Examination of Witnesses (Questions 824-839)
SIR JONATHAN
MICHAEL, MR
MIKE SOBANJA
AND MS
SUSAN HODGETTS
18 JANUARY 2007
Q824 Dr Naysmith: Good morning. I am
Doug Naysmith. I am standing in for our Chairman who is on important
parliamentary business elsewhere in Europe and has taken with
him our chief clerk. We are very pleased that you have come along
this morning. We have a lot of questions for you. I ask you to
introduce yourselves for the record.
Mr Sobanja: I am Michael Sobanja,
chief executive of NHS Alliance.
Ms Hodgetts: I am Sue Hodgetts,
chief executive of the Institute of Healthcare Management.
Sir Jonathan Michael: I am Jonathan
Michael, former consultant physician and chief executive of Guy's
& St Thomas' NHS Foundation Trust. I am also chairman of the
Association of University Hospitals which has provided written
evidence to the Committee. I am chairman of the board of the Foundation
Trust Network.
Q825 Dr Naysmith: That just emphasises
that there is a lot of expertise available to us today. We are
very grateful to you for coming. I start off with the Griffiths
inquiry, with which I am sure all of you are familiar, which concluded
in 1983 that if Florence Nightingale was carrying her lamp through
the corridors of the National Health Service today she would almost
certainly be searching for the people in charge. Perhaps the question
is: is it that different today? General managers were brought
in to address this problem. Have managers succeeded in taking
charge of the National Health Service over the past 20 years?
Sir Jonathan Michael: I suspect
it depends on how you define "being in charge", but
in terms of accountability there is no doubt in my mind about
the accountability which rests with the board of an organisation
and specifically the chief executive of an NHS organisation.
Q826 Dr Naysmith: You will not venture
an opinion. Is it much more obvious now who is in charge than
it was in 1983?
Sir Jonathan Michael: I would
say that it is much more obvious. The 1998 or 1997 Act established
clinical governance and gave the boards of NHS trusts specific
accountability not only for things like finance but also clinical
quality and outcomes of the organisation, whereas previously perhaps
there had been some uncertainty as to management's accountability
and responsibility for clinical matters. That legislation made
very clear that responsibility rested with the board and chief
executive of the organisation in particular.
Q827 Dr Naysmith: What other benefits
have resulted from knowing who is in charge?
Sir Jonathan Michael: Clear accountability
is important. I suppose that I am an example of somebody who has
moved from the clinical side of the divide, if there was one,
to the management side. I do not believe that fundamentally there
is a divide between the two. Members of the NHS who are working
in a management capacity have just as much interest in accountability
for the quality of the service provided to patients as do clinicians.
I am of the view that the much talked about differences are over-hyped
and we all share a common interest.
Ms Hodgetts: In terms of common
interest and benefit for patients, that is what all of us are
working towards. Accountability has been very clearly outlined
by Sir Jonathan. I would add that working together is of utmost
importance for both present and future provision.
Mr Sobanja: The notion of the
accountable officer seems to be extremely important not only in
terms of clinical governance but also in lines of reporting which
are now much clearer in the health service. Previously, that was
done through chairmen of health authorities; now it is from Strategic
Health Authorities directly to the chief executive and ultimately
to Parliament. I think that makes a difference. The comments I
add in respect of primary care relate to the nature of the management
task. Colleagues and Sir Jonathan have been involved in the management
of an institution—if he will forgive me—which is slightly
different from working, as Dr Stoate will know, with a range of
independent contractors in primary care where there is no line
management relationship. That probably magnifies the comment about
the management task not being the sole territory of managers particularly
in primary care. Where this works well and effectively it is about
partnerships and shared objectives and goals. As to the benefits,
I start from the point that the health service is an improved
service now compared with, say, 10 or 12 years ago. Whilst not
all of that is attributable to management, managers have played
their part in reduced waiting times and the introduction of national
service frameworks and new contractual arrangements, by and large
achieving 48-hour waits in general practice. To say a word about
practice managers in that regard, if one takes the implementation
of the QOF, which in my view increased standards in primary care,
there is little doubt in my mind that at that level and in PCT
managers have played their part in enhancing services to patients.
Q828 Dr Naysmith: Would it be a reasonable
assumption—perhaps you could give a yes or no answer—that
a number of the objectives of the Griffiths report and inquiry
of 1983 have been implemented and are relatively successful?
Sir Jonathan Michael: I would
say it was.
Ms Hodgetts: I would agree.
Q829 Dr Naysmith: It is widely perceived
that managers are in conflict with doctors and other clinicians
particularly over the control of reform. Is that an accurate perception?
If so, why is it that managers and clinicians tend to come into
conflict over this?
Mr Sobanja: It is not the case
that managers and clinicians in the widest sense, including doctors,
nurses, physiotherapists and others who deliver services directly
to patients, are always in conflict. There is a chequered set
of relationships across the country. For me, where that conflict
exists it is probably something to do with the background and
culture arising from the training of both disciplines. Most clinicians
are trained and brought up with the ethos of doing the best possible
for the patient in front of them. I think that is right and proper.
Most managers are required to take a wider perspective about how
to get the greatest benefit for a group of patients, whether it
is a registered list or resident population. Inevitably, it involves
managing some sort of trade-off on priorities. That can create
tensions in the relationship. There are other elements such as
managers sometimes being seen as instruments of political policy
which clinicians may not find acceptable or even desirable, but
at the heart of it is the individual versus the population leader.
Q830 Dr Naysmith: You have set out
very clearly the problem. What is the solution? How do you resolve
it?
Mr Sobanja: To my mind, the resolution
is always centred on good communication and sharing the vision
and understanding of what we are here for. If I take the introduction
in primary care of practice-based commissioning, which I understand
the Committee may wish to consider later, around the country in
too many instances there has been a debate about its introduction
without considering what we are trying to achieve by using that
mechanism. Where managers and clinicians are able to come together
and answer the latter the process of implementation and introduction
is so much easier because there is a shared view and objective.
Ms Hodgetts: Anybody who has been
watching the BBC and listening to Sir Gerry Robinson will be very
aware of some of the tensions, some stronger than others, between
clinicians and managers. It is important for managers to gain
credibility with clinicians. While there is not any particular
way in which managers are subject to certain forms of training,
that gap will not really be closed. Until managers become subject
to a more rigorous compulsory CPD programme that will be an issue
that adds to the tensions between managers and clinicians.
Q831 Dr Naysmith: For the record,
what does "CPD" stand for?
Ms Hodgetts: Continuing professional
development. Clinicians have extremely rigorous training followed
by extremely rigorous CPD, whereas managers do not have to have
any specific qualification and are not subject to any particular
CPD, unless they are part of an organisation that demands it.
Organisations across the piece in terms of national health organisations
are erratic in terms of how they ask manager to become qualified.
Until we have something that is specifically for managers we will
not bridge that gap.
Q832 Dr Naysmith: Is there any programme
or anything else in existence to make that happen?
Ms Hodgetts: Members of the Institute
of Healthcare Management are subject to continuing professional
development, but that represents only a proportion of managers
across the NHS.
Q833 Dr Naysmith: Sir Jonathan, you
have experience of this side of the line in senior positions.
The turnover rate among management staff is much higher than among
clinical staff, particularly consultants. Do you think the fact
that senior managers move on and have a relatively short lifespan
at the top, whereas clinicians tend to stay there forever, has
any effect on what we are talking about? That is an add-on to
what has already been asked.
Sir Jonathan Michael: First, I
agree entirely that the focus of an individual clinician is the
patient in front of him or her at the time and the focus of a
manager, whether clinical or non-clinical, tends to be the wider
group. It may be a department or a whole organisation. Sometimes
that is the source of tension between the two. My solution—I
would say it, would I not?—is to involve clinicians in management
much more thoroughly and move towards an integrated unitary management
structure where clinicians have not only clinical responsibility
but responsibility for the management of the service within a
defined resource. In our professional and personal lives we all
have to work within constraints in terms of a resource envelope
or a legislative or regulatory framework. The same applies to
clinicians. My view is that it is easier if you empower clinicians
to be responsible for running services, but to have that responsibility
they must accept accountability. That is my solution. It does
not always work easily.
Q834 Dr Naysmith: I have to interject
to say that as a Member of Parliament for Bristol thinking back
to the so-called heart baby scandal as revealed in the Evening
Post the idea of clinicians turning into senior managers was
not an entirely happy one, without going into it in great detail.
Sir Jonathan Michael: I entirely
accept that. I make two comments. First, it predated the legislation
which gave the management and organisation formal legal accountability
for what was happening on the clinical side to deal with that
particular issue where the chief executive denied responsibility
but also the ability to interfere or intervene in poor clinical
practice. Second, I remind you that that clinician who was the
chief executive also suffered personally as a result of that failure.
To return to the question about turnover, it is a big problem.
To give you an example, when I was appointed to the University
Hospital in Birmingham in my former role I was the fourth chief
executive of that organisation in five years. I was given the
opportunity to leave a 30-year tenure consultant's position for
the insecurity of an NHS chief executive's job. I think that is
something which causes senior clinicians to think twice before
they move to a full-time managerial role.
Mr Sobanja: If I may refer to
the interface between management and clinicians in primary care,
I urge the Committee to consider the role of the professional
executive committee within trusts. That is currently the subject
of consultation by the Department of Health. That is meant to
be the central forum that handles the interface. The alliance
has done a fair amount of work on this in terms of publishing
the work behind the consultation document on the question whether
or not the professional executive committee is truly executive,
advisory or representative and its relationships with the board
and management team. Unless all of those things and others are
crystal clear the scope for conflict and confusion abounds. It
seems to me that that is critical in primary care.
Q835 Dr Naysmith: Is the high turnover
rate for senior management something about which we can do anything
or is it part of the way that things will have to work?
Sir Jonathan Michael: I hope it
is something that would be amenable to improvement. One of the
problems is that if you have specific personal accountability
as head of an organisation every time there is a potential problem
there is a risk that accountability may result in the departure
of whoever is leading that organisation. Many healthcare organisations
are dealing with pretty difficult services and functions that
will not always work well and have satisfactory outcomes. I am
not trying to defend poor management or clinical practice, but
the downside of accountability resting very firmly with an individual
on behalf of the organisation is that in event of organisational
weakness or failure there is likely to be a need for that person
to take responsibility.
Q836 Dr Stoate: I think we are getting
to the nub of the problem. From what I understand you to say,
there is no formal interpretation structure for NHS management
and no formal CPD or continuous assessment of any sort. The simple
question is: how do we know if any managers are any good at all?
Who objects?
Ms Hodgetts: Within the organisation
hopefully there are professional development plans which are fulfilled
and people work within a structure whereby there are checks on
managers who meet targets and have some CPD in progress, but you
cannot guarantee that that happens right across the board.
Q837 Dr Stoate: It is totally ad
hoc?
Ms Hodgetts: It is ad hoc if you
look across the board; it is not necessarily so within an organisation.
Q838 Dr Stoate: Therefore, you hope
that the organisation has these structures but it does not have
to have them?
Ms Hodgetts: One hopes.
Q839 Dr Stoate: Obviously, the number
of primary care managers has increased dramatically over the past
few years since the introduction of PCTs. I would like to draw
a working distinction between management and administrators. I
think that we have a lot of administrators in Primary Care Trusts
but I think there are very few managers. How can we tell the difference?
Mr Sobanja: I think it is extremely
difficult. The "numbers" argument is an interesting
one. At one stage we had health authorities and family health
services authorities and some would argue that FHSAs were administrators
and literally about managing the reimbursement of contracts in
primary care. When they were merged with health authorities it
was extremely difficult to count any sort of numbers of managers
or administrators in primary care because they became that group.
In 1999 with the introduction of 481 primary care groups we were
able to see clusters of numbers around primary care managers and
administrators, often using the senior manager grades which included
many of the administrative and clerical grades at the time. Numbers
have fallen because of the rationalisation from 481 to 303 PCTs
and now to 152. To get to your question about whether you can
count the difference between those involved in administrative
and management functions, my answer is no, although management
functions will not be confined to those in purely managerial grades
because there are people employed within PCTs who are clinicians
carrying managerial responsibilities. If I take that still further
into general practice, as you know clinicians are at the heart
of management there as well. I do not think it is possible to
make sense of the numbers in the way you seek given the currently
available data.
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