The year ahead will be important for the NHS. It will be a year that determines if the leadership across the system inverts and changes.
Currently it is based on compliance. Instructions are issued from the centre and the expectation is that they will be followed. Targets are set, with an implied threat that, if they are not met, the consequences will be personally felt.
When I was contemplating moving, full time, into management I rang three clinicians I knew who, at the time, were working with the Department of Health. Without hesitation each of them advised me not to do it. They said the system was brutal, unsupportive, and destroyed many people’s careers. Despite their warnings, ringing in my ears, I took the step which I have never regretted.
Working alongside NHS managers, many of whom have no clinical background, I have been humbled by their values, principles, and passion. The NHS is an iconic institution and it seems to me that many people commit to it and work for a greater, rather than a personal, good. It is what drives many managers to work idiotic hours – as long, if not longer, than many clinicians – and put up with a management culture that insists on compliance even if the experience and understanding of the local context, in such a complex system, tells the managers on the ground that what they are being told to do is not going to work.
That whole culture is now facing a significant challenge.
Over the last year I have sat at the interface between the old and the new. The culture across the emerging Clinical Commissioning Groups is one of membership. The leaders of the groups have gained their authority by securing the support of their members – their professional colleagues. They in turn are supported by senior NHS managers who have been assigned to work alongside them. The managers bring a skill set and experience which most clinicians’ lack: skills and experience which are vital to commissioning. What the clinicians’ also lack is an attitude of absolute compliance. Compliance and membership sit uneasily together. The members only join (or stay in) if they agree with what is being asked of them. Ask them to do things they decry and the membership quickly fritters away. The positive aspect of membership is the force for rapid and radical change it can create. I have seen more challenge, driven at a pace across and up the system, with the sense of empowerment local GP practices have felt in the last year, than ever before. The compliance with what is being asked of the members is terrific – because they have agreed and own it.
Recognising, supporting, and incentivising this sort of compliance through membership has, I believe, better potential to sustain and improve the NHS given the challenges it faces.
We are all being asked to be innovative. For commissioning, perhaps, could we start by embracing a new and innovative management culture across the system?
Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.