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In management - The Role of the Physician in Geriatric Medicine in the Ageing Society

Age and Ageing, Nov, 1994 by M.P. Severs

There is no right or wrong way to learn how to be a manager or how to manage. However, there are several roles which are common throughout the National Health Service (NHS), but even these are being modified. The rapid changes in the NHS since the Griffiths Review of 1983 [1] have been startling. The newest proposal Managing the New NHS [2] was published in October 1993 and was aimed at streamlining the high command of the NHS. This important document produced four key recommendations:

1. It created a clear identity for the NHS Executive

(NHSE) within the Department of Health, As the

`headquarters of the NHS'.

2. Fourteen statutory Regional Health Authorities

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(RHAs) would be abolished and the NHSE

outposts would be reorganized to produce eight

regional offices, each headed by a Regional Director

to replace both the RHAs and the existing

NHSE outposts.

3. The new Regional Officers would supply nonexecutive

members to the NHS Policy Board,

providing a link between Ministers and local

DHAs, FHSAs, and Trust Chairmen.

4. It enabled District Health Authorities (DHAs) and

Family Health Service Authorities (FHSAs) to

merge to create stronger local purchasers. The new NHS structure is shown in the Figure and identifies the key areas where physicians in geriatric medicine could have a role in management.

This paper takes a very broad view of `management' as the act or skill of controlling or directing. This broad view is important because many tasks undertaken by physicians outside direct patient care fall into this definition and could therefore be defined as management.

NHS Trusts

The rapid move to Trust status continues such that the reality of the directly managed unit will become an organization of the past. Within Trusts, physicians have management roles as individuals, in representing the specialty and in specific general management roles.

As individuals, physicians in geriatric medicine lead a clinical team and manage that team to achieve the optimum in individual patient care. Management skills are needed in leadership, co-ordination, education, training, interpersonal skills and implementation. Educational and training skills often extend beyond the clinical team to other clinical colleagues, e.g. general practitioners and schools of nursing. In-depth knowledge of geriatric medicine enables the physician to exert a vital managerial skill, that of influence to create service developments in partnership with those who hold general management responsibilities. The skill of the geriatrician in this area is manifest by the range and flexibility of geriatric services across hospital sites and community settings.

In representing the specialty or consultant body across specialties the physician has a range of managerial duties. These will vary in precise details between organizations but in general will include the following committee roles, e.g. Ethics Committee, Drugs and Therapeutics Committee, Education Committee, Audit Committee, and Research and Development Committee. Certain individuals may have specific roles in these domains: obvious examples occur in Education and Audit. Education is important not only in its intrinsic value but also from a managerial perspective since the introduction of the Medical and Dental Staff in Training; Education Contract. This is between the Trust and the Postgraduate Dean (presently via the RHA) and is crucial for a Trust's survival. This contract needs to be managed and be seen to be managed in every specialty if doctors and dentists in training are to continue to be allocated to that Trust. Audit is an essential professional activity but again contracts from April 1994 will be made, this time with Health Commissions or District Health Authorities. These contracts will need development, monitoring, delivery and appropriate action. Specific managerial responsibility for these tasks will need to be developed within each Trust and probably in each specialty within a Trust particularly the larger specialties like Geriatric Medicine. Representative functions outside the Trust are important with regard to regional and national duties. However, there is increasing tension in Trusts on the resource loss of these activities to the Trust, balanced against the potential benefits of having a leading regional or national expert within the Trust. This subject will be covered more fully later.

Specific general management roles within the Trust fall broadly into two groups, those involved with the Medical Director role and those with the Clinical Director role. Within both roles there is a core of managerial roles. A useful introduction which focuses appropriately on strategy and structure was provided by Chantler in 1989 [3]. The key aim of physicians in management is to create effective clinical management which should:

progressively improve and explicitly develop

approaches to quality, efficiency and effectiveness of

patient care;

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In management - The Role of the Physician in Geriatric Medicine in the Ageing Society

Age and Ageing, Nov, 1994 by M.P. Severs

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