This is the eighth 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.

As with so many management decisions, there isn’t really a bible to tell you what to do. Instead experience and empathy can help manage the delicate balances that are required. In the world of block contracts hospital services are forced to live within budgets despite growing need or complexity; whereas previously such growth could be supported by the revenue increases or altered revenue provided. Now this is not possible and for many services this is crippling. It means choosing to limit referral acceptances sometimes based on geography or other criteria. Or else risk putting at risk existing patients by limiting the follow up slots available. There is only so much time in a job plan and if more slots are needed and no extra people can be paid for to provide these, then choices have to be made. True some efficiencies are always possible. True reducing administrative tasks to allow maximal patient facing time can help; but you can only make existing things stretch so much. Worse still than the horrible efficiency and ethical issues that are created is the overwhelming sense of frustration and inequity that teams feel.

One way around this is to empower the teams to choose how to spend the limited resources. If the money pot control is handed to the service leads and service managers the opportunity to make choices and at least feel a sense of limited control is better than being told what to do. The challenge of this is the trust required. What if the teams overspend, or misjudge choices? Even if double checks or balances are put in – for those less experienced in this sort of decision making it can be hard to get right. There are also losses of scale. If you manage a bigger unit you can juggle budgets at times to support greater need in one area and offset this against savings in another; harder if the scale is smaller.

So it’s hard for teams and hard for leaders to enable this. One management mantra earned autonomy is the concept that services can be allowed more freedom if they can show they can manage. The slowly slowly approach; clearly safer and clearly encouraging continued attention by all. The leader though has to accept that at the start they will have to put a huge effort into training / mentoring / coaching and dealing with minute details. Over time though once a service has full autonomy there is a new challenge. How does a leader let go and allow the service to run free? How to oversee and not micromanage? How to hold to account without appearing like a critical friend (emphasis on critical)? The flip is also true. How to support the service to feel empowered and not to suffer from respectful neglect?

There are no right answers that fit every situation. I think I’ve learnt I have to go with the sixth sense of who and which service can do this. You have to start by showing – how to get vacancy forms through, how to organise recruitment, how to check monthly budgets. You have to ask strategic questions and explain why you’re asking. You set up data flows that show the key areas: drug spend / workforce information etc. Then slowly you ask less and instead watch the data, asking questions only when the data moves away from acceptable norms. But the key is to keep checking in with the whole team. The odd coffee / the what’s app message, the conversation by the water cooler.. they really matter. What matters even more is being available – that means answering the phone at 7pm when the team is suddenly challenged by sickness and there’s no money in the kitty for locums. It means all hands on deck when a peer review makes costly suggestions. Sometimes it means just listening – that’s what makes earned autonomy work and not drift into respectful neglect.

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.