This is the sixth 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.

One of the joys of working in a large hospital is that one inherits the benefits: the amazing and clever work of brilliant predecessors. Clever management can lead to the metaphorical hiding money down the back of the sofa for using later, during rainy days. Or creating just enough slack in the system to use later to improve productivity without the need for more costs.

Times are very hard now. Block contracts based on previous year costs and huge spending on PPE or other COVID related costs are having a massive impact on business planning and other services. The effect is particularly felt by smaller services without the elasticity to manage sickness absences or increased demand (whether new true demand or simply managing increasing backlogs due to COVID). Now more than ever I spend time looking down the sofa to find these tiny pots of gold to rescue services.

The problem is that there is a finite amount of good luck. Increasingly now there is no more money. This leads to such hard conversations with colleagues. They do of course eventually understand but how do you compassionately say to a longstanding colleague you cannot retire and return because we need all your salary to try and scrimp together the money for a replacement. How does that honour their years of service? Previously we could have lessened the challenge of transition by offering one or two PAs post retirement to continue clinical work alongside research for a bit longer. True, this a luxury, but it honours the good will that the services survive on and it encourages others to continue to go above and beyond.

If there is no more money the options are stark. Find a cheaper way to deliver the services? Given the largest cost area in the NHS is staff, this is tricky. All too often, it isn’t really a cheaper option, just a less rollercoaster one. For example, replacing a fellow post with a CNS is often not cheaper but given how hard filling fellow posts can be it does reduce the overall cost because the services don’t have to rely on locums that are hugely costly. Equally CNS’s tend to stay for longer so that delivery of care is more stable: without the dips that training new people causes, but cost saving is in the short term only.

The flip of this is to ask all to do more, or do it more efficiently. This is also theoretically a good option but for many the “waste” is not in the control of the front line, for example complicated administrative waste such as missed, cancelled or wasted appointments due to the person dependent processes. One day, automation will make this feasible but at the moment all too often adding extra slots into a clinic doesn’t actually solve the problem because the slots end up unfilled or not fully utilised. Nothing drives clinicians crazier than agreeing to see extra patients or do extra clinics or lists only to find that they are sitting twiddling their thumbs instead of doing the work they know needs to be done.

Another option is delay. So if a service has a growing demand instead of recruiting more staff now, this can be nudged to the next financial year. This creates increased heartache for many: frontline staff and of course families. This runs the risk of impact on activity and 52 week breaches. This requires complicated message management to the services, with a focus on 3 rather than 1 year strategies. This also then takes up huge amounts of management time juggling those patients close to breaching targets within already crammed schedules. It also means more time is spent by clinicians validating lists – something that is universally hated but done to protect patients.

Another option is sharing the pain. So if one service has a bit more slack “borrowing the spare resource” aka cash and using this to support other services. Popular with the receiver not so much those who have resources borrowed from. The challenge here is remembering the complicated game: I borrowed from y and gave to x, I borrowed a little bit of x and gave to z and so on. Truthfully the transactions get lost in management history and grudges alone get remembered. It also requires teams to accept that they do not exist as truly separate entities and it creates challenging hierarchies.

So the answer eventually becomes just say “No”. The problem here is that service growth needs eventually become quality issues and indeed safety issues. The decline story can happen so fast. An efficient service, with a few retirements and no replacements or a bit of sickness becomes overstretched and then there’s more leave because moral declines. Or even if staff stick they work harder and harder getting more and more demoralised and we know this too impacts quality. Or lists build up and harm happens because care is delayed.

Right now in the midst of so many hard conversations, these conversations are even harder. My colleagues get it. But like me it pains them. I don’t have a magic solution- except maybe to keep smiling when I see a rainbow out of the ward window and hoping that there are really pots of gold at the end of the bow.

Magical Meander

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.