Professor Alan Maynard OBE looks at the role of doctors in management ... and finds that though it already exists, it isn't working properly

A fundamental part of the Darzi report is the role of doctors as managers in producing improved quality of patient care in the NHS. The notion is that if doctors are brought into management, resources will be used more efficiently.

Is this assertion a non-sequitur in need of resolution by Sooty and his magic wand? Or is the promised land about to arrive?

The doctors in management thesis is epitomised by the earnest Comrade Nicholson, who has repeatedly declared over the last year that the role of doctors in management is crucial and that he expects that within two years every shortlist for a chief executive appointment will include at least one medical practitioner (Editor’s note – most chief executive shortlists have only one candidate).

But what does the good Comrade mean by “manage” and “management”? It is always useful to start with a clear definition of such terms of endearment! The Oxford Dictionary defines the verb to manage as “handle, wield, conduct, control”. The art of management is defined as “trickery, deceitful contrivance”.

Management by DH objectives
So some facts: firstly the Department of Health is involved in management, as all in the NHS who are in receipt of their trickery can vouch! The civil servants in Richmond House spend their time ensuring that policy is fragmented and evidence-free, while declaring the virtues of the evidence base and integrated policy and care packages.

"Management consultants' reports, being 'commercial in confidence' (so they can be repackaged for the next Minister), are never subject to critical peer review"

They fuel Ministers with the rhetoric of “evidence-based” decision-making, but neither they nor their political masters can distinguish between good evidence and glossy recycled tripe from consultancies.

Indeed spending £5,000-10,000 per day for senior partner advice from McDonald’s Consultancy Agency must be good, as it is expensive!

Sadly, management consultants' reports, being “commercial in confidence” (so they can be repackaged for the next Minister), are never subject to critical peer review.

But what of doctors?
But what of doctors?

"The cause of poor NHS management by doctors is the notion of autonomy and the fact that there is a lack of corporate responsibility, which is in turn a product of poor regulation and the absence of routine comparative performance data"

It is arrant nonsense to advocate that doctors should manage.

They already do so. It is they who “handle, wield, conduct and control” the allocation of resources and access to patients care in the NHS and every other healthcare system on the planet.

The policy problem is that they are so lousy at their job!

The cause of poor NHS management by doctors is the notion of autonomy and the fact that there is a lack of corporate responsibility, which is in turn a product of poor regulation and the absence of routine comparative performance data.

Where bankers meet Sinatas
The medical profession has much in common with bankers, and with the Emperor who had no clothes. They usually learn by rote in medical school, so that the intelligence of the intellectual cream of our society is blunted.

They are taught to act as independent agents, when they will work in the NHS in teams. Having learnt by rote in medical school, they learn to emulate Frank Sinatra when delivering care to the patients who fund their large salaries by paying taxes.

"They are taught to act as independent agents, when they will work in the NHS in teams"

“Doing it my way” like Sinatra means that similar patients with similar needs get very different treatment packages. Large, unexplained variations in clinical care are universal. This is epitomised by stroke care: we have a good idea what we should provide, but herding the Sinatras continues to be very difficult.

Another classic example is the variation in day surgery rates. Surgeons do it their way, and the day surgery laggards waste resources and endanger their patients by keeping them in hospital over-long and exposing them to errors and infections. Lack of compliance with good practice damages patients - and wastes society’s resources, of course.

"The central policy issue is not getting doctors involved in management. Rather it is to accept they are already key managers, but ones who may have neither the skills nor information to conduct their business efficiently."

That society and the profession have tolerated such nonsense for so long is indicative of the power of witchcraft and the fear of death, as well as of weak leadership in medicine and government.

The central policy issue is not getting doctors involved in management. Rather it is to accept they are already key managers, but ones who may have neither the skills nor information to conduct their business efficiently.

Crab-like and tardily, the NHS is beginning to recognise this with the provision of comparative performance data at the patient level and about costs, activity and outcomes (both comparative death rates and comparative patient reported outcomes data (PROMs)).

"The immediate problem such doctors' activation in purposeful management will cause is the quality of non-clinical management; in particular, the analytical capacity of such folk to inform doctors hungry for relevant modelling and analysis of data"

With these data and capped clinical budgets with clear activity, cost and outcome targets, doctors will have to manage in a meaningful way.

Outliers - for instance poor performers - will become obvious. Failure to deliver care to protocol will become evident and beg remedial action by clinical colleagues. The poachers are thus turned into gatekeepers!

Many doctors will just love to manage in this way. They are naturally bright and competitive. The immediate problem such doctors' activation in purposeful management will cause is the quality of non-clinical management; in particular, the analytical capacity of such folk to inform doctors hungry for relevant modelling and analysis of data.

"It is amazing how PCTs and hospitals have failed to invest in analytical capacity"

It is amazing how PCTs and hospitals have failed to invest in analytical capacity. With PbR, PROMs, activity data, CQUIN and patient level costing we are all to be “buried” in data. The risk is that as ever, we will be data-rich and analysis-poor.

Golden investment opportunity

"Failure to exploit this opportunity will be costly when productivity gain is essential in this time of depression. Failure to invest in analytical capacity will alienate the doctors set to manage purposefully the NHS"

This is a golden opportunity to invest in analysis. Failure to exploit this opportunity will be costly when productivity gain is essential in this time of depression. Failure to invest in analytical capacity will alienate the doctors set to manage purposefully the NHS.

This then is the priority for the NHS, but where is its recognition and the timely investment?