edges - perhaps chaos theory functioning at its best. Now chaos, rather than chaos theory seems to reign supreme.

What was so special about 1983? The implementation of government publication, NHS management Inquiry, Report. London: DHSS, (Griffith  Report). This introduced line management and non-medical managers and thus began the systemic marginalisation of the preceding triumvirate of senior doctors, matron and hospital administrator. Thus began the politicians’ wrestling the reins of leadership from the hands of senior doctors and nurses. That  proved to be merely the end of the beginning. Remarkably few doctors seemed aware of the profound implications of line management and of non-medical chief executive for the profession. You might, though,  have expected the BMA (and government insistence on its assuming trade union status under threat of losing its terms and condition of service negotiation ’privilege’) might have had their smoke alarm switched on. Alas, no.

Then in 1984 a non-medical lecturer. R Steele, in the Department of Social Administration at Manchester University of Manchester writing in the BMJ dissected the problem. I condense cruelly here. “….NHS line management system and theory runs into trouble because it is those on the shop floor, doctors in hospitals, who commit resources and make decision on their use who are the major determinants and not the minor ones envisaged in a traditional line-management structure.” This contrasts with supermarkets where the shopfloor folk filling the shelves do not have such responsibility. Let me add Griffith was plucked from Sainsbury’s management to reorganise the NHS.

Also where the traditional medical model champions cooperation at all levels in clinical settings general management  must pursue control and competition in its goal of maximising profit. Curiously, in 1985 even as government proclaimed the virtues of management’s putative beneficial impact on the NHS with its deliberate sidelining of doctor influence on new healthcare policy the Association for Public Policy Analysis and Management’s own Journal of Public Policy, Analysis and Management  published a monograph by E Etzioni suggesting the medical model as especially suited to grappling with complex policy decisions: (healthcare systems were not specifically addressed here though clearly qualified for inclusion)  “ since it [medical model] combines practical knowledge with the findings of numerous disciplines and includes procedures for dealing with high uncertainty”. 

A further government publication directive, Working for patients (1989) introduced ‘Trusts’ and endorsed the responsibility of hospital consultants “….[who are] responsible for all aspects of the clinical care of patients under their charge“. Then the politicians undermined still more the vigorous leadership of doctors by a unilateral decision affecting newly appointed consultants’ work contract which abolished previous employment con tract clause whereby….. “ a practitioner shall be free, without any prior consent from the employing authority, to publish books, articles etc and to deliver any lecture or speak, whether on matters new ‘Hospital Trusts’ to do as they pleased. This has led to gagging and suspension of outspoken doctor critics who perceived policy proposals potentially eroding existing care standards. The stage was set for old soviet-style management of the NHS. 

As ineluctably as night follows day a systemically diminished medical profession is followed by deteriorated patient treatment and care . The most recent example ( be assured I possess a litany) was patient Mrs. Judith Roe who died last year aged 74. She had been diagnosed with Alzheimer’s Disease in 2002.  He case was revealed in the public press in August 2009.

 Her family was told she did not have a health problem but a ’social illness’. She was forced to sell her home to fund her increasing ’social’ care needs. In 2003 her family paid a social worker to visit her twice daily. In 2004 she moved to a care home, too ill to remain at home. In 2007 she had to be moved to another nursing home. She was bed-ridden and required 24-hour care still no help from the trust. Her tenaciously devoted son wanted to know just how ill his mother had to be before her condition was deemed a health issue. Finally in May 2008 the Health Ombudsman ruled in the family’s favour and directed that all nursing home fees (£130,000) repaid.

Paul Bates, Chief Executive, Worcestershire NHS Trust, proclaimed that the issues surrounding Mrs. Roe were most complex, that the dividing line between need for health care and social care “is indeed a very thin one indeed “ (what rubbish). Doubtless he was fervent in declaring “..we would not wish to see Mrs Rowe’s experience repeated”. And, oh yes, he uttered that all too familiar NHS healthcare shibboleth that “ there are clearly lessons for us to learn”. I have no figures to hand for incidence of learning disability amongst NHS chief executives.

Perhaps even more worrying than NHS  CE’s  IQs is the absence in what I have read of doctor comment. Of course it is difficult to speak out if you are gagged. However way you cut it that mere 51% debate confidence in doctors leadership in England is something we should worry about.