Examination of Witnesses (Questions 840-859)
SIR JONATHAN
MICHAEL, MR
MIKE SOBANJA
AND MS
SUSAN HODGETTS
18 JANUARY 2007
Q840 Dr Stoate: In that case would
it be fair to say what I have been saying for some time, that
the NHS is chronically under-managed and over-administered?
Mr Sobanja: I entirely agree with
that.
Q841 Dr Stoate: What are we to do
about it?
Mr Sobanja: We have to be clear
about the nature of the management task, who is responsible for
doing that, make sure it is not a label attached to managers alone,
which very much echoes Sir Jonathan's point about shared responsibilities,
and get away from box-ticking on targets and targets for their
own sake and think about issues relating to health outcomes and
those which matter for patients. We should focus management's
efforts on those issues.
Q842 Dr Stoate: When Primary Care
Trusts were set up should it not have been obvious that there
were not enough people with the right skills to fulfil the huge
number of administrative jobs created?
Mr Sobanja: I think that is a
reasonable assumption. However, many of the tasks attributed to
Primary Care Trusts were completely new. The whole business of
commissioning in a proper sense remains poorly understood and
defined in many cases. Currently, there is a move towards the
introduction of plurality, as it is often put, and some sort of
market discipline. I hear expressions like "market shaping"
and "market making" as well as "market operation".
As a health service manager of 30 years, I have no experience
in that discipline. I am not quite sure whether anybody really
knows what it means, never mind the skills necessary to carry
it out.
Q843 Dr Stoate: There has been reform
right across the piece; it is not just in primary care but also
in secondary care. Why is it there has been a massive boom in
administrators in the primary care sector, which I believe has
caused a fair amount of difficulty and confusion, whereas in the
secondary sector there has been only a 3% increase in managers
and yet they also have had to cope with quite a large amount of
reform and change? How come you have managed to do so much with
only a 3% increase in administration when primary care has had
such an enormous boom and variable results?
Sir Jonathan Michael: I do not
think I am in a position to comment on what has happened in primary
care, but I accept that there is a significant advantage in having
a clear line management accountability regime within an organisation.
Within an organisation such as mine it is clear that clinicians
are employees of the organisation in the same way as I am and
there is a line management relationship between all of us. That
applies to all of the administrative as well as clinical staff.
In a way, I think it also helps to manage resources appropriately,
including administrative resources. It may be that that more compact
management structure allows us to look very carefully at processes
and functions with which we try to manage the number of staff
required to do them. If you have a handle on those processes and
can simplify them you can manage the organisation more efficiently.
Q844 Dr Stoate: Why is it that primary
care has not been able to do the same? Perhaps you are not the
best person to answer that. Mr Sobanja, why has not primary care
been able to handle the same types of changes with the same structure?
Mr Sobanja: I think you need to
look at the reference period. The Griffiths report and the institution
of management structures in the hospitals were well bedded down
up until 1999. Since then we have seen the introduction of the
role of management in primary care which is quite different from
anything that has gone before. If for example you take the implementation
of the new types of contracts for general practice, a great deal
more skill and management effort needs to go into that. I am not
absolutely convinced that in this regard we are comparing apples
with applies. The development of Primary Care Trusts and practice
management means that there been greater growth in the management
function in primary care that is both desirable and laudable.
Whether or not it has been matched by outputs is an entirely different
question.
Q845 Mike Penning: If we can move
on to management roles and responsibilities, perhaps we can look
at general managers rather than go through the whole gamut of
the management side. What should be the functions performed by
general managers in the NHS, and how well does the current management
workforce within the NHS meet those qualities and standards?
Ms Hodgetts: I think that a good
manager has a unique role to play, particularly in healthcare
management. That is quite different from general management because
it has to bring together several facets of management within the
context of health care. One is to understand and implement the
political agenda and the work that clinicians do and how to support
them to do their job properly, but the most fundamental point
is to make sure that patients get the best possible service and
combine those three unique factors within a management context
with a limited resource. That is the role of a good manager. Whether
they come up to standard, which I think is the second part of
your question, is dependent on the skills and support around them
and whether they can work effectively in their organisation with
the tools that they have.
Q846 Mike Penning: Within the large
NHS general management structure what percentage of managers are
stepping up to the plate and performing that function and what
percentage are failing? Would it be 50% or 60%?
Ms Hodgetts: That is a very difficult
question.
Q847 Mike Penning: That is why I
ask it.
Ms Hodgetts: I think it is an
impossible question for me to answer.
Q848 Mike Penning: If we have no
ability to judge how well the management is doing how do we know
how the NHS and the general managers are performing? This was
considered by Griffiths in 1983. It is guesswork, is it not?
Ms Hodgetts: If you look at the
targets that managers have to fulfil you can base your assumption
on whether they have met the targets, and maybe they are doing
a good job. If you go back to the point made earlier you can hit
the targets and miss the point in terms of whether they are still
being good managers.
Q849 Mike Penning: Many of the vital
functions that you said a good manager should have do not fall
within any of the present target structures. We have structures
from central government which it is said should be performed,
but many of the vital roles that you said a general manager would
need do not fall within those criteria. How will you continue
to judge general managers in the future?
Ms Hodgetts: I think that comes
back to having a solid and formal continuing professional development
structure for managers that makes sure they are competent to do
the job.
Q850 Mike Penning: Therefore, it
is far from perfect at the moment?
Ms Hodgetts: Far from perfect.
Mr Sobanja: I agree with my colleague
about CPD. To go back a little, if you want to look at the percentage
of managers who are being effective I suppose you can go back
to the report of the Healthcare Commission. Look at those organisations
that were seen to be succeeding or failing in different areas
and attach management results to it. It would not be perfect but
it would be as close as one could get. As to CPD, every health
organisation is supposed to have a performance appraisal system
in place for all members of staff including managers. I used to
be a health authority chief executive. I have views upon the adequacy
of that performance appraisal because it can be anything from
a quiet chat with the chairman over a cup of coffee to something
far more demanding. It seems to me that it has to be far more
demanding. If I go back to the question, we need to institute
something like a 360° feedback around managers particularly
in primary care but across the board. That would give us an opportunity
to assess how well managers were working with their colleagues,
peer groups, clinicians and staff, as well as fulfilling the line
management function directly up to the Secretary of State and
so on. We simply do not do that well at the moment. I think that
your diagnosis, if I read it correctly, is absolutely right: we
do not know how well management in the NHS is doing.
Sir Jonathan Michael: I am slightly
less pessimistic about whether we can measure. Although I merely
accept the Secretary of State's comments that the NHS is not a
business I see the component parts of it as businesses. I am in
the healthcare business. As an organisation we have to deliver
the objectives of the organisation within a framework of standards,
resources and regulation. It is possible to measure the outcome
of that activity and the organisation, whether it meets its objectives,
activities, financial targets and quality standards. Therefore,
you can measure the organisation and its effectiveness. The question
is whether that reflects on the managers within that organisation,
but there must be some relationship. The other element is how
that is achieved, because certainly from my point of view it is
the behaviour of managers as well as their performance which is
important and needs to be measured.
Q851 Mike Penning: With that in mind,
is this lack of understanding of the full role of general manager,
perhaps from within the NHS, contributing to the lack of understanding
outside the NHS as to what managements do within the service?
I include Members of Parliament. There are different management
structures within my local trust and I do not have a clue about
them. If we can firm up this understanding of the structure and
accountability it will help in understanding accountability.
Sir Jonathan Michael: It depends
on how you define management. A ward sister is a manager because
she runs a ward; a consultant is a manager because he manages
his practice; and a general practitioner is a manager. Therefore,
you are still separating out the definition of management in general
and general management. I argue that we need to put them back
together again.
Mike Penning: I would probably agree
with that.
Dr Taylor: I think we have a unique opportunity
to explore the life of a consultant in management, a medical director
and a chief executive. I should inform the Committee that I have
a slight interest in that Sir Jonathan helped me many times with
renal matters when I was a hack general physician and he was a
proper kidney specialist. Sir Jonathan, you have told us a little
about the difficulties of moving and the loss of security. What
made you decide that you would give up a very satisfying career
in renal medicine and go this way?
Q852 Sandra Gidley: Clearly, it was
not!
Sir Jonathan Michael: It clearly
was. I enjoyed my clinical practice. The reality is that at the
time I made the transition we were having some significant difficulties
in Birmingham in terms of the organisation of which I was part.
I was a clinical representative on the management team having
been the elected chairman of the staff committee at the time.
Therefore, I had been participating in the management structure
in a professional advisory role. When it was clear that a change
needed to be made I was asked to take on a more formal management
role. Interestingly, as a clinician it allowed me to make a move
from dealing with individual patients to helping a larger group
of patients but by stepping back from the direct clinical role.
I think that it is a very satisfactory and fulfilling transition
from a clinical to a managerial role.
Q853 Dr Taylor: As chief executive
in Birmingham and more recently in London, have you had a medical
director under you, as it were?
Sir Jonathan Michael: Yes. As
you will know, the legislation requires that there be a doctor
on a trust board. I briefly thought about whether I could fulfil
that legislative requirement but the reality is that you would
need to separate the two roles. I do not think it is easy to be
the medical director working with a medically qualified chief
executive because there is a temptation to try to do both roles.
Q854 Dr Taylor: But does your previous
experience make it easier for you to communicate with the medical
side of your workforce who are the people responsible for spending
most of the money?
Sir Jonathan Michael: Undoubtedly
it does. First, you understand the language; you have what may
be described as domain knowledge, which is helpful. Second, I
suppose that I am a classic poacher turned game-keeper. I have
done most of the things that my clinical colleagues may wish to
do to me and I have learned the tricks by changing roles, which
is helpful. Sometimes it is easer to give uncomfortable messages
to clinical colleagues if they feel that you have been there yourself.
Q855 Dr Taylor: Should we really
be trying to get clinicians to play a much bigger role in management?
Sir Jonathan Michael: Yes.
Q856 Dr Taylor: How?
Sir Jonathan Michael: You have
to look at the managerial training within the clinical training
of nurses and doctors. I am not talking just about doctors in
terms of clinical managers. At the moment, I think there is relatively
little managerial training in the already quite crowded curriculum
of both undergraduate and postgraduate trainees, but I think it
needs to be strengthened. If you go back to my business analogy,
clinicians are fee-earners. People do not come to our hospital
to see me; they come to see clinicians, so they are fee-earners
who also generate cost. They need to be involved and to understand
their involvement. At the moment, I think that comes very late
in clinical training.
Q857 Dr Taylor: How did you get training
to take on all that you took on? Did you just go into it and learn
as you went along?
Sir Jonathan Michael: I suppose
it was like learning to swim by being thrown into the deep end.
I just had to do it, but I do not recommend it. To go back to
the early issue about training, I do not think it is a good way
to do it. I would endorse the idea that much more structured management
training is helpful.
Q858 Dr Taylor: When we went to California
we discovered that it had a system of picking out promising young
consultants who might take on a management role and pushing them
in that direction with training. Is that something we should be
recommending here?
Sir Jonathan Michael: In my own
organisation there is a structure which gives management roles
to clinicians at a relatively early stage. We have developed a
training programme to try to give them the competencies necessary
to allow them to fulfil their role.
Q859 Dr Taylor: Do you go as far
as to say that you can be a consultant with a special interest
in management doing quite a good proportion of your clinical work
but trained for that special interest in management?
Sir Jonathan Michael: That is
certainly a model I have seen in Australia where clinicians can
go off into formal clinical management training at SHO level.
I think there are advantages in having been an active clinician
for some time. Having the tee-shirt, as it were, and having done
it yourself does help, whereas having a medical qualification
per se but never having practised as a doctor or nurse is not
quite the same.
Ms Hodgetts: There is some hope
on the horizon in helping clinicians to manage in terms of work
being done by the NHS Institute for Innovation and Improvement
by way of a pilot scheme for the introduction of a management
module into the core training of doctors in the future. Therefore,
just for your information something is starting to happen.
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