19. Management and Clinicians
19.1. Linked to previous chapters, I am aware that the relationship between managers and clinicians is a critical one. It appears that the intersection in decision-making between management and clinicians is not working well enough and is a cause of much frustration and sub-optimal performance. Of course, many managers are clinicians who are promoted to the management role, perhaps without requisite training.
19.2. I do not feel that I have got fully to the bottom of how this affects service delivery and impacts upon behaviours but I have gathered the views of a number of respondents in this chapter in the hope that, by drawing these out now, something can be done to change the mood, tone and relationships for the better.
19.3. Generally, I heard from some clinicians who felt they were not valued, not respected, not supported in carrying out very stressful work, not listened to regarding patient safety concerns, that funding issues affected performance, that decisions were made behind closed doors and that they were undermined when managing staff issues. As we have seen already, and is further developed in this chapter, many managers are also under immense pressure.
19.4. The sensitive interaction of management and clinicians is captured here:
"There are departments where clinicians have been under huge clinical pressure and have reacted in ways, which while not the most constructive, are understandable. They have been labelled as being difficult. Instead of acknowledging that these problems are structural national problems and not the fault of any group of clinicians, they have been rewarded by being managed, not by the most able managers available, but by the weakest. These difficult problems have now become critical."
19.5. A highly respected senior clinician told me that matters are exacerbated in NHSH:
"At times I have found working in NHS Highland extremely frustrating and stressful, not because of the clinical work but because of the dysfunctionality of the interface between clinicians and managers and because of the lack of senior decision making and lack of clarity of decision making. One might argue that this is a common theme across the NHS in the UK but in NHS Highland there has been very poor leadership and lack of decision making when implementing possible solutions that would relieve some of this pressure."
19.6. Another clinician, who reported not being sure he had ever been directly bullied but had "been ignored, side-lined and forced to work in a consistently negative working environment", went on ".…the combination of staff marginalisation in decision making, the lack of a clear clinical plan for NHS Highland and the 'head in the sand' approach to managing the clinical risks …. has gone on too long and I have found it tiresome and demoralising."
19.7. From another consultant:
"The bullying appeared to represent a top-down culture with a consistent approach to clinicians raising clinical concerns: isolating, marginalising and discrediting individuals coupled with reprisal actions. There were several examples of this leading to sickness absence followed by resignation.
Managers used jargon like 'golden thread' and 'catch ball'. When they came to speak to us about the HQA and told us that 'patients are at the centre' it was one of the most demeaning things I have ever been told by a manager – why do they think we became doctors?"
19.8. Once again, the tensions created between clinicians and managers are highlighted in this contribution:
"These [local area] managers are in a position where they have little decision-making power but are the link between clinical staff and the senior managers who can make decisions regarding services. It is become clear that many are choosing to filter information from clinical staff to avoid delivering 'bad news' and are instead tending to report only good news. The result of this is that clinical staff are being told to implement 'top down' directives for service change and when it is clear that those directives cannot be implemented or made to work there is a reluctance to report potential failure and instead increased pressure is applied to clinical staff to 'make things work' often without the appropriate resources to deliver. In some instances resources have been promised to support service change and then been withheld with the clinical staff being berated for failure to deliver despite not having the resources made available."
19.9. This captures some of the broader issues already mentioned elsewhere:
"The pressure on Raigmore management to stay within a budget that some might say was always set too low, in the face of increases in activity year on year, has eroded the morale of both the clinicians and the middle managers. It has also resulted in a relatively rapid turnover in the individuals at the top of the management structure in Raigmore, many of whom have been able and hardworking people who have subsequently gone on to success in other jobs, inside or outside the NHS."
19.10. From one clinical department comes commentary about the increase in manager numbers, changes in structure, and destabilising impact:
"There was over 100% increase in managers during my time in Raigmore, decisions were becoming remote from clinical departments and managerial decisions were being taking without a working knowledge of the services provided or any detailed analysis to back up changes. I have and always will be an advocate for patients; I was regularly reprimanded for using the word and advised that the term was clients.
Over that period of time there was a regular series of poor leadership decisions, leading to negative service impact. It started to become clear that some of these changes were also having a financial impact. During this time the management structure was regularly changing: this caused, across all staff groups, a level of unease as decisions and directions were regularly being changed on an ad hoc basis ultimately destabilising the whole structure in many departments. Many of these changes had a clinical impact on patients."
19.11. A professional lead told me about lack of trust and integration:
"When I came in, they were on the offensive – senior managers and other professionals. I sit between the senior managers and everyone else. It's a difficult point – managers want to cost cut but want to increase efficacy with less resources, and the people on the ground dealing with that. Because there was so much distrust, which seems to have been repeated in other areas around Highland. Because of the geography, you can't help but have some fragmentation, but they have not learned to work in an integrated way despite locations. They have done a good job with what they have, but they got caught up in this."
19.12. A change in attitude is perceived; the language of enmity expressed in the following remarks reinforces the strength of feeling:
"For my own perspective, there's been a change in attitude towards the people working on the ground. Working on budgets. At some point, the staff become the enemy. The dialogue between staff and managers changed. It used to be about listening to what we thought – that's gone…They've stopped listening to us as professionals. If I have a professional judgment and it's not what wanted to be heard, it's closed off and you feel that you've done something wrong…Partnership working between senior management and nurses is gone. I don't trust them. It's not just me. It's about the way they try to manage me – I think I need to be empowered. I don't need to be micromanaged or feel intimidated by into doing what they want me to do. I'm quite a strong person – but it's what they do to my teams. By not developing them, by driving them into the ground. These are good, caring [members of staff]. They deserve better than to be run into the ground, retire, be on the sick. We need someone to work with us and not against us. We're not the enemy, we're their solution."
19.13. There is sympathy for managers placed in difficult positions:
"I recognise that the behaviour I was subjected to is in part related to the individual in question, but also acknowledge that he would be under pressure to maintain a service. For several years our consultant group have raised concerns to management about inadequate staffing to maintain a safe service. Inevitably, if rotas are always stretched, then there is no resilience for unforeseen events such as prolonged ill health of a colleague and the impact on a department, without support from managers, may drive unsupportive or bullying behaviour."
19.14. Looking ahead, a senior manager expressed the views of a number of people in saying that:
"We still need to secure more clinical engagement and leadership. We are still challenged by increasing demand, limited capacity & difficulties in recruitment to key areas that are vital to the function of an acute service eg diagnostics. I remain positive this is a good place to work, with significant challenges but at the risk of being idealistic it is a time to come together not be divisive and critical of each other. Many of the clinical and management colleagues I work with are dismayed about the current situation, fearful of the future impact on attracting people to work here and worried about the impact of patient and the public's confidence in our services."
19.15. A consultant described problems in smaller departments and the need for better long-term planning:
"I feel that in the past there have not necessarily been adequate systems in place to ensure that any allegations of bullying are taken seriously and I think it will be important that this is the case in the future. From my perspective I feel that consultants working in smaller departments need to be given more of a voice to bring about change. In view of the recent lack of medical managers I have not really known whom to turn to help bring about improvements and in particular to raise concerns around patient safety issues. Time pressures mean that these issues are often not addressed in a timely fashion. The fast change over in personal of the service managers has at times perpetuated this problem as it can take time for them to understand the workings of the department. Financial pressures are often blamed for not being able to bring about change, but I feel better long-term planning is needed."
19.16. This probably provides a good reminder that systems, time pressure, lack of understanding, the financial situation and the desirability of strategic planning are recurring themes.
19.17. I record here the views of one consultant on how matters might be improved; this may simply serve as a useful provocation of new ways of thinking:
- "Move to a GP practice model: give a department a budget and autonomy on how they spend it. Let clinicians make decisions and give them a good departmental administrator implement them. This allows those who are close to the needs to make decisions
- Get senior managers to attend departmental meetings rather than expecting service leads to go to the senior management to ask for something.
- Senior managers to bring an accountant to those meetings so there can be clarity about what is in the budget.
- Invite clinical leads to attend board meetings and speak to management directly rather than being filtered by another manager. It's easier for a clinical lead to speak up as they have tenure whereas a manager will be looking for promotion.
- With accountants and good departmental administrators, could probably do away with most middle managers who create extra layers of bureaucracy by reviewing clinical decisions where they have nothing to add.
- Treat departments consistently. Don't reward overspend and take away from departments that manage themselves better.
- Create job plans (time budgets for standard tasks) and use this as a planning tool across the hospital.
- Do away with … quality initiatives such as Highland quality approach and rapid performance improvement….. Replace with good departmental administrators.
- CEO to thank and appreciate staff as well as addressing problems. The job is getting harder and staff need support.
- CEO to visit the hospital.
- Consider the tone of CEO communications."