This is the third part of the BMJ Leader blog series written anonymously by “Magical Meander”, a medical manager working in the NHS, to help align perspectives and build understanding of medical management across these two professions.
Change is hard. Habit is comfortable. But to misquote the iconoclastic work of fiction -The Leopard: “if you want things to stay as they are, then things will have to change”. This is exactly the challenge of healthcare. Even if we are comfortable with the status quo, with all its imperfections, the world around us will not stay still. The population is aging, inequality increasing not decreasing, technological innovations snapping at our heels, public expectations rising, and finances getting tighter.
So there are macro levers of change: payment mechanisms, activity targets, and national standards to mention but a few. But to enable these levers to function the change has to happen at “the frontline”. To earn more income in a fee for service world, more patients need to be seen. To improve efficiency in a block contract world, costs need to be reduced.
The challenge for managers is how to make these macro levers translate to changes on the frontline without necessarily having the ability to effect the changes needed. The key clearly is to engage clinicians in this. The skill is to find a way to communicate these required changes to clinicians to enable their experience and expertise to find the solutions. The risk is that without skilled communication this sounds or indeed is a management requirement rather than a focus on achieving a better system for the good of the patients.
In my experience managers in the NHS want the same as clinicians, wonderful services optimised for the financial requirements. But clinicians speak different languages than managers, all too often. I remember as I started to learn about management a clinician providing the “business case” for a new pathway for the service: investing in new treatment for macular degeneration. The “business case” was actually a series of papers from the NEJM exploring the cost benefit of new drug treatments. Clearly, this exciting and important discovery was of benefit for patients. The challenge for the manager was to try and work out if this service, was the best place for this innovation. The manager needed to understand the why: the population needs, the why this service, understand the “competitors” aka the other local or specialist hospital plans and how this service fitted with this. Even if this hospital was the best place to meet this need, did the financial mechanisms enable this to be enacted without deleteriously affecting the existing service, or maybe even create a surplus for the service. And then the manager needed to understand the how – how do you give a new drug into the retina: the mechanics of what equipment was needed, the roles able to deliver this, the time this would take and the impact on job plans. The manager needed to understand the who: which of the patients with the disease would be suitable, how would this be identified; how would the impact of the treatment on the patients be monitored.
The problem is the manager cannot do this on their own. That’s were a clinical manager comes in. As a translator, taking the managerial needs and using their knowledge of the clinical situation, or being able to ask the right questions, to create this nuanced detailed explanation for the more senior team: the business case. To do this the medical manager needs to understand what the manager needs and why. They need to understand who reads the business case, who has to approve the expenditure. They need to be able to work out what motivates these people, so that business case can answer their questions. They need to be able to pull out of the story that clinicians are exploring whether this fits within a revenue generating (or cost saving) paradigm or whether the reason to do this is about quality or safety. Being able to answer these questions in the right way means the business case is more likely to land effectively (and quickly) and enable the clinicians and manager to achieve their specific goals.
Being a translator means speaking multiple languages, yet few medical managers are trained in managerial speak. True you can learn to speak languages formally or by experience but to learn experientially you need immersion and this can be a tricky juggle with clinical commitments. Being a translator means something more though, it means understanding the mood music of both languages: the soft stuff. It means understanding the different cultural norms – in the same way that someone who can speak a language also needs to know how the practitioners of that language tick, e.g. if you speak Spanish but go to Spain and don’t understand that the cultural norm involves late eating, your ability to navigate the environment is limited. It means understanding that managers can work wonders with excel but don’t understand how a clinician senses (based on education, experience and assessment of clinical symptoms and signs) individual patient need. It means understanding that clinicians can follow complex algorithms but may never have seen a balance sheet. To be a great bridge between these two crucial fields is to be a diplomat and a teacher.
The macular degeneration service did start, allied to the local specialist centre. It took investment in equipment in people, it took changes to pathways, it took new space to deliver the care, but mostly it took teamwork and understanding the commitment that all were showing to making a potential benefit real.
Magical meander is an anonymous blog written by a medical manager working in the NHS and published every six weeks on BMJ Leader Blog.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.