Examination of Witnesses (Questions 880-899)
SIR JONATHAN
MICHAEL, MR
MIKE SOBANJA
AND MS
SUSAN HODGETTS
18 JANUARY 2007
Q880 Charlotte Atkins: Can anyone
tell me whether or not it does happen? Hopes are fine, but we
have just seen TV programmes that tell us very often it does not.
Ms Hodgetts: If I look across
at the membership of IHM and at senior, middle managers and first
line managers there is a diverse response to that question. Some
people say that they have had a fantastic opportunity within their
organisation and have had a lot of training to help their careers;
others say that they have been limited by lack of support and
training in their careers. There is a real continuum of experience
in the range of managers.
Q881 Charlotte Atkins: Therefore,
there is no systematic approach?
Ms Hodgetts: There is not a systematic
approach across the country; it is a bit of a postcode lottery.
Sir Jonathan Michael: In a way,
your question is predicated on assumptions that the NHS is a single
organisation but it is not; it is a virtual organisation made
up of a whole range of different bodies. As part of a strategy,
at the moment we are seeing greater decentralisation rather than
greater centralisation. The implication is that responsibility
for training and delivery and matters like that is that of the
component parts of the organisations that sit within the NHS.
It seems to me that the NHS has a responsibility or interest in
making sure that there are training opportunities for people,
such as the graduate management framework. Maybe there are not
enough of them, but ultimately it is for the organisations to
make sure that the staff working within them get professional
training and have the competencies required to do the jobs.
Q882 Charlotte Atkins: I recognise
that the NHS is obviously an organisation made up of many parts.
Having said that, given there are national pilots targets and
everything else one would have thought that training might possibly
have an impact on meeting targets and making the workforce more
effective. What worries me is that from what you say it very much
depends on the effective management of those different parts,
and what we are talking about is the training of those managers.
Sir Jonathan Michael: But that
is a consequence of a policy that moves towards a decentralised
model, and I think that is a better way of doing it than having
a totally centralised structure and trying to run everything from
Whitehall. Given the size of the organisation and workforce, one
will not manage a training programme for over one million staff
from one point in the organisation.
Q883 Charlotte Atkins: If you look
at the area of education, at least you would have much more stress
on leadership. While we are talking about these issues, can you
tell me whether there are enough integrated training opportunities
for clinicians and managers so that they understand the different
points of view coming from those two roles?
Sir Jonathan Michael: There is
some but probably not enough. In working practices clinicians
and managers are working very much together and therefore are
learning about the particular perceptions of managers and clinicians.
My belief is that we need to see more integration and the use
of clinicians in management which will help. Are there integrated
training programmes? I suspect that there are not many. There
are multi-professional training opportunities certainly at undergraduate
level and at various stages of postgraduate training, but I suspect
that they are relatively limited.
Ms Hodgetts: There is medical
and management training that comes together at national level
in that courses are put on around the country, but again they
are for people who want to turn up as opposed to compulsory courses.
There are opportunities to bring both managers and medics together,
but again it is about people who want to do that as opposed to
people being directed to do it.
Q884 Charlotte Atkins: The graduate
management training scheme involves both clinicians and others,
does it not?
Ms Hodgetts: Yes, it does.
Mr Sobanja: It seems to me that
at the heart of it is Ms Hodgetts' point about continuous professional
development and performance appraisal. I entirely take Sir Jonathan's
point that one does not want a centrally managed or administered
scheme, but we have an arrangement within general practice and
with nurses which operates for 35,000 GPs under which there is
a system requirement to have an annual review and for development
opportunities to be identified. One of the principal points is
that it is a matter of career development as opposed to a retrospective
look at how one has done and one needs to separate out the two.
It seems to me perfectly possible to say that managers should
have the benefit of a similar type of experience, even if that
is to be administrated, managed—however it is put—locally
and met within local criteria and against local needs, but there
is no such system of which I am aware.
Q885 Dr Taylor: Ms Hodgetts, towards
the end of your written submission you say that there is a key
skill and knowledge deficit in moving from public service models
to a market-led model. You go on to say that developing commercial
skills now forms a key part of your programmes. Can you explain
what you mean by "commercial skills"? What grades and
types of staff need them? Are they in PCTs or trusts?
Ms Hodgetts: It is about the NHS
moving towards a mixed economy of providers in a contracted for
environment. Bearing that in mind, there will be an increasing
need for an improvement in terms of skills like negotiation, contracting
with people and managing risk. We can learn a lot from the private
sector in terms of those skills. Compared with the NHS, the commercial
sector is more nimble, flexible, takes more risks and is more
responsive to quick changes in direction, but it is profit-driven.
Currently, the NHS is not profit-driven. Therefore, in public
sector terms delivering to budget would be the closest we could
get in terms of that definition. The commercial skill is very
much about being a lot more astute in terms of contract management,
project management and working to an agreed and non-negotiable
timescale, which is not always the case—often it is elongated,
and so forth—to get things done in an efficient and effective
manner.
Q886 Dr Taylor: What grade of managers
would you be training? Would you go down to clerks in the accounting
departments?
Ms Hodgetts: No; it would be more
senior management.
Q887 Dr Taylor: So, it would be senior
management?
Ms Hodgetts: It would be senior
and middle management.
Q888 Dr Taylor: Since the market
came in has there been an explosion of staff necessary to drive
both the commissioning side and the providing side.
Ms Hodgetts: I think we come back
to a previous question that Mr Sobanja answered. There has not
been an explosion; there has just been a redirection of staff.
Some of them perhaps have not got those new skills that are needed
in the new environment.
Q889 Dr Taylor: You are producing
the training programmes now hopefully to give them those skills?
Ms Hodgetts: We do have some training
programmes, yes.
Q890 Dr Taylor: Sir Jonathan, in
your experience of foundation trusts have you needed more managers
or managers with different skills?
Sir Jonathan Michael: I agree
with Ms Hodgetts in terms of the range of skills required. Another
issue that I think is important is an understanding of an assurance
framework for an organisation which is the wider aspect of making
sure the governance, risk management and so on of the organisation
is assured and it is doing what it should be doing and what it
says it is doing. As to a more commercial approach, this is linked
back to my view that we are running a healthcare business and,
therefore, we need to understand the dynamics of that business
broken down to the individual subsets of the service we deliver.
Therefore, teams need to understand what we call service line
accounting and what income is generated by the work that they
do and what costs are being generated. Whether they are making
effectively a theoretical profit or loss is a fundamental discipline
in the new world, although we are not generating a profit as such.
Those are important skills, but it does not mean that you need
an increase in the number of managers. To go back to a point made
earlier by Dr Stoate, we have talked a lot about increases in
management, but I think the NHS remains under-managed. There may
be an excess of administrative burden and functions, but the management
costs of my own organisation are only 3.5%. That is an organisation
with a turnover approaching £700 million per annum and 9,000
staff. If you look at comparable organisations in the private
sector, their management costs are significantly higher than that.
Q891 Dr Taylor: I cannot remember
whether the department's paper Better Care, Better Value
applied to foundation trusts, but it showed that a large number
of acute trusts were not performing to the best on length of stay
and length of admission to hospital before operation. Is that
the sort of thing you have addressed automatically in your foundation
trust?
Sir Jonathan Michael: It is the
sort of thing that we are addressing. It is very helpful information.
One of the problems with the data we are currently seeing is that
they are not properly case-mixed adjusted which therefore makes
it quite difficult to compare one organisation with another, but
all foundation trusts are looking at what I describe as productivity—the
efficiency of the organisation and the way it is organised, for
example the utilisation of theatres, beds and so on. That is a
sensible discipline for any organisation to manage costs.
Q892 Dr Taylor: Do you think you
get enough data for management purposes?
Sir Jonathan Michael: We produce
the data. The data that come back to us are produced by us in
the first instance, so it is coming round a loop. What it helps
us to do is provide comparative bench-marking data.
Q893 Dr Taylor: As a foundation trust
are you better at that than other organisations?
Sir Jonathan Michael: I think
the financial disciplines required of a foundation trust encourage
us to do that slightly earlier, but the same financial requirements
apply to all NHS organisations. I think that foundation trusts
are just a year or so ahead.
Q894 Dr Taylor: I think one of the
witnesses mentioned managers from the private sector having commercial
skills. Should we be using more of them?
Ms Hodgetts: I am not sure that
we should be using more of them, but we should be making sure
that our own managers have those kinds of skills.
Q895 Dr Taylor: That is what you
would prefer?
Ms Hodgetts: Yes.
Q896 Sandra Gidley: It was said earlier
that managers should be managing health improvements but also
that they were under siege in some respects. Do they focus too
much on implementing change and too little on making improvements?
Is it just poor management or the pressures of the current system?
Ms Hodgetts: If you look at the
amount of change that has occurred over the past 20 years—we
have had at least 10 Secretaries of States in that time, a number
of junior ministers have been involved and a number of changes
have been forced upon managers—no doubt they are distracted
by that. The consequence is that there is a parallel process of
trying to think about what you have to do in terms of the political
agenda and what has to be done in terms of the organisation, making
sure that we get the essential patient care whatever management
that needs. The changed management process is bound to be a distraction.
Q897 Sandra Gidley: How do you say
those three are balanced?
Ms Hodgetts: They are not. I think
the distraction is the constant change. We could do with a period
of calm to imbed some of those good policies that need to be maintained
and followed through, as opposed to being suddenly changed again
as a result of another governmental directive.
Q898 Sandra Gidley: We live in a
particular NHS culture where everything has to be evidence-based.
Are managerial decisions evidence-based?
Mr Sobanja: No. I think it is
particularly difficult because of the shifts to which Ms Hodgetts
has referred to collect evidence particularly when new arrangements
are not piloted and the political ambition is such that we go
full tilt into one thing and then go full tilt into another without
necessarily evaluating the outcomes, particularly in patient care.
Many management decisions and processes are not evidence-based,
unless one considers experiment in practice as being part of the
evidence, which sometimes it is. There are evaluations of some
things, but in terms of overall management processes I believe
there is relatively little research and evidence as to what works.
Q899 Sandra Gidley: Would that go
for the acute section as well?
Sir Jonathan Michael: Yes, to
a certain extent. Clearly, individual management decisions are
probably not evidence-based, but if you look at the performance
of an organisation you can take a cumulative view of management
decisions. If that organisation is delivering quality of care
against its objectives and requirements it is likely, one would
hope, there is some relationship between that fact and the management
decisions made within that organisation.
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