Most doctors who continue to work on the shop floor of medicine, those who deal with individual patients, often remark on the uncertainty engendered by the continual change of management techniques and structures imposed on them from on high. I was about to wax eloquent in similar vein when I reflected on some lines from a song “Perpetual Change” by the Yes (a symphonically oriented rock group popular in the 60s. That dates me.) and realised that perpetual change is one of the necessary ways in which large organisations like the NHS avoid stagnation. Like Christian revivalists the NHS has to continually reinvent and thus revitalise itself. Perpetual change has to be recurring cycles of similar changes “pseudo-initiatives” because there are few totally new managerial initiatives.

How should doctors respond to this insight? How should they play this particular management game? There seem to be two game ploys. One is for losers. One is for winners.

The losers are the clinicians, mostly young, who throw themselves headlong into the latest change without realising the perpetual change nature of the game “We should commit ourselves wholeheartedly into (insert latest management pseudo-initiative) which is the answer to all our problems.” Their enthusiastic faces, with twinkling evangelical eyes of enthusiasm often accompany articles espousing the latest management initiative. Such clinicians gain importance but only temporary favour. I suspect that most find that the next change of management initiative leaves them high and dry and not a little disillusioned. For example fundholding was divisive, don’t you know.

The winners are those who instinctively or consciously realise that the game is not continued stability as a result of the latest pseudo-initiative but rather perpetual change. They engineer their position accordingly so that they can move seamlessly onto the next change of management pseudo-initiative “I was a supporter of (insert last management pseudo-initiative) but now we have something better.” In this way their perpetual enthusiasm is continually noted and they accumulate favour with successive managements and politicians. Such doctors can then climb up the management ladder away from the clinical shop floor and can then hand down changes of their own to those who remain on the shop floor.

No one wishes to be a loser. Some do not wish to be winners of this particular game and some, no it actually has to be the majority, are happy to stay on the clinical shop floor. The advice for these is to resemble the Vicar of Bray who carried on doing his job to the best of his abilities no matter which brand of Christianity was temporarily in the ascendant. He remained basically an ecclesiastical clinician whilst some vicars who committed themselves by braying the current religious wisdom were literally consumed by fire!

And this is law, that I’ll maintain
Until my dying day, Sir1,
That whatsoever King may reign
I’ll be the Vicar of Bray, Sir.

1. Kings Charles, James, William, George and Queen Ann according to the song

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