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

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

(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;

make decisions on the use of resources explicit and

consistent with defined goals and targets;

contribute to the development, understanding and

implementation of shared goals, both within the

medical profession and within NHS organizations

(e.g. the Trust within this context);

fully exploit the skills and experience of clinicians in

general and doctors in particular to innovate, and feel

empowered to act to improve patient care;

promote the culture of investment in education,

training and development for members of the

organization to enhance patient care directly or

indirectly;

ensure the availability of accurate, timely, patient-based

information to support the process and create a

culture of decision-making based on this information.

What the process of doctors in management must not do is repeat the mistakes of the past, as shown by Maurice Kogan in his report of research undertaken on behalf of the Royal Commission [4], which found the roles of clinical members of management teams `unrewarding and thankless'.

Focusing firstly on the devolved management structures within a Trust, there are a number of different models of clinical management each with its own advantages and disadvantages. An overview of the common hospital models is shown in the Institute of Health Services Management Report [5]. A key feature of all models is a devolution of responsibility as far as possible, these devolved units of management are termed Clinical Directorates. The Clinical Directorate philosophy is now the dominant philosophy. It can accommodate a number of differing clinical management models. The precise role of physicians in geriatric medicine within clinical directorates is a significant paper in its own right. The most comprehensive guide to the potential participant is the recent publication by the Royal College of Physicans of London in association with the King's Fund on The Role of Hospital Consultants in Clinical Directorates: The Synchromesh Report [6], which had a significant input from the specialty of Geriatric Medicine.

The role of the Medical Director is a relatively new one. The common role to all Medical Directors is that they form part of a `Trust Board'. Boards have four main functions: to formulate strategy, supervise execution, evaluate performance, and maintain accountability. The Board itself is a group of people authorized to act as an individual and recognized in law as a single entity, especially in business. The Medical Director is a key participant in the Board and the delivery of its functions. For those interested, the publication by the National Association of Health Authorities and Trusts on Healthy NHS Boards [7] offers an excellent introduction. However specific guidance on the roles of Medical Directors is not easy to find. Some Medical Directors of Trusts are stressed by unreasonable demands on their time, worried about their colleague's feelings and wondering where they go next in career terms. These tensions are often rooted in the lack of clarity in the role of the Medical Director and/or a lack of support to deliver it. The core Medical Director roles which are emerging are:

Advising the Board on clinical, medical manpower

and contracting issues:

Development and implementation of an effective

clinical audit process, and systems to act on the

results;

Leadership and development of research and

development within the Trust;

Leadership of the medical and dental education and

training function;

Providing professional leadership for the Trust's

medical staff;

Changing the balance of services in co-operation with

Trust colleagues and purchasers;

Harmonising changes in services with trends in

medical education;

Changing attitudes to re-thinking clinical practices in

light of recommendations and results, especially

audit, research and development, clinical guidelines

and outcome indicators.

Health commissions

At the level of contracting between purchasers and providers there are several differing medical roles. It is essential that doctors and other clinicians are involved in the process [8]. This involvement includes a mixture of roles as individuals, specialty representative, Clinical Director or Medical Director. The specific role which has not been covered in this paper is with regard to clinical advice to purchasers including GP fundholders. Providers must ensure that purchasers have access to clinical advice from consultants and other professionals in provider units. Purchasers can go to any source they choose to, for advice. This is increasingly coming from the regional and national levels. However, contracting is now so fundamental to the NHS that it is worth highlighting the medical role in contracting. This medical role is:

Determining capacity and case mix;

Identifying new opportunities, clinical developments

and changes in volume;

Agreeing referral and activity guidelines (and

protocols);

Preparing service profiles and contract specifications;

Addressing clinical concerns of all GPs;

Monitoring contract performance;

Contract review with DHAS and GPFHs.

Central management

Central management is the function of the NHS Executive and the new `Regional Offices'. It has been identified that central management must support three important responsibilities of doctors and other clinicians, namely: to provide the best possible care to individual patients, to consider the wider interests of the communities in which they work, and to make the most effective use of resources. NHS central management will be responsible for building on the work of RHAs in developing networks and mechanisms to assist the four programmes central to this process namely; the research and development strategy; the development of clinical audit programmes; the development of service specifications and outcome measures for contracts; and continuing professional education.

There are thus going to be continued regional and national managerial functions which require medical expertise. These could be produced by two separate but equally credible routes. The first is through regional/ national management structures.

In the new NHS management structures these `central' management functions are preserved. How they will be organized to reflect not only the new Regional Offices but also the needs of Trusts is being discussed. If consultants are working outside the Trust in this capacity for significant periods the subject of pay back to the Trust is becoming one which is increasingly discussed.

The second route into central management is through the Royal Colleges and the British Geriatrics Society. Increasingly, purchasers are looking to `national guidelines' or `statements of good practice', `professional standards', etc. to influence purchasing. The professional bodies have a major role as `influencers'. Their recommendations are gathering increasing momentum and as such need to be carefully assessed before implementation.

Careful thought will need to be given by doctors developing policy on how they should be monitored. Non-implementation may be an individual, a provider, or a purchaser issue. Actions on non-implementation will need to be worked through, and should be part of the testing function of recommendations.

Conclusion

The role of the physician in geriatric medicine in the ageing society in management is a complex one which touches the NHS at all levels. Many of the roles are not clear. The single most important skill is to orchestrate significant organizational changes and still deliver and keep on delivering services in quantity and up to required standards. Learning to balance continuity and discontinuity has become a most difficult juggling act. Change is a high risk business or as Machiavelli observed, `There is nothing more difficult to carry out nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things'. Three major difficulties face the doctor manager in the NHS:

The sick and infirm cannot be put on hold whilst

the necessary changes are being planned and

implemented;

The sheer complexity of the task, as everything is so

interconnected, e.g. structure relationships,

technology, people, values, beliefs, etc;

The fact that ambiguity, uncertainty and emotion

pervade every aspect of the change process. Doctors cannot escape these issues. Geriatricians in their training have been given skills which are readily transferable into the management arena and in particular are well endowed with skills for managing change. The geriatrician's ability to balance impairments, disabilities and handicaps in someone with multiple pathologies and their ability to achieve a positive outcome (however that is measured) through a team of independent professional colleagues is precisely what is needed in the NHS.

My personal approach to management was instilled in me by my retired colleague Dr Philip Wilkins FRCP whose only words of advice were `Remember that you may be theoretically correct but for your service to survive and prosper you must be practically useful to your patients and colleagues'.

Recommended standards

1. All new consultant physicians in geriatric medicine

should have completed a management course during

higher professional training.

2. All departments, which contain physicians in

geriatric medicine should have a lead physician in

audit and medical education, clearly identifiable.

Those lead physicians should be linked to Trust,

and if possible regional and national, activities.

3. Physicians in geriatric medicine should be involved

in management. An explicit model of clinical

management should be demonstrable within a

Trust, in which physicians in geriatric medicine

should have an explicit role.

4. Physicians in geriatric medicine should have

participated in the development of contracts in

which they have a role. They should also receive

regular contract performance information and

should have been directly involved in discussions

with purchasers.

5. Central Management should include geriatric

medicine specifically in its main clinical

responsibilities of Research and Development,

Clinical Audit, Education and Training, and

Outcome Measurement programmes.

References

[1.] NHS Management Inquiry Report. London: Department of Health and Social Security, 1983 (Griffiths report). [2.] Managing the new NHS: a background document. London: Department of Health, 1993. [3.] Chantler C. How to do it: Be a manager. Br Med Y 1989;298:1505-8. [4.] The working of the National Health Service (Research Paper Number 1). London: HMSO, 1978. [5.] Models of clinical management. London: Institute of Health Services Management, 1990. [6.] The role of hospital consultants in clinical directorates: the synchromesh report. Royal College of Physicians of London in association with the King's Fund, 1993. [7.] Healthy NHS Boards: Guidance for Board Members of NHS Authorities and Trusts. National Association of Health Authorities and Trusts, 1993. [8.] Review of contracting-guidance for the 1994-95 contracting cycle. NHS Management Executive EL (93) 103.

Author's address

Elderly Health Unit, Queen Alexandra Hospital, Cosham, Portsmouth PO6 3LY

COPYRIGHT 1994 Oxford University Press
COPYRIGHT 2004 Gale Group