Abstract
As England approaches the elections this spring, politicians should pledge to increase the numbers of medical doctors and other clinically experienced staff within NHS management. The NHS is a popular point-scorer in electoral debates because of the ongoing crisis it faces in funding, strikes, under-staffing and disruption in hospitals. One problem that is not being sufficiently addressed is that NHS governance is out of touch with medical doctors and other frontline staff.1,2 A survey in 2008 showed that 87% of senior doctors and NHS managers want doctors involved in business planning, and 78% want doctors involved in budgeting, finance and resource allocation. 3 Clinical staff are still excluded from core NHS decision-making, such as spending large sums of public money on management consultancies, restructuring and other non-essential expenses. In 2013, the NHS spent £210,000,000 on getting advice/help from private management consultancy companies such as Ernst & Young, McKinsey and Pricewaterhouse. 4 The reality that many NHS managers have no first-hand experience of working with patients or clinical teams could be blamed for this sort of poor decision-making and the inappropriate application of models from the business world.
The British Medical Association has questioned the use of efficiency targets that are not clinically evidenced, the erosion of clinical staff as a way of making efficiency savings and the exclusion of clinical staff from NHS decision-making.1,2 Billions of pounds in NHS ‘efficiency savings’ have come from cuts to the numbers of clinical staff 3 with dire consequences for patient care. Some hospitals are resorting to desperate measures such as postponing all non-emergency operations and asking non-clinical staff (e.g. HR/IT staff) to work on wards. 5 The lack of clinical prioritisation in NHS spending is compounded by government funding cuts, and the result has been the current funding crisis. Two-thirds of hospitals in England are now in deficit, with an estimated £500 million shortfall accumulated by NHS England within just the first three months of this financial year. 6 Pay freezes and worsening working conditions due to under-staffing prompted NHS health personnel to embark on nationwide strikes in 2014. The latest planned strike (due to take place on 29 January) was called off when the government improved its pay offer.
Increasing staff pay, public spending on the NHS and ward staffing levels will, however, not solve the problems if there remains under-representation of clinical staff in NHS management. In one hospital, an entire team of accident/emergency consultants resigned at the same time because of chronic staff shortages and the hospital’s management reported reluctance to listen to suggestions about how to improve the department. 7 Clinicians cannot play a central role in NHS decision-making because the current structure gives them a peripheral role – they are consulted if need be; for example, clinical senates were introduced after the NHS acknowledged the need to gain their advice before making decisions. 8 There are 12 clinical senates across the country and they comprise doctors, nurses, allied health professionals, patients and others. The problem is that the structure of the NHS isolates clinical senates. It was intended that they will advise clinical commissioners, Health and Wellbeing boards, the NHS Commissioning Board and others, but it is not clear how they can systematically influence decision-making while being geographically restricted and while potentially competing with clinical networks to fulfil the same advisory function. In the case of clinical commissioning groups, the requirement is that there should be at least one doctor per group but this is not enough and it is not surprising that only 38% of general practitioners in non-leadership roles within clinical commissioning groups feel that they and their colleagues’ views are properly represented. 9
The idea of clinicians as people who should be consulted occasionally on an ‘if need be’ basis is not an approach that has worked. The alternative option, whereby clinicians become integral to the running of the NHS, should be considered. At present, entry into many NHS management jobs requires any degree-level qualification. The lack of clinical experience as a precondition could be blamed for the prevailing business ideology of continuous organisational change and ideologies about ‘transformational commissioning functions’ and ‘market management’, 8 which are of questionable necessity and clinical value. Clinical experience can be realistically introduced as a precondition applicable to all new management recruits by revising the ‘person specification’ documents and listing it among the essential criteria. Getting a pool of applicants with clinical experience is achievable if we consider the number of people who apply for these jobs relative to the number of vacancies available. Natural selection will lead recruiters to prioritise applicants who are clinicians or who have gained experience through a significant amount of time working in a ward or in community-based healthcare, with appropriate indicators of their personal values and aptitude (e.g. qualifications, appraisals/references). Natural selection will also help to deter entrants who do not have the motivation towards working in these settings. For existing NHS managers, it is possible to introduce clinical experience as an essential quality by providing incentives (e.g. time off and inclusion in continuous professional development goals) to volunteer on wards/in community health and by providing managers with the opportunity to ‘peer-buddy’ with or be informally mentored by a clinician.
Rectifying the under-representation of medical doctors and other clinically experienced staff within NHS management could end the current crisis and help it become a stable healthcare organisation. There have been calls for the NHS to increase the extent to which certain workforce processes affecting doctors are clinically focused, 10 and the extent to which clinically experienced staff are involved in NHS management.1–3 Introducing clinical experience as a precondition for a job in NHS management will ensure that it is run by staff with first-hand experience of working with patients and in clinical teams, giving them practical knowledge about how wards run, what patients need and what is of greatest clinical priority when it comes to NHS spending and staff supply.